POSITION STATEMENT – OCTOBER 18, 2018
A recent paper published in Psychological Medicine journal, titled “Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials,” (https://bit.ly/2x1fWJU) has been greeted with mixed reactions by the eating disorder community. Over the past few weeks F.E.A.S.T. has heard from families and clinicians with concerns that this paper tells us new information: that specialized treatments do not work, and that weight restoration does not improve recovery.
The policy implications of a lower priority for weight restoration and evidence-based interventions would, without a doubt, be serious, if true. We were genuinely curious if this paper meant we needed to reevaluate our core beliefs.
This issue is important to our community. Families are always seeking the best treatments for their loved ones. Some clinicians have reported feeling confused and undermined and that doubt has been cast on them continuing to provide what they are confident, based on science, and experience, works.
“For families doing the hard work of restoring weight and working with treatment providers, the seeds of doubt are so dangerous.” Nicki Wilson, F.E.A.S.T. Chair.
In response to the controversy, the article’s authors published a statement: https://bit.ly/2QpuDNM. We have also been following discussions over the paper’s methodology, and the conclusions being drawn from the meta-analysis. One example, published on September 27, is here: https://bit.ly/2E3GS1m. We understand others are forthcoming.
Based on our conversations with the authors and others in the field, F.E.A.S.T. wants to emphasize that the meta-analysis does not actually address, or change, either of the two issues listed above. It also does not change published results in multiple previous clinical trials supporting the use of evidence-based treatments, and the need for weight restoration. While media reports and some commentators have implied otherwise, the following are still true:
- Findings from this study do not change the commitment to the necessity of weight restoration, ideally to personal growth history, in order for cognitive and behavioral recovery to follow.
- Evidence-based treatments, like FBT and CBT, are indeed effective. While these treatments alone are not sufficient for all patients, they remain the best options as a solid starting point.
Through these discussions with our eating disorder community, we have become aware that many parents felt relieved to think that weight restoration and EBT could be de-emphasized, and have felt marginalized and blamed by other families and by professionals who did not believe them when they said that the solutions they were offered did not work for their families. Regardless of the facts around this paper, this must change. F.E.A.S.T. fully believes that all families struggling with an eating disorder deserve to be heard, supported, and not made to feel ‘less’ for their concerns. These calls for more options, more personalization, and to be believed must be heard and addressed.
F.E.A.S.T. notes that no responsible eating disorder expert has ever promised miraculous automatic and lasting recovery from an eating disorder simply through weight restoration. This myth is unhelpful and unfair to families seeking to support their loved ones. Weight restoration, for those who are malnourished by their eating disorder behaviors, is “necessary but not sufficient” and is only the first step on the way to lasting recovery. While F.E.A.S.T. believes food is medicine we do not promote the idea that food alone cures these dangerous brain disorders.
Evidence-based treatments have never been promoted by our organization, or by any responsible treatment providers or researchers, as the universal answer. We hope that all families facing an ED diagnosis are made aware of and given access to EBTs as the most likely to be helpful option, but every patient and every stage of illness is unique. When we call for EBT we are asking that data, not dogma, guide decision-making and policy.
We have consulted the authors of the paper itself and several of our Advisory Panel. Here are some of their remarks:
“All effective treatment for restrictive eating disorders involves nutritional restoration and, in cases of weight loss or weight suppression, weight restoration to one’s individual historic growth curve. The latest scientific research on eating disorders supports this, as does my clinical experience with individuals suffering from eating disorders.” – Dr. Sarah Ravin Ph.D, F.E.A.S.T. Advisory Panel
“While welcoming any meta-analysis which can contribute to the advancement of knowledge, it is important to understand that this synthesis of evidence takes place against a background of a sparse range of treatments and a still-developing understanding of eating disorders and how best to treat them. This paper suggests that weight restoration in itself is not sustained if not accompanied by psychological improvement, that some of the treatments we have perhaps often get people only halfway there, and that just weight restoration often leads to relapse. There is nothing to disagree with there! However, we know that malnutrition affects thinking and entrenches eating disorder psychopathology even further; we also know we have to address malnutrition even as we engage in the long, slow struggle to recover psychologically from eating disorders, which is what true recovery is. All this paper suggests is that we need to push on to continue to research and deepen our understanding of eating disorders and how treatments work and continue to develop better treatments which can help more people, even while we continue to try to help people to true recovery as best we can.” – Dr Jacinta Tan, F.E.A.S.T. Advisory Panel
“As for biological vs psychological aspects of AN, clearly recovery involves both, and the former generally precedes the latter.” – Rachel Bachner-Melman, PhD, F.E.A.S.T. Advisory Panel
“I find it biologically implausible that some aspects of mood and cognition would be unaffected by adequate weight restoration, given the cascade of hormonal and transmitter changes associated with starvation.” – Dr. Julie O’Toole, F.E.A.S.T. Advisory Panel
“Because most subjects included in this meta-analysis were never adequately weight restored, it is hard to come to any conclusion about the impact of weight restoration or its relationship to cognitive recovery or specialty treatments. However, I agree completely with the authors that our field needs to always continue to move forward and focus on new treatments, adjunctive treatments, and an ever-improving understanding of how our patients’ brains, cognitions, physiologies, and behaviors, can best reach a complete recovery. All patients deserve to achieve an enduring recovery in all of these domains.” – Rebecka Peebles, MD, F.E.A.S.T. Advisory Panel
We believe the most important outcome of the controversy over this meta-analysis is that we have too little research to analyze. This is something that all of us who care about eating disorders must address together. We urgently need to develop treatments to help more patients for whom cognitive and behavioral recovery remain elusive. The actual conclusion of the Psychological Medicine article states:
“As precision medicine initiatives gain momentum, it is imperative that the core mechanisms underpinning psychological (anorexia nervosa) psychopathology are identified and examined.”
The Psychological Medicine paper does not say that weight restoration does not matter. It does. It does not say that evidence-based treatments are not effective. They are. What the paper tells us is that there is insufficient research and we need to do more. We agree.
The Board of Directors of F.E.A.S.T.
The following also individually endorse this letter:
James Lock, MD, PhD
Sarah Ravin Ph.D
Stephanie B.Milstein, Ph.D
Lauren Muhlheim, Psy.D., FAED, CEDS-S
Dr. Mark Warren
Rachel Bachner-Melman, PhD
Dr Jacinta Tan
Rebecka Peebles, MD
CONTACT: Laura Collins Lyster-Mensh, CEO
(540) 227-8518 [email protected]
ALSO PLEASE NOTE THE LETTER TO THE EDITOR IN THE JOURNAL PUBLISHED December 2018