The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Design
2.2. Participants
2.3. The Treatment
2.4. Assessment
- Body weight and BMI: BMI-for-age percentiles were calculated using the Center for Disease Control and Prevention growth charts [16]. (http://www.cdc.gov/growthcharts/percentile_data_files.htm (accessed on 5 May 2022)). To this end, each patient’s weight was measured on a beam balance scale, and their height on a wall-mounted stadiometer. A BMI-for-age percentile with a value < 1 was calculated as 0.5.
- Weight suppression: following Singh et al.’s [17] suggestions, each patient’s developmental weight suppression (DWS) was calculated as the difference between their highest premorbid z-BMI (i.e., BMI z-score) and their current z-BMI. The z-BMIs were calculated using the mean value expected for the patient’s age and standard deviation, via the Pediatric Z-Score Calculator (Children’s Hospital of Philadelphia).
- Eating-disorder features were assessed via the Eating Disorder Examination Questionnaire (EDE-Q, 6th edition, Italian version) [18,19]. The EDE-Q assesses the eating disorder psychopathology over the last 28 days. It includes four subscales (restraint, eating concern, weight concern, and shape concern) and a global score. The internal consistency in our sample was 0.96.
- Functional impairment secondary to the eating disorder was assessed via the Italian version of the Clinical Impairment Assessment (CIA) [22,23]. The CIA refers to last 28 days and the global score refers to the clinical impairment secondary to the eating disorder. The internal consistency in our sample was 0.95.
2.5. Outcome Categories
2.6. Statistical Analysis
3. Results
3.1. The Sample
3.2. Intent-to-Treat Findings at EOT and at a 20-Week Follow-Up
3.2.1. Treatment Completion and Follow-Up
3.2.2. Response to Treatment
3.3. Developmental Weight Suppression as a Predictor of Clinical Outcome
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Lowe, M.R.; Piers, A.D.; Benson, L. Weight Suppression in Eating Disorders: A Research and Conceptual Update. Curr. Psychiatry Rep. 2018, 20, 80. [Google Scholar] [CrossRef] [PubMed]
- Gorrell, S.; Reilly, E.E.; Schaumberg, K.; Anderson, L.M.; Donahue, J.M. Weight suppression and its relation to eating disorder and weight outcomes: A narrative review. Eat. Disord. 2019, 27, 52–81. [Google Scholar] [CrossRef]
- Berner, L.A.; Shaw, J.A.; Witt, A.A.; Lowe, M.R. The relation of weight suppression and body mass index to symptomatology and treatment response in anorexia nervosa. J. Abnorm. Psychol. 2013, 122, 694–708. [Google Scholar] [CrossRef]
- Carter, F.A.; Boden, J.M.; Jordan, J.; McIntosh, V.V.; Bulik, C.M.; Joyce, P.R. Weight suppression predicts total weight gain and rate of weight gain in outpatients with anorexia nervosa. Int. J. Eat. Disord. 2015, 48, 912–918. [Google Scholar] [CrossRef] [PubMed]
- Piers, A.D.; Espel-Huynh, H.M.; Lowe, M.R. The independent and interacting effects of weight suppression and admission body mass index on treatment weight change in patients with anorexia nervosa or bulimia nervosa. Int. J. Eat. Disord. 2019, 52, 1301–1309. [Google Scholar] [CrossRef] [PubMed]
- Wildes, J.E.; Marcus, M.D. Weight suppression as a predictor of weight gain and response to intensive behavioral treatment in patients with anorexia nervosa. Behav. Res. Ther. 2012, 50, 266–274. [Google Scholar] [CrossRef]
- Bodell, L.P.; Racine, S.E.; Wildes, J.E. Examining weight suppression as a predictor of eating disorder symptom trajectories in anorexia nervosa. Int. J. Eat. Disord. 2016, 49, 753–763. [Google Scholar] [CrossRef]
- Uniacke, B.; Attia, E.; Kaplan, A.; Walsh, B.T. Weight suppression and weight maintenance following treatment of anorexia nervosa. Int. J. Eat. Disord. 2020, 53, 1002–1006. [Google Scholar] [CrossRef] [PubMed]
- Witt, A.A.; Berkowitz, S.A.; Gillberg, C.; Lowe, M.R.; Råstam, M.; Wentz, E. Weight suppression and body mass index interact to predict long-term weight outcomes in adolescent-onset anorexia nervosa. J. Consult. Clin. Psychol. 2014, 82, 1207–1211. [Google Scholar] [CrossRef]
- Meierer, K.; Hudon, A.; Sznajder, M.; Leduc, M.F.; Taddeo, D.; Jamoulle, O.; Frappier, J.Y.; Stheneur, C. Anorexia nervosa in adolescents: Evolution of weight history and impact of excess premorbid weight. Eur. J. Pediatr. 2019, 178, 213–219. [Google Scholar] [CrossRef]
- Swenne, I.; Parling, T.; Salonen Ros, H. Family-based intervention in adolescent restrictive eating disorders: Early treatment response and low weight suppression is associated with favourable one-year outcome. BMC Psychiatry 2017, 17, 333. [Google Scholar] [CrossRef] [PubMed]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; (DSM-5™); American Psychiatric Publishing: Arlington, TX, USA, 2013. [Google Scholar]
- Dalle Grave, R. Intensive Cognitive Behavior Therapy for Eating Disorders; Nova, Hauppauge: New York, NY, USA, 2012. [Google Scholar]
- Dalle Grave, R.; Calugi, S. Cognitive Behavior Therapy for Adolescents with Eating Disorders; Guilford Press: New York, NY, USA, 2020. [Google Scholar]
- Fairburn, C.G. Cognitive Behavior Therapy and Eating Disorders; Guilford Press: New York, NY, USA, 2008. [Google Scholar]
- Kuczmarski, R.J.; Ogden, C.L.; Guo, S.S.; Grummer-Strawn, L.M.; Flegal, K.M.; Mei, Z.; Wei, R.; Curtin, L.R.; Roche, A.F.; Johnson, C.L. 2000 CDC Growth Charts for the United States: Methods and development. Vital Health Stat. 2002, 11, 1–190. [Google Scholar]
- Singh, S.; Apple, D.E.; Zhang, F.; Niu, X.; Lowe, M.R. A new, developmentally-sensitive measure of weight suppression. Appetite 2021, 163, 105231. [Google Scholar] [CrossRef] [PubMed]
- Calugi, S.; Milanese, C.; Sartirana, M.; El Ghoch, M.; Sartori, F.; Geccherle, E.; Coppini, A.; Franchini, C.; Dalle Grave, R. The Eating Disorder Examination Questionnaire: Reliability and validity of the Italian version. Eat. Weight. Disord. 2017, 22, 509–514. [Google Scholar] [CrossRef] [PubMed]
- Fairburn, C.G.; Beglin, S.J. Cognitive behavior therapy and eating disorders. In Eating Disorder Examination Questionnaire (EDE-Q 6.0); Fairburn, C.G., Ed.; Guiford Press: New York, NY, USA, 2008; pp. 309–313. [Google Scholar]
- Derogatis, L.R.; Melisaratos, N. The Brief Symptom Inventory: An introductory report. Psychol. Med. 1983, 13, 595–605. [Google Scholar] [CrossRef]
- De Leo, D.; Frisoni, G.B.; Rozzini, R.; Trabucchi, M. Italian community norms for the Brief Symptom Inventory in the elderly. Br. J. Clin. Psychol. 1993, 32 Pt 2, 209–213. [Google Scholar] [CrossRef]
- Bohn, K.; Doll, H.A.; Cooper, Z.; O’Connor, M.; Palmer, R.L.; Fairburn, C.G. The measurement of impairment due to eating disorder psychopathology. Behav. Res. Ther. 2008, 46, 1105–1110. [Google Scholar] [CrossRef]
- Calugi, S.; Sartirana, M.; Milanese, C.; El Ghoch, M.; Riolfi, F.; Dalle Grave, R. The clinical impairment assessment questionnaire: Validation in Italian patients with eating disorders. Eat. Weight. Disord. 2018, 23, 685–694. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization. The Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016–2030). Available online: http://www.who.int/life-course/partners/global-strategy/ewec-globalstrategyreport-200915.pdf?ua=1 (accessed on 5 May 2022).
- Cole, T.J.; Flegal, K.M.; Nicholls, D.; Jackson, A.A. Body mass index cut offs to define thinness in children and adolescents: International survey. BMJ 2007, 335, 194. [Google Scholar] [CrossRef]
- Mond, J.M.; Hay, P.J.; Rodgers, B.; Owen, C. Eating Disorder Examination Questionnaire (EDE-Q): Norms for young adult women. Behav. Res. Ther. 2006, 44, 53–62. [Google Scholar] [CrossRef] [PubMed]
- Bardone-Cone, A.M.; Harney, M.B.; Maldonado, C.R.; Lawson, M.A.; Robinson, D.P.; Smith, R.; Tosh, A. Defining recovery from an eating disorder: Conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behav. Res. Ther. 2010, 48, 194–202. [Google Scholar] [CrossRef] [Green Version]
- Takahashi, M. Statistical Inference in Missing Data by MCMC and Non-MCMC Multiple Imputation Algorithms: Assessing the Effects of Between-Imputation Iterations. Data Sci. J. 2017, 16, 37. [Google Scholar] [CrossRef]
- Raudenbush, S.W.; Bryk, A.S. Hierarchical Linear Models: Applications and Data Analysis Methods, 2nd ed.; Sage Publications, Inc.: Thousand Oaks, CA, USA, 2002. [Google Scholar]
- Shek, D.T.; Ma, C.M. Longitudinal data analyses using linear mixed models in SPSS: Concepts, procedures and illustrations. Sci. World J. 2011, 11, 42–76. [Google Scholar] [CrossRef] [PubMed]
- Singer, J.D.; Willett, J.B. Applied Longitudinal Data Analysis; Oxford Press: New York, NY, USA, 2003. [Google Scholar]
- O’brien, R.M. A Caution Regarding Rules of Thumb for Variance Inflation Factors. Qual. Quant. 2007, 41, 673–690. [Google Scholar] [CrossRef]
- Dalle Grave, R.; Conti, M.; Calugi, S. Effectiveness of intensive cognitive behavioral therapy in adolescents and adults with anorexia nervosa. Int. J. Eat. Disord. 2020, 53, 1428–1438. [Google Scholar] [CrossRef] [PubMed]
- Dalle Grave, R.; Calugi, S.; Doll, H.A.; Fairburn, C.G. Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: An alternative to family therapy? Behav. Res. Ther. 2013, 51, R9–R12. [Google Scholar] [CrossRef]
- Dalle Grave, R.; Calugi, S.; El Ghoch, M.; Conti, M.; Fairburn, C.G. Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: Immediate and longer-term effects. Front. Psychiatry 2014, 5, 14. [Google Scholar] [CrossRef] [PubMed]
- Lowe, M.R. The effects of dieting on eating behavior: A three-factor model. Psychol. Bull. 1993, 114, 100–121. [Google Scholar] [CrossRef] [PubMed]
Age at Presentation (Years) | 16.8 ± 1.5 (Range 14–19) |
---|---|
z-BMI at presentation | −4.01 ± 2.27 (range −14.17–−0.85) |
Age at top weight (years) | 14.7 ± 1.7 (range 8–18) |
z-BMI at top weight | 0.21 ± 0.9 (range −2.34–2.22) |
Duration of ED (years) | 2.2 ± 1.8 (range 0–8) |
Developmental weight suppression | 4.2 ± 2.3 (range 0.37–14.11) |
EDE-Q global score | 3.9 ± 1.4 |
EDE-Q restraint | 3.9 ± 1.7 |
EDE-Q eating concern | 3.3 ± 1.4 |
EDE-Q weight concern | 3.9 ± 1.6 |
EDE-Q shape concern | 4.6 ± 1.5 |
BSI global score | 1.1 ± 0.8 |
CIA global score | 33.8 ± 11.0 |
Mean and (SE) | Analysis of Variance for Repeated Measures | Linear Mixed Model | ||||
---|---|---|---|---|---|---|
Baseline a | End-of-Treatment b | 20-Week Follow-Up c | Pairwise Comparisons * | Linear Growth | Quadratic Growth | |
z-BMI | −4.01 (0.20) | −0.43 (0.06) | −0.97 (0.45) | a < b,c | β = 13.26, t = 9.53, p < 0.001 | β = −11.37, t = −5.56, p < 0.001 |
Eating Disorder Examination Questionnaire | ||||||
Restraint | 4.0 (0.2) | 0.9 (0.2) | 1.1 (0.5) | a < b,c | β = −10.4, t = −6.15, p < 0.001 | β = 8.5, t = 4.19, p = 0.001 |
Eating concern | 3.3 (0.1) | 1.4 (0.1) | 1.5 (0.1) | a < b,c | β = −6.9, t = −12.56, p = 0.001 | β = 5.7, t = 8.67, p = < 0.001 |
Weight concern | 3.9 (0.1) | 2.0 (0.1) | 1.7 (0.1) | a < b< c | β = −2.7, t = −12.39, p = 0.001 | --- |
Shape concern | 4.6 (0.1) | 3.3 (0.1) | 2.7 (0.2) | a < b<c | β = −2.2, t = −9.78, p = 0.001 | --- |
Global score | 3.9 (0.1) | 1.9 (0.1) | 1.7 (0.1) | a < b,c | β = −6.9, t = −12.0, p = 0.001 | β = 5.1, t = 7.86, p < 0.001 |
Brief Symptom Inventory | ||||||
Global score | 2.0 (0.1) | 1.1 (0.1) | 1.1 (0.1) | a < b,c | β = −3.4, t = −9.49, p = 0.001 | β = 2.8, t = 7.07, p = <0.001 |
Clinical Impairment Assessment | ||||||
Global score | 33.8 (1.0) | 16.4 (1.4) | 15.5 (1.9) | a < b,c | β = −62.7, t = −10.4, p = 0.001 | β = 48.0, t = 6.55, p < 0.001 |
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Calugi, S.; Dalle Grave, A.; Conti, M.; Dametti, L.; Chimini, M.; Dalle Grave, R. The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study. Int. J. Environ. Res. Public Health 2023, 20, 3221. https://doi.org/10.3390/ijerph20043221
Calugi S, Dalle Grave A, Conti M, Dametti L, Chimini M, Dalle Grave R. The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study. International Journal of Environmental Research and Public Health. 2023; 20(4):3221. https://doi.org/10.3390/ijerph20043221
Chicago/Turabian StyleCalugi, Simona, Anna Dalle Grave, Maddalena Conti, Laura Dametti, Mirko Chimini, and Riccardo Dalle Grave. 2023. "The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study" International Journal of Environmental Research and Public Health 20, no. 4: 3221. https://doi.org/10.3390/ijerph20043221
APA StyleCalugi, S., Dalle Grave, A., Conti, M., Dametti, L., Chimini, M., & Dalle Grave, R. (2023). The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study. International Journal of Environmental Research and Public Health, 20(4), 3221. https://doi.org/10.3390/ijerph20043221