Gymnastik- och idrottshögskolan, GIH

OBJECTIVE: The COVID-19 pandemic caused millions of deaths worldwide and significantly impacted people with eating disorders, exacerbating symptoms and limiting access to care. This study examined the association between COVID-19 death-related loss-defined as the death of a family member, friend, or acquaintance due to COVID-19-and mental health among people with preexisting eating disorders in the United States (US), the Netherlands, and Sweden.

METHOD: Participants with a history of eating disorders completed a baseline survey early in the pandemic (US: N = 511; Netherlands: N = 510; Sweden: N = 982) and monthly (US, the Netherlands) or biannual (Sweden) follow-ups from April 2020 to May 2021. The surveys assessed pandemic impact on eating disorder-related behaviors and concerns, anxiety, depression, sleep disturbances, and COVID-19-related deaths. A matched nested case-control design was used to compare individuals experiencing a death-related loss with matched controls.

RESULTS: A substantial proportion experienced a COVID-19 death-related loss (US: 33%; Netherlands: 39%; Sweden: 17%). No significant differences were found between cases and controls on eating disorder, anxiety, depression, or sleep outcomes.

DISCUSSION: Despite the expected influence of COVID-19 death-related loss on mental health, our study found no significant association. Reactions to pandemics may be highly individual, and practitioners may want to consider broader losses-such as bereavement, missed educational experiences, relationship disruptions, financial instability, and employment challenges-when addressing patients' needs. Future research should continue to explore how death-related loss impacts eating disorder risk and progression.

OBJECTIVE: The Nine Item ARFID Scale (NIAS) is a widely used measure assessing symptoms of avoidant/restrictive food intake disorder (ARFID). Previous studies suggest that individuals with eating disorders driven by shape/weight concerns also have elevated scores on the NIAS. To further describe NIAS scores among individuals with diverse current and previous eating disorders, we characterized NIAS scores in a large sample of individuals with eating disorders and evaluated overlap in symptoms measured by the NIAS and the Eating Disorder Examination-Questionnaire (EDE-Q) version 6.0.

METHOD: Our sample comprised 9148 participants from the Eating Disorders Genetics Initiative Sweden (EDGI-SE), who completed surveys including NIAS and EDE-Q. NIAS scores were calculated and compared by eating disorder diagnostic group using descriptive statistics and linear models.

RESULTS: Participants with current anorexia nervosa demonstrated the highest mean NIAS scores and had the greatest proportion (57.0%) of individuals scoring above a clinical cutoff on at least one of the NIAS subscales. Individuals with bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorder also demonstrated elevated NIAS scores compared to individuals with no lifetime history of an eating disorder (ps < 0.05). All subscales of the NIAS showed small to moderate correlations with all subscales of the EDE-Q (rs = 0.26-0.40).

DISCUSSION: Our results substantiate that individuals with eating disorders other than ARFID demonstrate elevated scores on the NIAS, suggesting that this tool is inadequate on its own for differentiating ARFID from shape/weight-motivated eating disorders. Further research is needed to inform clinical interventions addressing the co-occurrence of ARFID-related drivers and shape/weight-related motivation for dietary restriction.

BACKGROUND: Many patients with eating disorders report exercise as a central symptom of their illness-as a way to compensate for food intake, prevent weight-gain, and/or reduce negative affect. Previous findings show associations between maladaptive exercise and more severe eating disorder pathology, higher risk for relapse, other co-morbid symptoms, and worse treatment outcome.

METHODS: In this study, we included 8252 participants with eating disorders and investigated associations between maladaptive exercise (both lifetime and current) and ED pathology, illness duration, depression, anxiety, self-harm and suicidal ideation, and treatment seeking patterns in individuals with lifetime maladaptive exercise. Participants were included via the Swedish site of the large global study The Eating Disorders Genetics Initiative (EDGI) and completed measures of both lifetime and current symptomatology.

RESULTS: Results indicate that lifetime maladaptive exercise is associated with higher prevalence of lifetime depression and anxiety and with patients more often receiving treatment, although these results need to be investigated in future studies. Current maladaptive exercise was associated with more severe ED symptoms, and higher levels of depression, anxiety, obsessive-compulsive traits, and suicidal ideation.

CONCLUSIONS: Our findings point to the complexities of exercise as an eating disorder symptom and the need for clearly assessing and acknowledging this, as well as tailoring interventions to treat this symptom to achieve sustainable recovery.

BACKGROUND: Compulsive exercise is common in eating disorders (EDs), but a systematic treatment model is lacking. The CompuLsive Exercise Activity TheraPy (LEAP) is a cognitive behavioral therapy treatment for compulsive exercise in EDs, delivered by trained therapists in groups over four consecutive weeks (8 groupsessions and 1 individual session), aiming to promote healthy physical activity. LEAP is currently evaluated in a randomized efficacy trial. In parallel, it is crucial to learn more about how it is perceived by qualitatively investigating participants' subjective experiences.

METHODS: Nine patients with various EDs participating in the LEAP trial were interviewed about their experiences of taking part in LEAP and about compulsive exercise as an ED symptom using a semi-structured interview guide. The interview transcripts were analyzed according to thematic analysis.

RESULTS: The informants expressed that compulsive exercise had not been addressed in their standard ED treatment and that LEAP as such provided an important complement, spurring reflection, awareness, and changed feelings and behaviors in relation to compulsive exercise. Initially, increased PA was triggered for some, but this side effect was transitory. A wish for more treatment time, in terms of longer or additional sessions, was expressed.

CONCLUSIONS: Overall, LEAP seemed to fill an important treatment need and seemed both acceptable and feasible to patients. However, treatment time and the initial increase in PA may need further investigation and attention in order to optimize this treatment.

TRIAL REGISTRATION: The trial is registered with the ISRCTN registry (registration date 20200325), trial ID ISRCTN80711391.

Objective We assessed eating disorder (ED) illness status, symptomatology, treatment access, anxiety, and depression in the first year of the COVID-19 pandemic among individuals with a pre-existing ED in the United States (US), the Netherlands (NL), and Sweden (SE). Methods Participants completed online surveys in April-July 2020, at the early stage of the pandemic, and one year later. At one-year follow-up, we added questions addressing retrospective changes in ED symptoms, treatment, and anxiety/depression since the start of the COVID-19 pandemic. We present descriptive statistics and assess change in ED symptomatology, treatment, and anxiety/depression among those with an active or lingering ED. Results Participants (US n = 132; NL n = 219; SE n = 702) were mostly young and female with a history of anorexia nervosa (>60% in all three countries). Across countries, respondents reported impact of COVID-19 on ED symptoms at both time points, with improvement in US and NL at one-year follow-up, and stable but less impact on ED symptoms in SE. Furthermore, at one-year follow-up, roughly half of those in treatment reported reduced treatment access and quality, and the majority of the sample reported increased anxiety and depressive mood since the start of the pandemic. Discussion Our findings suggest that the self-perceived impact of COVID-19 changed over time but remained concerning even one year after the start of the pandemic. Clinicians, community organizations, and policy makers are encouraged to address potentially changing treatment needs in the face of public health emergency events. Public Significance Our findings suggest that the impact of COVID-19 on individuals with eating disorders decreased over time but remained concerning even one year after the start of the pandemic and that the impact differed across countries. Clinicians, community organizations, and policy makers are encouraged to incorporate this knowledge to address potentially changing treatment needs in the face of public health emergency events.

Atypical anorexia nervosa (AAN) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM5), is characterized by meeting all criteria for anorexia nervosa (AN) except for weight being within or above the "normal" range despite significant weight loss. The current definition is plagued by several problems, resulting in widely heterogeneous operationalizations in research and clinical practice. As such, the poorly defined diagnosis of AAN negatively impacts affected individuals and frustrates research attempts to better understand the syndrome. We consider conceptual flaws in the AAN description and contend that the undefined weight range and nature of weight loss renders these two factors functionally inapplicable in research and practice. They also represent a departure from the originally intended use of the AAN category, i.e., arresting a negative weight trajectory likely to result in AN, making the target population, and the application of the label, unclear. We propose revised criteria and a new name, restrictive eating disorder (RED), intended to reduce stigma and encompass a wide but better-defined range of presentations. The RED criteria focus on clinically significant restrictive behavior that disrupts normal living (i.e., impairment), and cognitive symptoms of overevaluation, disturbed experience, and lack of recognition of illness seriousness. We believe that RED may enable more appropriate clinical application, but also inspire coordinated research toward a more valid psychiatric nosology in the eating disorders field.

Introduction Binge eating is a common behaviour that is strongly linked to both obesity and eating disorder. There is evidence that binge eating commonly co-occurs with other problematic and addictive-like behaviours; however, this has not been explored systematically. The present study aimed to examine the relationship between binge eating, body weight, disordered eating behaviours and associated addictive-like behaviours, with particular attention paid to gender differences. Method A community sample (N = 500; 75% female, M-age = 32.5 years) reported disordered eating behaviours (i.e. binge eating, purging, restriction of eating, compulsive exercise), body mass index (BMI), food addiction, starvation addiction, exercise dependence, tobacco use and alcohol consumption. Results 42% of females and 21% of males reported binge eating during the past four weeks. Binge eating was significantly associated with all investigated behaviours in females, and with purging, compulsive exercise and overweight/obesity in males. Controlling for BMI, self-starvation predicted binge eating in males (OR = 1.07), while food addiction (OR = 1.73) and alcohol dependence (OR = 1.11) predicted binge eating in females. Conclusions The multiple associations between binge eating and addictive-like behaviors supports broad screening and generalized prevention efforts. Prevention efforts should reflect gender differences.

Introduction Transdiagnostically relevant psychological traits associated with psychiatric disorders are increasingly being researched, notably in substance use and addictive behaviors. We investigated whether emotion dysregulation mediated by impulsivity and/or compulsivity could explain variance in binge eating, food addiction, self-starvation, and compulsive exercise, as well as alcohol use (addictive-like behaviors relevant to the obesity and eating disorder fields). Method A general population sample of adults (N = 500, mean age = 32.5 years), females (n = 376) and males (n = 124), completed the Difficulties in Emotion Regulation Scale-16, the Trait Rash Impulsivity Scale, the Obsessive-Compulsive Inventory-Revised, the Eating Disorders Examination Questionnaire, the Self-Starvation Scale, the Exercise Dependence Scale, the Yale Food Addiction Scale, and the Alcohol Use Disorders Identification Test online. Besides gender comparisons and intercorrelations between measures, we used predefined multiple mediation models with emotion dysregulation as independent variable, impulsivity and compulsivity as parallel mediators, to investigate whether these factors contributed explanatory power to each addictive-like behavior as outcome, also using age and body mass index as covariates. Results Females scored higher than males on emotion dysregulation and the eating-related addictive-like behaviors food addiction, self-starvation, and binge eating. Intercorrelations between measures showed that emotion dysregulation and compulsivity were associated with all outcome variables, impulsivity with all except compulsive exercise, and the eating-related behaviors intercorrelated strongly. Mediation models showed full or partial mediation of emotion dysregulation for all behaviors, especially via compulsivity, suggesting a behavior-specific pattern. Mediation models were not affected by age or gender. Discussion Addictive-like behaviors seemed to be maintained by trait levels of emotion dysregulation, albeit channeled via trait levels of compulsivity and/or impulsivity. The role of emotion dysregulation may help us to understand why addictive-like behaviors can be difficult to change in both clinical and nonclinical groups, and may be informative for treatment-planning in patients where these behaviors are present. Our findings support adopting a more dimensional approach to psychiatric classification by focusing psychological facets such as those studied.

Plain English summary Fitness instructors, coaches and trainers are often looked up to within their sporting community. They are also likely to meet individuals at risk for developing eating disorders, since excessive or compulsive exercise is a common symptom of these disorders. Coaches therefore need to know more about how to promote healthy ideals and how to detect and approach individuals at risk of developing an eating disorder. We studied if a brief online education called I Care could improve personal compulsive exercise tendencies, knowledge about eating disorders, and readiness to approach individuals seemingly at risk, in 150 coaches, trainers, and fitness instructors. We found that coaches felt more confident and knowledgeable about warning signs and how to approach a person at risk after completing I Care. They also showed increased insight about EDs not being recognizable just by looking at a person and their attitudes about their own exercise behavior changed in a positive way. Although the lack of a comparison group makes conclusions tentative, I Care may have positive effects in terms of a "declaration of intent" toward more positive role-modeling and interactions with clients. Background Fitness instructors, coaches and trainers are often looked up to and seen as role-models within their sporting community. Since problematic exercise is a common symptom of eating disorders, they are also highly likely to meet individuals at risk for developing eating disorders within their profession. Thus, educating coaches about how to promote healthy ideals within their sports/training context and equipping them with knowledge to be able to detect and approach individuals at risk, is of great importance. Method We studied the pre-to-post effects of the I Care online psychoeducational intervention in 150 coaches, trainers, and fitness instructors. Variables included the Compulsive Exercise Test, as well as knowledge of eating disorders, and confidence and awareness regarding approaching, talking to, and referring individuals whose observed behavior raised concerns. Results Results showed significant and large improvements in coaches' confidence and knowledge regarding warning signs and how to approach an at-risk person, and a decrease in their perceived ability to recognize eating disorders by sight, e.g., insight about EDs not being recognizable just by looking at a person. Also, significant positive change in attitudes about their own rule-driven exercise behavior and lack of enjoyment of exercise was observed. Conclusions Although the lack of a control group compels caution, the study suggests that I Care may have positive effects in terms of a "declaration of intent" toward more positive role-modeling and interactions with clients.

The Swedish National Patient Register (NPR) includes population-level longitudinal data, and determining the validity of NPR diagnoses is critical to undergirding the research and policy recommendations they inform. Sweden also has the integrated "Riksa & BULL;t " and "Stepwise " National Quality Registers (QR), with data from specialized eating disorder (ED) treatment based on structured, valid assessment methods. To validate NPR ED diagnoses, we compared ICD-10-based anorexia nervosa (AN), bulimia nervosa (BN), and unspecified ED in NPR to DSM-IV-based AN, BN, and ED not otherwise specified category (EDNOS) in QR. Patients' first diagnoses registered in QR between February 2008 and August 2013 were compared with NPR diagnoses entered within & PLUSMN;1 month (N = 2074). QR registration includes the semi-structured DSM-IV-based Structured ED Interview. Each ED diagnosis was analyzed separately for degree of match using several indices: overall agreement, sensitivity, positive predictive value, specificity, negative predictive value, area under the curve, and Cohen's kappa. Results showed moderate to excellent agreement depending on estimate (e.g. positive predictive values AN: 0.747; BN:.836; EDNOS: 0.761), except for a somewhat low sensitivity for BN, and EDNOS agreement was overall the lowest. Case prevalence in the NPR and QR was highly similar for AN, and within five percentage points for BN and EDNOS. Generalizability is hampered by limited age range and diagnostic resolution as well as few males. Available data precluded study of presence/absence of ED, and complementary approaches are considered for future research. We conclude that NPR ED diagnoses have acceptable validity and are appropriate for use in research.