Table 38 Multimodal inpatient treatment for anorexia nervosa and/or low weight eating disorders
From: Canadian practice guidelines for the treatment of children and adolescents with eating disorders
Certainty assessment | Impact | Certainty | Importance | ||||||
|---|---|---|---|---|---|---|---|---|---|
№ of studies | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | |||
Weight (assessed with: Change in Weight Measures from Admission to Discharge), ED Symptoms (EDE-Q, EDI, EAT), motivational stage of change, laxative use, binge eating | |||||||||
20 | Case Series | very serious a | serious b | not serious | serious c | none | Twenty studies examined change in weight during inpatient treatment for total 1346 patients. Various measures of change in weight used across studies including BMI, absolute weight in KG, %TGW, weight gain per week and % of patients attaining predetermined D/C weight prior to d/c. Seventeen (N = 1319) used BMI as measure of weight. Mean BMI at admission varied from 13.2 to 16.3 between studies. Mean BMI at d/c varied from 16.3 to 19.49. Change in BMI from admission to d/c varied from 1.4 to 4.1. One study (n = 40) reported on mean BMI% change which rose from BMI 8.98 (+/−2.07) to 21.25 (+/− 3.13). Six studies (n = 134) reported mean absolute weight gain during admission which varied from 5.4 to 10.1 kg. Three studies (N = 151) reported mean %TGW change admission to discharge of 10.3 and 10.5%. One study (n = 40) only reported weight outcomes as rate of weight gain per week which was 1.86 kg/wk. with a mean LOS of 20.63 days (SD 13.03). Finally 2 studies reported on the % of patients attaining a pre-determined adequate weight as inpatients with 1 study reporting 76.1% (n = 196) reaching a mean BMI of > 17.63 and 1 study reporting 79.6% (n = 108) attaining > 90%TGW at time of d/c. LOS varied considerably which is likely related to difference in weight change as an inpatient. Mean LOS ranged from 20.10 to 328.5 days between studies. One study noted that longer LOS, lower age at admission and no previous inpatient treatment was associated with greater improvement in BMI. | ⨁◯◯◯ VERY LOW | CRITICAL |
very serious d | serious e | not serious | serious c | all plausible residual confounding would reduce the demonstrated effect | Three studies - Two self-report measures of symptoms were used (EDI-3 and EDE-Q), change reported from admission to discharge. Treatment provided was multimodal. Three studies (total n = 88) reported on EDE-Q. Change in EDE-Q was found to be significant in one of these studies (n = 44, p < 0.05) - this difference was attributed to the restraint and eating concerns subscales. In the other 2 studies there was no difference in EDE scores from admission to discharge. LOS for these studies was a mean of 203 and 115 days. BMI at discharge was higher in the study which found significant change in EDE-Q (ie BMI 19.49 vs 18.5 and BMI% 21.25 at discharge). | ⨁◯◯◯ VERY LOW | CRITICAL | ||
very serious d | serious e | not serious | serious c | all plausible residual confounding would reduce the demonstrated effect | All three studies (total n = 126) reported EAT scores at admission and discharge. Two studies used the EAT-26 and 1 study used the EAT-40. Treatment was multimodal and varied between studies. The difference in EAT score was noted to be statistically different in 2 studies (p < 0.001) and the third study reported a difference of 19 on the EAT-26 pre-post. LOS varied between studies (29.8 days, 91 days and not reported). Mean BMIs at discharge in these 3 studies were 19.2. 18.4 and 16.3. | ⨁◯◯◯ VERY LOW | CRITICAL | ||
very serious f | serious e | not serious | serious g | all plausible residual confounding would reduce the demonstrated effect | One study - Number of patients reporting laxative use, binge/purge, exercise symptoms, even at admission were exceedingly small (ie laxatives 0, bingeing 3, exercise 5). Overall study small (total n = 11 at admission and 7 at discharge). No statistical change noted in any of these outcomes. | ⨁◯◯◯ VERY LOW | IMPORTANT | ||
very serious d | not serious | not serious | serious c | all plausible residual confounding would reduce the demonstrated effect | One study with n = 49 patients and mean LOS 30 days. Change in mean ANSOCQ was statistically significant, however both admission and d/c scores fall into “preparation” phase of motivation and confidence intervals wide (ie admit score 53.6, SD 19.7 and d/c score 62.9, SD 24.5). During the course of the study BMI rose from 15.5 to 18.4. | ⨁◯◯◯ VERY LOW | IMPORTANT | ||
very serious d | serious e | not serious | serious c | strong association all plausible residual confounding would reduce the demonstrated effect | Three studies (n = 353), mean LOS 115 days, 33.61 and 81.9 days respectively, reported on EDI-2 outcomes. One study (LOS 115 days) found no significant change in total or subscales of EDI-2 from admission to discharge. One study (n = 71 and LOS 33.61 days) found statistically significant improvement on Drive for Thinness (13.19 +/− 6.86 at admission and 11.23 +/− 6.52 at discharge, p < 0.05) and Bulimia (1.50 +/− 2.15 at admission and 0.66 +/− 1.08 at discharge, p < 0.05), but no change in Body Dissatisfaction. The final study (n = 238) found statistically significant improvements in global (ES 0.8) and all subscales of the EDI-2. The largest effect size was found for Drive for Thinness (ES = 1.1) and the lowest for “Maturity Fears” (ES = 0.3). | ⨁◯◯◯ VERY LOW | CRITICAL | ||
Weight | |||||||||
1 | Case Study | very serious d | serious e | not serious | serious c | strong association all plausible residual confounding would reduce the demonstrated effect | One case report describing a 17.1 kg wt gain | ⨁◯◯◯ VERY LOW | CRITICAL |