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Eating disorders (EDs) are associated with thoughts and emotions leading to disturbances of eating behaviors which can be severe, persistent, and distressing, resulting in psychological and medical complications. We sought to identify common, self-reported triggers for anorexia nervosa (AN) development in adolescents and young adults who are hospitalized for medical stabilization. We also examined socio-demographic and weight-related factors associated with increased risk of certain triggers on this population.
We conducted a retrospective, cross-sectional electronic chart review of youth admitted to Boston Children's Hospital for treatment of the medical complications of AN or Atypical AN. A total of 150 patients, ages 9-19 years were identified between January 2015-February 2020 using ICD-10 billing codes for ED diagnoses or patients who were admitted multiple times during this time period, only their first admission was used for analysis. We reviewed admission notes from medical and psychology clinicians for patient-reported events or triggers for changing their diet/exercise behaviors and/or onset of their eating disorder. Data were coded by two independent reviewers and coding was examined for reliability. We used qualitative thematic analysis to create binary codes for quantitative analyses. We then used binary logistic regression to compare risk factors for triggers.
Among 150 patients, 129 (86%) were female, 120 (80%) White, and 138 (92%) non-Hispanic/Latinx. 140 (93%) patients reported at least one trigger. The average age was 14.1 years (SD=2.27). Seven main triggers were identified: 30% of patients reported experiencing environmental changes (e.g., transitioning schools, divorce, or a terminal medical diagnosis in family members); 29% reported others making comments on the way they looked or ate; 29% stated their own internal perception about their weight and body shape; 19% identified weight-related teasing; 17% reported experiencing changes in their physical activity related to sports; 14% said they received health education about healthy food, exercise, or lifestyle habits; 9% reported experiencing positive reinforcement about changes to their food habits or weight changes, encouraging their ED behaviors. Additionally, 12% reported unintentional weight loss or gain (e.g., from medication, puberty, or illness) as a trigger for their ED behaviors. Regression analyses showed that for every year younger, patients had 1.30x odds of reporting health education (95%CI 1.02-1.64 [p=0.032]) and 1.25x odds of weight-related teasing (95%CI 1.01-1.56 [p=0.042]) as triggers for their ED behaviors when controlling for amount and time of weight loss. A similar trend was seen with age and physician comments about weight, but this was marginally significant (p=0.059). Patients who were older had 1.45x odds of reporting a preceding unintentional weight change as a trigger for their ED (95%CI 1.11-1.89 [p<0.01]).
Our results suggest that individuals may experience various types of triggers for their ED behaviors, allowing for different targets for the prevention of EDs. Those who are younger may be especially vulnerable to messaging via health education and weight-related teasing. These findings highlight the need to improve public health initiatives to promote body positivity and weight inclusivity in not just social aspects, but also in health education and medical care.