Update: Longitudinal Study

The 19th Annual Meeting of the Eating Disorders Research Society took place on September 19-21, 2013 in Bethesda, Maryland.  Among the winners of the top-five abstract awards was "How Do We Define 'Recovery' from Anorexia Nervosa and Bulimia Nervosa at 25 Years?" This is the first paper out of the 25-year follow-up to Dr. David Herzog's NIMH-funded Longitudinal Study of Anorexia and Bulimia Nervosa.

Eating Disorder Symptoms: Differences among Ethnic Groups

Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, is an internationally renowned expert on eating disorders.  He founded and directed the Harvard Eating Disorders Center, which later became the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital.

Detection of high-risk attitudes and behaviors is critical in the goal of preventing eating disorders. In 1996, the National Eating Disorders Screening Program (NEDSP) was launched on 409 college campuses across the United States. The NEDSP reached a diverse student population and used a self-report screening questionnaire to identify those at risk for eating disorders.  NEDSP participants were offered an opportunity to meet with an on-site counselor to review their responses to the questionnaire in order to receive a recommendation for what, if any, further clinical evaluation would be necessary.

Dr. Herzog and his team analyzed data from 5,435 NEDSP questionnaires for a study of ethnic differences in the prevalence of eating disorder symptoms and related distress. Questionnaire items assessed the presence and frequency of restrictive eating, amenorrhea, binge eating, self-induced vomiting, use of laxatives and diuretics, and potentially problematic exercise behaviors. Three questions were used to measure distress related to the reported symptoms. Participants were asked to select the best response on 4-point scales ranging from ‘‘never’’ to ‘‘all of the time’’ reflecting the degree to which eating and weight concerns (a) caused a great deal of distress, (b) interfered with relationships, and (c) interfered with academic/work performance.

The frequency of binge eating, restrictive eating, vomiting, and amenorrhea

did not differ significantly across ethnic groups.  However, significant between-group differences were found with respect to modes of purging. Binge correlates (such as eating until uncomfortably full) were significantly more frequent among Caucasian than African American participants. Binge eating was the best predictor of distress among Caucasians, African Americans, and Latinos, whereas vomiting was the best predictor of distress among Asians. Asian participants who used laxatives were significantly less likely to receive a recommendation for further evaluation than non-Asian participants.

The findings suggest there may be some important differences among ethnic groups in regard to eating disorder symptoms, symptom-related distress, and likelihood for referral that merit further investigation. Clinician recognition of this

potential diversity may enhance culturally competent care for eating disorders.

Weight Gain, Restoration of Menses, and Bone Density Change in Adolescent Girls with Anorexia Nervosa

Dr. David Herzog—Emeritus Professor of Psychiatry at Harvard Medical School—founded the Harvard Eating Disorders Center in 1994, which later became the Harris Center at Massachusetts General Hospital (MGH).  For over 25 years, Dr. Herzog has collaborated with the Neuroendocrine Unit at MGH to learn more about the biology of eating disorders. This team found that bone loss is a serious complication for most adolescents with anorexia nervosa, placing them at increased risk of debilitating fractures.

 

Dr. Herzog and his colleagues in the Neuroendocrine Unit went on to conduct a prospective, observational study on the effects of weight gain and menstrual recovery on measures of bone mineral density. Sixty-seven girls between the ages of 12 and 18 participated; thirty-four of the girls had anorexia nervosa and 33 were healthy controls. Dual energy x-ray absorptiometry (DXA) was used to measure participants’ lumbar and whole-body bone density at baseline and at 6 and 12 months. 

Weight gain was defined as a 10% increase in body mass index and menstrual recovery as three menses or more in the previous 6 months. The 34 subjects with anorexia were characterized as AN recovered (AN-recovered) if they had both weight gain and menstrual recovery (n=14) and as AN not recovered (AN-not recovered) if they did not have both weight gain and menstrual recovery (n=20). Median duration of recovery was 9 months.

The girls with anorexia had lower spine bone mineral content for bone area and lower whole-body bone area for height, compared with controls.  Weight gain and menstrual recovery in anorexia (AN-recovered) resulted in stabilization of bone mineral density measures, whereas bone density continued to decline in those with anorexia who did not gain weight and resume their menses (AN-not recovered). AN-recovered also predicted greater increases in spine bone mineral content for bone area and whole-body bone area, compared with AN-not recovered.

The data indicate that weight gain and menstrual recovery are associated with a halting of deterioration in bone measures, even in the short term. This raises the question of whether sustained recovery would result in significant increases in bone density parameters. The findings underscore the importance of optimizing weight gain in adolescents with anorexia and highlight the beneficial effects of even short-term weight increase with resumption of menses.

Bone Metabolism in Adolescent Boys with Anorexia Nervosa

For over 25 years, Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, has worked closely with the Neuroendocrine Unit at Massachusetts General Hospital (MGH) to better understand the biology of eating disorders. Research conducted by this team found that bone loss is a serious complication for the majority of adolescent girls and adult women with anorexia nervosa, placing them at increased risk of fracture and permanent disability. 

Dr. Herzog and his team in the Neuroendocrine Unit went on to conduct the first controlled study of bone mineral density in boys with anorexia. Thirty-four boys between the ages of 12 and 19 participated; seventeen of the boys had anorexia nervosa and 17 were healthy controls.  Dual energy x-ray absorptiometry (DXA) was used to measure participants’ bone density. Blood was drawn for IGF-1 (insulin-like growth factor 1); testosterone; SHBG (sex hormone-binding globulin); estradiol (a main form of estrogen); the appetite-regulating hormones ghrelin, PYY, and leptin; and biochemical markers of bone formation and bone resorption. The participants completed questionnaires that assessed their food intake and levels of physical activity.

The boys with anorexia nervosa had lower bone mineral density at the spine, hip, femoral neck, trochanter, intertrochanteric region, and whole body, compared with controls. The hip and its subregions were affected by low bone density at least as severely as the spine. The markers of bone formation and bone resorption were reduced in the boys with anorexia compared with controls, who were in a state of increased bone turnover. Low body mass index and lean mass and low testosterone levels were important predictors of low bone mineral density.

The findings of this study are concerning for low bone mineral density and possibly a decreased rate of bone mass accrual during adolescence, a period characterized by marked increases in  bone accrual toward achievement of peak bone mass. This raises questions regarding bone health and fracture risk in later life. Because body mass index is a key predictor of low bone density, emphasizing weight recovery is critical.

Pregnancy and Eating Disorders

Dr. David Herzog was the first Endowed Professor of Psychiatry in the Field of Eating Disorders at Harvard Medical School. He is board certified in pediatrics, child and adolescent psychiatry and general psychiatry and has treated over 3,000 individuals with anorexia nervosa, bulimia nervosa, and associated diagnoses. Dr. Herzog founded and directed the Harvard Eating Disorders Center, which later became the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital. 

In 1987, Dr Herzog initiated his National Institute of Mental Health-funded Longitudinal Study of Anorexia and Bulimia Nervosa, mapping the course and outcome in 246 women followed at frequent intervals. The Longitudinal Study – the largest and most extensive of its kind – has provided a better understanding of how anorexia and bulimia progress, including rates of recovery and relapse, medical consequences, associated psychiatric illnesses, the quality of patients’ relationships, and functioning at school or at work.

As part of the Longitudinal Study, Dr. Herzog and his team examined the course of pregnancy and neonatal status for babies born to women with eating disorders. Forty-nine live births were included.  The participants were interviewed by trained assistants and completed a brief self-report questionnaire that assessed both birth statistics and birth-related complications. Medical records and/or self-report data describing the babies’ birth status were obtained.

The researchers found that women with eating disorders who regain their health prior to conception and remain nutritionally stable throughout pregnancy are not more prone to obstetrical problems than those who have never had an eating disorder. However, engaging in abnormal weight control behaviors during pregnancy can increase the risk of complications such as miscarriage, premature delivery, Cesarean delivery, low-birth-weight babies, and postpartum depression.

The results of this study emphasized the importance of viewing pregnant women with past or current eating disorders as high risk and monitoring them closely both during and after pregnancy to optimize maternal and fetal outcomes.

Weight Suppression and Bulimia Nervosa

Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, is a renowned expert on eating disorders.  He is a distinguished researcher, teacher, clinician and advocate and is the recipient of many honors and awards. Dr. Herzog was the first Endowed Professor of Psychiatry in the Field of Eating Disorders at Harvard Medical School. In 1994, he founded the Harvard Eating Disorders Center, which later became the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital.

Dr. Herzog collaborated with researchers at Drexel University in Philadelphia to investigate the role of weight suppression in predicting recovery or relapse in bulimia nervosa.  Weight suppression is defined as the difference between a patient’s past highest weight and her weight at entry into the study. The participants were 110 women with bulimia nervosa from Dr. Herzog’s National Institute of Mental Health-funded Longitudinal Study.  At study entry, these 110 participants were, on average, 25 years old and had been ill for an average of 6 years. The researchers collected data by interviewing the women at 6-12 month intervals over 8 years about their eating behaviors, mood symptoms, and general life functioning.

Weight suppression was significantly associated with time to first full remission, indicating that women who were more weight-suppressed at study entry took longer to recover. These results support previous research suggesting that high weight suppression may fuel binge eating and make weight gain more likely. Future research is needed to explore methods of improving treatment outcome for highly weight-suppressed individuals with bulimia nervosa.

Anorexia Nervosa and Stigma

Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, is an internationally respected scholar on eating disorders credited with over 280 publications.  He is board certified in pediatrics, child and adolescent psychiatry, and general psychiatry and has treated over 3,000 individuals with eating disorders such as anorexia and bulimia nervosa. He founded and directed the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital and, prior to that, the Harvard Eating Disorders Center.

Dr. David Herzog and his staff collaborated with Boston University to explore public stigma associated with eating disorders. In 2010, 173 college students were shown one of three videos describing anorexia as a product of either biology, culture, or an interaction between the two. 

Each video ran about 5 minutes and consisted of two parts. All three videos opened with the same two-minute segment, in which an average-weight actress portrays a young woman who has recovered from anorexia. She describes her descent into the disorder and the suffering she experienced while actively ill, including her self-loathing, impaired concentration, physical consequences, obsessionality, and social isolation. She also discusses her attempts to appear fine to the outside world while feeling miserable inside.

The second part of each video varied by condition, but each consisted of a three-minute segment in which a middle-aged actor portrays a doctor who is an expert on anorexia nervosa. In all conditions, the basic structure of the segment was the same, though specific content varied. First, the doctor describes the seriousness of anorexia. Next, he indicates that much debate surrounds the etiology of anorexia but that a great deal of evidence points to the role of (biological/sociocultural/both biological and sociocultural) factors in the development of the disorder. Then, he elaborates the research evidence supporting the roles of (biology/society/an interaction between biology and society) in the development of the disorder.

Finally, in each video, the expert states that anorexia can be treated but often requires a team of doctors and sometimes occurs in the context of hospitalization. He also says that "adequate insurance coverage and other supports for those with this disease are very much needed."

After watching the videos, the participants completed a questionnaire designed to measure which explanation evoked the least stigmatizing attitudes. Those who viewed the interaction video demonstrated less stigma than those who viewed the sociocultural video but more than those who viewed the biology video. The stigma against anorexia tended to be blame-based, meaning that the disorder was seen as the patient’s own doing.  Both the biological and the interaction groups showed more intention to engage in helping behavior than the sociocultural group.

The preponderance of empirical evidence points to anorexia as a product of an interaction between both biology and culture.  More research is needed to learn how to accurately portray the etiology of the disorder while, at the same time, trying to reduce stigma.