This randomized clinical trial investigates how self-reported symptoms of depression, eating disorders, and binge eating change for adolescents with obesity during an intensive behavioral intervention.
Key Points
Question
How do self-reported symptoms of depression, eating disorders, and binge eating change for adolescents with obesity during an intensive behavioral intervention?
Findings
In this randomized clinical trial of 141 adolescents, symptoms of depression, eating disorders, and binge eating reduced after 4 weeks of a very low energy diet, and this reduction was maintained to 52 weeks after transition to intermittent or continuous energy restriction. A subset of adolescents required additional support for depression and/or disordered eating.
Meaning
Results suggest that obesity treatment interventions may have a dual role of improving physiological and psychosocial health; screening and monitoring for depression and disordered eating are important to facilitate early intervention.
Abstract
Importance
Depression and eating disorders are heightened for adolescents with obesity. Clinical reviews alongside self-report questionnaires are important to ensure appropriate intervention.
Objective
To evaluate changes in self-report symptoms of depression, eating disorders, and binge eating in adolescents with obesity during the Fast Track to Health trial.
Design, Setting, and Participants
This was a randomized clinical trial conducted from 2018 to 2023. It was a multisite trial conducted at children’s hospitals in Sydney, New South Wales, and Melbourne, Victoria, Australia, and included adolescents (13-17 years) with obesity (defined as adult equivalent body mass index ≥30; calculated as weight in kilograms divided by height in meters squared) and 1 or more related complications.
Interventions
Duration was 52 weeks including a very low energy diet for 4 weeks followed by intermittent energy restriction (IER) or continuous energy restriction (CER).
Main Outcomes and Measures
Self-report symptoms of depression (Center for Epidemiologic Studies Depression Scale–Revised 10-Item Version for Adolescents [CESDR-10]; scores 0-30), eating disorders (Eating Disorder Examination Questionnaire [EDE-Q]; scores 0-6), and binge eating (Binge Eating Scale [BES]; scores 0-46) were assessed. Adolescents were screened for depression and eating disorders (weeks 0, 4, 16, and 52) and monitored for the onset of new symptoms of disordered eating during dietetic consults.
Results
Of 141 adolescents (median [IQR] age, 14.8 [12.9-17.9] years; 71 male [50.4%]) enrolled, median baseline EDE-Q score was 2.28 (IQR, 1.43-3.14), median baseline CESDR-10 score was 9.00 (IQR, 4.00-14.50), and median baseline BES score was 11.00 (IQR, 5.00-17.00). There were no differences between groups for change in CESDR-10 (mean difference at week 52, 0.75; 95% CI, −1.86 to 3.37), EDE-Q (mean difference at week 52, 0.02; 95% CI, −0.41 to 0.45), or BES (mean difference at week 52, −2.91; 95% CI, −5.87 to 0.05). The within-group reductions at week 4 were maintained at week 52, for CESDR-10 and EDE-Q, indicating reduced symptoms of depression and eating disorders. Within-group reductions on the BES were maintained in the IER group only. Seventeen adolescents (12.1%) required support or referral for depression and/or disordered eating, including 7 (5%; 5 IER, 2 CER) adolescents who experienced the onset or reemergence of symptoms during the intervention.
Conclusions and Relevance
Results suggest that many treatment-seeking adolescents with obesity self-reported symptoms of depression and eating disorders. Although symptoms reduced for most, some required additional support. Obesity treatment is an opportune time to screen and monitor for depression and disordered eating.
Trial Registration
Australian New Zealand Clinical Trials Registry: ACTRN12617001630303
Introduction
Adolescents with obesity are vulnerable to impaired psychosocial health. Through this life stage, symptoms of depression and eating disorders increase, and adolescents with obesity are at higher risk compared with peers with lower weight. Depression and disordered eating symptoms were exacerbated during the COVID-19 pandemic in adolescents, and obesity prevalence increased. Youth with obesity and disordered eating are likely to experience exacerbated physical and psychological health issues. It is important to understand the proportion of adolescents with obesity who are seeking treatment and experiencing these symptoms and effects of obesity treatment.
Intensive behavioral lifestyle intervention is first-line treatment for adolescents seeking treatment for obesity and associated complications. Systematic reviews have examined change in symptoms of depression and eating disorders after structured pediatric obesity interventions. Meta-analyses indicated a mean reduction in symptoms of depression, binge eating, and shape and weight concerns, with no change in eating concerns or global risk after the intervention. All outcomes were reduced at a follow-up of 14 weeks to 6 years from baseline. Similarly, reductions in binge eating and loss of control eating have been reported after behavioral weight management, pharmacotherapy, and bariatric surgery for adolescent obesity. However, most included studies involved moderate dietary interventions, providing nutrition education alone or with a moderate continuous energy restriction. These findings cannot be extrapolated to more prescriptive dietary interventions or higher levels of energy restriction (eg, very low energy diets [VLEDs] or intermittent energy restriction [IER]), as more restrictive dieting practices have been associated with disordered eating in adolescent community samples. These approaches are recommended for use in adolescents with severe obesity and/or concurrent complications, warranting further investigation.
It is important to understand the effect of obesity treatment on symptoms of depression and disordered eating and how these change over time. This knowledge can be used to inform health services, increasing awareness and understanding of these issues by clinicians, and inform psychological care needs. We aimed to assess change in self-report symptoms of depression, eating disorders, and binge eating during the Fast Track to Health trial.
Methods
Fast Track to Health was a parallel, multicenter, randomized clinical trial conducted in Sydney, New South Wales, and Melbourne, Victoria, Australia, between January 31, 2018, and March 31, 2023. The protocol has been published, was approved by The Sydney Children’s Hospitals Network Human Research Ethics Committee (HREC/17/SCHN/164), and was reported according to the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines. The trial protocol, amendments, and statistical analysis plan are available in Supplement 1, Supplement 2, and Supplement 3, respectively. The primary outcome was change in body mass index (BMI) z score at 52 weeks, reported separately.
Participants
Eligible adolescents were aged 13 to 17 years with obesity (defined as the adult equivalent BMI ≥30; calculated as weight in kilograms divided by height in meters squared) and 1 or more cardiometabolic complications (eg, insulin resistance, hypertension). Agreement to participate was obtained from adolescents and written consent from parents/carers. Information on ethnicity was collected as per standard clinical practice for clinical trials.
Intervention
Fast Track to Health was a 52-week intensive behavioral intervention comparing 2 dietary approaches, IER and continuous energy restriction (CER). In brief, the trial included 3 phases: (1) weeks 0 to 4, VLED (approximately 800 kcal per day); (2) weeks 5 to 16, participants transitioned to IER or CER; and (3) weeks 17 to 52, continued intervention and/or maintenance with reduced support. IER involved 3 energy-restricted days per week (approximately 600-700 kcal per day), and 4 days per week of healthy eating without energy restriction. CER involved tailored energy prescription based on age (13-14 years, 1430-1670 kcal per day; 15-17 years, 1670-1900 kcal per day).
Screening and Monitoring
Participants were screened for depression and eating disorders, using self-report questionnaires at baseline and week 4, 16, and 52 (Figure 1). Participants were monitored for disordered eating by trained study dietitians during each consultation according to a prespecified protocol (Figure 1). If support for depression or disordered eating was needed, this was provided as part of the study or referral to external services as per standard clinical care. Additional support visits for disordered eating were recorded. All adolescents were referred to their primary care practitioner for ongoing care at week 52.
Figure 1. Depression and Eating Disorder Screening and Monitoring Protocol.
CESDR-10 indicates Center for Epidemiologic Studies Depression Scale–Revised 10-Item Version for Adolescents; EDE-Q, Eating Disorder Examination Questionnaire.
Measures
The Center for Epidemiologic Studies Depression Scale–Revised 10-Item Version for Adolescents (CESDR-10; scores 0-30), Eating Disorder Examination Questionnaire (EDE-Q; scores 0-6), and Binge-Eating Scale (BES; scores 0-46) were used. CESDR-10 scores of 8 or greater indicate subthreshold symptoms of depression, with a possible, probable, and major depressive episode, defined by the presence of anhedonia, dysphoria, or irritability with additional symptoms (eTable 1 in Supplement 4). An EDE-Q cutpoint of 2.7 or the presence of disordered eating behaviors was used to identify adolescents at risk of eating disorders (Figure 1). On the BES, a score of 17 or less indicates no binge eating, scores 18 to 26 indicate mild/moderate binge eating, and scores of 27 or greater indicate severe binge eating. The eMethods in Supplement 4 contains additional details.
Statistical Analysis
Statistical analyses were performed using SPSS statistics, version 28.0 (IBM Corp) blinded to group allocation. All participant data were retained, consistent with intention to treat for longitudinal analysis. Linear mixed models, with an autoregressive first-order covariance structure and restricted maximum likelihood, were used to estimate the change in outcomes between baseline and week 4, 16, and 52. Assumptions of modeling were met. Analyses were repeated using an unstructured covariance model as part of sensitivity analyses. A pairwise post hoc comparison was conducted to compare means over time. Results are presented as the difference in estimated marginal means (EMM). Nine sibling pairs were recruited. Analyses were repeated removing 1 participant from each pair, with no differences in results; therefore, all data were retained in analyses. Independent-sample t tests and Mann-Whitney U tests were used to test for differences between continuous variables at baseline, week 4, and week 16 between those who completed and those who did not complete the study. For categorical variables, descriptive statistics were used to describe the number of participants meeting screening criteria at each time point and those above and below prespecified cutpoints at baseline and week 52. These proportions are presented for those with complete data at each time point. The content of additional support visits provided to adolescents was independently coded by 2 authors, with agreement reached through discussion.
Results
In total, 141 adolescents (median [range] age, 14.8 [12.9-17.9] years; 70 female [49.6%]; 71 male [50.4%]) enrolled, and 97 (48 female [49.5%]) completed the 52-week intervention (eFigure 1 in Supplement 4). A total of 117 of the 141 participants (82.9%) were born in Australia, 17 (12.1%) were born in another country, 67 (47.5%) reported 1 or both parents were born outside of Australia, 57 (40.4%) reported speaking a language other than English at home, and 2 (1.4%) identified as Aboriginal or Torres Strait Islander. Seven participants declined to respond. Adolescents had a mean (SD) BMI of 35.39 (4.17; calculated as weight in kilograms divided by height in meters squared) and a BMI z score of 2.40 (0.46) at baseline. At baseline, adolescents had median scores of 9.00 (IQR, 4.00-14.50) on CESDR-10, 2.28 (IQR, 1.43-3.14) on EDE-Q, and 11.00 (IQR, 5.00-17.00) on BES, with no difference between groups.
Depression
Change Over Time
There was an initial reduction in CESDR-10 scores at week 4 (change in EMM IER, −4.23; 95% CI, −5.66 to −2.81; change in EMM CER, −4.99; 95% CI, −6.42 to −3.57) and maintained at week 52 (IER, −2.70; 95% CI, −4.95 to −0.45; CER, −3.87; 95% CI, −5.98 to −1.77) with no difference between groups (mean difference at week 52, 0.75; 95% CI, −1.86 to 3.37) (Table and Figure 2). There were no differences between those who completed and those who did not complete the study at any time point.
Table. Mean Risk Scores for Self-Report Symptoms of Depression, Eating Disorder Risk, and Binge Eating and Difference Between Intervention Groupsa.
| Variable; time | Estimated marginal mean (95% CI) | Difference in means between groups (95% CI) | |
|---|---|---|---|
| IER | CER | ||
| CESDR-10, EMM (95% CI) b | |||
| Baseline | 9.95 (8.39 to 11.51) | 10.37 (8.80 to 11.95) | −0.42 (−2.64 to 1.80) |
| 4 wk | 5.72 (4.11 to 7.32) | 5.38 (3.77 to 6.99) | 0.34 (−1.93 to 2.61) |
| 16 wk | 6.56 (4.89 to 8.22) | 5.28 (3.62 to 6.93) | 1.28 (−1.07 to 3.63) |
| 52 wk | 7.25 (5.32 to 9.19) | 6.50 (4.74 to 8.26) | 0.75 (−1.86 to 3.37) |
| Total EDE-Q, EMM (95% CI) c | |||
| Baseline | 2.40 (2.14 to 2.66) | 2.31 (2.05 to 2.57) | 0.09 (−0.28 to 0.46) |
| 4 wk | 1.73 (1.47 to 2.00) | 1.85 (1.58 to 2.12) | −0.12 (−0.49 to 0.26) |
| 16 wk | 1.76 (1.49 to 2.04) | 1.66 (1.38 to 1.93) | 0.10 (−0.29 to 0.49) |
| 52 wk | 1.77 (1.46 to 2.09) | 1.75 (1.46 to 2.04) | 0.02 (−0.41 to 0.45) |
| Shape concern, EMM (95% CI) | |||
| Baseline | 3.34 (2.96 to 3.71) | 3.24 (2.87 to 3.62) | 0.09 (−0.43 to 0.62) |
| 4 wk | 2.05 (1.67 to 2.43) | 2.14 (1.76 to 2.52) | −0.09 (−0.63 to 0.45) |
| 16 wk | 2.09 (1.70 to 2.48) | 1.82 (1.43 to 2.21) | 0.27 (−0.28 to 0.83) |
| 52 wk | 2.28 (1.83 to 2.73) | 2.06 (1.65 to 2.48) | 0.22 (−0.40 to 0.83) |
| Weight concern, EMM (95% CI) | |||
| Baseline | 3.16 (2.84 to 3.48) | 3.08 (2.76 to 3.40) | 0.08 (−0.37 to 0.53) |
| 4 wk | 1.98 (1.65 to 2.30) | 2.01 (1.69 to 2.34) | −0.04 (−0.50 to 0.42) |
| 16 wk | 2.11 (1.78 to 2.45) | 1.86 (1.53 to 2.19) | 0.25 (−0.22 to 0.73) |
| 52 wk | 2.21 (1.83 to 2.60) | 2.16 (1.80 to 2.51) | 0.06 (−0.47 to 0.58) |
| Eating concern, EMM (95% CI) | |||
| Baseline | 1.62 (1.36 to 1.88) | 1.48 (1.21 to 1.74) | 0.14 (−0.23 to 0.52) |
| 4 wk | 0.72 (0.45 to 0.99) | 0.76 (0.48 to 1.03) | −0.04 (−0.42 to 0.35) |
| 16 wk | 0.97 (0.69 to 1.26) | 0.84 (0.56 to 1.19) | 0.14 (−0.26 to 0.54) |
| 52 wk | 1.09 (0.75 to 1.42) | 1.07 (0.77 to 1.37) | 0.02 (−0.43 to 0.47) |
| Dietary restraint, EMM (95% CI) | |||
| Baseline | 1.48 (1.15 to 1.80) | 1.43 (1.10 to 1.75) | 0.05 (−0.41 to 0.51) |
| 4 wk | 2.18 (1.84 to 2.51) | 2.48 (2.15 to 2.82) | −0.31 (−0.78 to 0.17) |
| 16 wk | 1.89 (1.54 to 2.24) | 2.12 (1.78 to 2.47) | −0.23 (−0.72 to 0.26) |
| 52 wk | 1.57 (1.15 to 1.99) | 1.70 (1.33 to 2.08) | −0.13 (−0.69 to 0.42) |
| BES score, EMM (95% CI) d | |||
| Baseline | 11.85 (10.04 to 13.67) | 11.42 (9.59 to 13.67) | 0.43 (−2.14 to 3.01) |
| 4 wk | 7.47 (5.62 to 9.32) | 7.98 (6.12 to 9.83) | −0.51 (−3.13 to 2.11) |
| 16 wk | 8.08 (6.18 to 9.98) | 7.20 (5.31 to 9.10) | 0.88 (−1.81 to 3.56) |
| 52 wk | 8.13 (5.96 to 10.31) | 11.04 (9.04 to 13.05) | −2.91 (−5.87 to 0.05) |
Abbreviations: BES, Binge Eating Scale; CER, continuous energy restriction; CESDR-10, Center for Epidemiological Studies Depression Scale–Revised 10-Item Version for Adolescents; EDE-Q, Eating Disorder Examination Questionnaire; IER, intermittent energy restriction.
Intention-to-treat analysis using linear mixed models. Values are estimated marginal means (95% CI).
CESDR-10 score ranged from 0 to 30. Total CESDR-10 participant number was 141.
EDE-Q score ranged from 0 to 6 for global scores and subscales. Total EDE-Q participant number was 141.
BES score ranged 0 to 46 (0-17 no binge eating; 18-26 mild/moderate binge eating; ≥27 severe binge eating). Total BES participant number was 139.
Figure 2. Change in Symptoms of Depression Between Baseline and Week 52.
Total number of participants analyzed was 141. Values are estimated marginal means (95% CI). Shaded area represents the 4-week very low energy diet phase of the trial. CER indicates continuous energy restriction; CESDR-10, Center for Epidemiologic Studies Depression Scale–Revised 10-Item Version for Adolescents; EMM, estimated marginal means; IER, intermittent energy restriction.
Symptom Classification
At baseline, 31 of 141 adolescents (22%) were classified as having a possible, probable, or major depressive episode in the 7 days before enrollment (eTable 2 and eFigure 2 in Supplement 4), with 47 (33%) reporting subthreshold symptoms. At week 52, the proportion of adolescents who completed the study classified as having a possible, probable, or major depressive episode was 8 of 92 (9%), with 60 (65%) reporting no symptoms. Five adolescents (5%; 1 IER, 4 CER) who reported no symptoms of depression at baseline had an increase in scores. Four adolescents reported subthreshold symptoms of depression, and 1 adolescent, with long-standing depression, met criteria for a probable depressive episode in the past 7 days.
Eating Disorders
Change Over Time
There was an initial reduction in EDE-Q global score at week 4 (IER, −0.67; 95% CI, −0.89 to −4.44; CER, −0.46; 95% CI, −0.68 to −0.24) and maintained at week 52 (IER, −0.63; 95% CI, −0.97 to −0.26; CER, −0.56; 95% CI, −0.89 to −0.22) with no difference between groups (mean difference at week 52, 0.02; 95% CI, −0.41 to 0.45) (Table and Figure 3A). There were no differences between those who completed and those who did not complete the study at any time point.
Figure 3. Change in Symptoms of Eating Disorders and Binge Eating Between Baseline and Week 52.
A, Eating disorders between baseline and week 52. B, Binge eating between baseline and week 52. Values are estimated marginal means (95% CI). Shaded area represents the 4-week very low energy diet phase of the trial. Total number of participants was 141 for the Eating Disorder Examination Questionnaire (EDE-Q) and 139 for the Binge Eating Scale (BES). CER indicates continuous energy restriction; EMM, estimated marginal means; IER, intermittent energy restriction.
Subscale Scores
At week 4, there was an initial reduction in subscale scores for shape (IER, −1.28; 95% CI, −1.59 to −0.98; CER, −1.10; 95% CI, −1.41 to −0.79), weight (IER, −1.19; 95% CI, −1.46 to −0.91; CER, −1.06; 95% CI, −1.34 to −0.79), and eating concern (IER, −0.90; 95% CI, −1.17 to −0.63; CER, −0.72; 95% CI, −1.00 to −0.45), which were maintained at week 52, with no difference between groups (Table and Figures 4A-C). Dietary restraint increased at week 4 (IER, 0.70; 95% CI, 0.34-1.06; CER, 1.05; 95% CI, 0.69-1.42]), returning to baseline by week 52 with no difference between groups (Table and Figure 3D).
Figure 4. Change in Shape Concern, Weight Concern, Eating Concerns, and Dietary Restraint Subscales of the Eating Disorder Examination Questionnaire (EDE-Q) Between Baseline and Week 52.
A, Shape concern. B, Weight concern. C, Eating concern. D, Dietary restraint. Values are estimated marginal means (95% CI). Shaded area represents the 4-week very low energy diet phase of the trial (total participants, n = 141). CER indicates continuous energy restriction; EMM, estimated marginal means; IER, intermittent energy restriction.
Disordered Eating Symptoms
At baseline, 110 of 141 adolescents (78%) reported any symptom of disordered eating as defined in Figure 1. Overeating (94 of 141 [67%]), binge eating (70 of 141 [50%]), and loss of control (58 of 141 [41%]) were most frequently reported (eTable 2 and eFigure 3 in Supplement 4). At week 52, the proportion of participants who completed the study and reported any symptom of disordered eating was 56 of 92 (61%).
EDE-Q Cutpoint
For those who completed the study and using an EDE-Q cutpoint of 2.7, a total of 51 adolescents (55%) remained below the cutpoint for the duration of the trial, and 8 (9%) remained above the cutpoint. There were 25 adolescents (27%) who had scores of 2.7 or greater at baseline but did not at week 52. A total of 8 adolescents (9%; 3 IER, 5 CER) had an increase in scores from less than 2.7 at baseline to 2.7 or greater at week 52. Of the 8 adolescents who had increased scores, 4 had psychological comorbidity at baseline and were already engaged with, or referred to, external psychological support. The remaining 4 adolescents were not identified as having overt concerns with disordered eating, although strategies to manage overeating were discussed.
Binge Eating
Change Over Time
At 4 weeks, there was a reduction in BES scores (IER, −4.38; 95% CI, −5.93 to −2.83; CER, −3.44; 95% CI, −5.00 to −1.88), maintained in IER at 52 weeks (−3.72; 95% CI, −6.20 to −1.24) but not CER (−0.38; 95% CI, −2.71 to 1.96), with no difference between groups (mean difference at week 52, −2.91; 95% CI, −5.87 to 0.05) (Table and Figure 3B). There were no differences between those who completed and those who did not complete the study at any time point.
Binge-Eating Classification
At baseline, 28 adolescents (21%) were classified as having mild/moderate or severe binge eating (eTable 2 and eFigure 4 in Supplement 4). At week 52, 15 of 92 adolescents (16%) who completed the study reported mild/moderate or severe binge eating. Sixty-five adolescents (71%) reported no binge eating at baseline and week 52. Four adolescents (4%) reported mild/moderate binge eating at both time points. Ten adolescents (11%) with mild/moderate binge eating and 2 (2%) with severe binge eating at baseline reported no binge eating at week 52. Ten adolescents (11%) experienced an increase in binge eating, with 8 (4 in each group) categorized as not binge eating at baseline moved to mild/moderate (n = 6) or severe (n = 2) binge eating at week 52. Two adolescents (CER group) increased from mild/moderate to severe binge eating. Of the 10 adolescents with an increase in binge eating, 5 had other mental health comorbidities identified at baseline or during the trial (eg, autism spectrum disorder, depression, anxiety, mild uncontrolled eating) and were referred for external psychological support or provided with additional support during the trial. On further assessment, 5 adolescents were not identified as having overt binge-eating symptoms; overeating behaviors were discussed with 3 adolescents.
Outcome of Screening and Monitoring
Seventeen adolescents (12.1%) required support or referral for depression and/or disordered eating.
Screening Questionnaires
At baseline, 7 adolescents (5%) were identified as requiring support for disordered eating and 4 (2.8%) for depression. This was provided during the trial if they were not already engaged with external support. At week 52, 2 of the adolescents who were identified at baseline and 1 additional adolescent required referral for ongoing psychological support for disordered eating.
Dietetic Monitoring
Seven of 141 adolescents (5%, all female; 5 IER; 2 CER) were identified via dietetic monitoring as requiring additional support for disordered eating or body image concerns. They received a median of 3 (range, 1-9) additional sessions with the dietitian, clinical psychologist, and/or pediatrician, often with multidisciplinary input. Additional support was mostly provided during phase 3 of the study, when scheduled reviews reduced. Of those requiring additional support, 1 adolescent had mild body image concerns after a sports injury, with no disordered eating concerns. Two adolescents had support for meal skipping with mild body image concerns or secret eating, together with excess weighing, both in the context of requiring psychological support from baseline for anxiety and social difficulties, respectively. One adolescent had additional support to address body dissatisfaction and rigidity around diet and exercise. Three adolescents received additional support for restriction or rigidity around eating, with rapid weight loss; 2 of these adolescents had a medical review for amenorrhea, which resolved during the trial.
Adverse Events
Two adolescents had adverse events related to mental health and were withdrawn. One adolescent was withdrawn at week 14 after the reemergence of prior body image concerns and related poor self-esteem. The second adolescent was diagnosed with atypical anorexia nervosa associated with excess restriction and rapid weight loss (identified via monitoring protocol, as reported previously), despite transition to weight maintenance plan, and was withdrawn at week 22 as a severe adverse event. This occurred during the COVID-19 pandemic when review appointments were predominantly conducted virtually. Both adolescents received ongoing mental health care.
Discussion
The aim of these analyses was to evaluate changes in self-reported symptoms of depression, eating disorders, and binge eating during the Fast Track to Health trial. At baseline, over one-half of adolescents reported some symptoms of depression and/or eating disorders, with 21% reporting mild, moderate, or severe binge eating. Mean scores on the CESDR-10, EDE-Q, and BES scales were reduced at week 4, after the VLED phase, and maintained at week 52 for depression and eating disorder risk, with no difference between groups. The reduction in BES score at week 4 was only maintained in the IER group at 52 weeks. A proportion of adolescents (12.1%) required additional support for depression or disordered eating, identified through self-report questionnaires or dietetic monitoring, with support for appropriate early intervention. One adolescent developed an eating disorder, occurring during the COVID-19 lockdown restrictions, making it difficult to isolate the influence of the intervention. Overall, participation in intensive behavioral interventions using a prescriptive dietary approach did not worsen mental health or eating behaviors. Indeed, an improvement in self-report symptoms was seen alongside relative reductions in BMI, and improved blood pressure percentile, total cholesterol level, and triglyceride level in both groups. This is particularly important as the trial was predominantly undertaken during the COVID-19 pandemic, with intermittent lockdowns and other public health restrictions, which also impacted adolescent depression, disordered eating, and BMI.
Symptoms of depression and disordered eating reduced, and did not increase, during the intervention, which is consistent with prior reviews and trials of alternate-day fasting and time-limited eating in adults and adolescents. Interestingly, the greatest reduction in scores occurred after the VLED phase, with no further reduction after transition to CER and IER. These outcomes have scarcely been measured during adolescent VLED interventions. Findings are consistent with adult VLED trials that show reduced binge eating, but are in contrast to longitudinal studies in adolescents showing higher degrees of energy restriction, are associated with disordered eating. Given the short 4-week VLED phase, it is difficult to speculate why this initial improvement was seen. It is possible that the initial reduction in BMI, together with frequent support, improved mental well-being. However, eating disorders can take several years to emerge. Further research is needed on mental health effects of VLED interventions and maintenance beyond 1 year.
Although adolescence is a time of increased prevalence of depression and disordered eating, and symptoms increased during COVID-19 pandemic, few adolescents had increased symptoms during the trial. Those who experienced elevated symptoms often had other mental health concerns at enrollment. To our knowledge, few studies have reported the onset of eating disorders during adolescent obesity treatment. One trial reported 2 cases of eating disorders from 125 adolescents receiving liraglutide, 3.0 mg, with lifestyle therapy, and another reported 3 cases of binge eating disorder at 6-year follow-up of a behavioral program. More data are needed to understand the proportion of adolescents who may be at risk of eating disorders while receiving obesity treatment. Addressing participants’ mental health within obesity programs, or enabling concurrent referral for psychological support, is important to support holistic health of adolescents during weight management.
Prescriptive dietary interventions, such as those used in this trial, are considered dieting behaviors that may precede eating disorder development. Dietary restraint scores increased during the intervention period, as might be expected due to the energy restriction targets, and returned to baseline at 52 weeks. Given that shape concern, weight concern, and depression all reduced during this time, the transient increase in dietary restraint is unlikely to represent ongoing problematic eating. Additionally, mean dietary restraint scores remained well below those of clinical samples of adolescents (4.00) or adults (4.17) with anorexia nervosa, even after the VLED phase of the intervention (2.18, IER group; 2.48, CER group) (Table). At 52 weeks, mean dietary restraint scores had returned to baseline and were similar to community norms for adolescent girls. This suggests that dietary prescription in the context of a multidisciplinary care poses less risk than when undertaken without supervision in the community. We speculate that this is due to the multidisciplinary nature of the intervention and frequency of support provided by trained clinicians. However, further research is needed to directly compare different dietary interventions, no-treatment controls, and community samples to understand the association between different diets and eating disorder risk.
Use of self-report questionnaires to screen for depression and eating disorders, particularly at baseline, enabled adolescents requiring support to receive this early. Clinical monitoring for emergence of disordered eating during dietetic reviews enabled a subgroup of adolescents with potentially problematic behaviors to be identified and assessed. Of note, some symptoms identified during dietetic monitoring, including rigidity and obsessionality or fixation with numerical changes, eg, weight and calories, are not included in the EDE-Q, with different adolescents identified by each approach. This highlights the need for regular contact with clinicians who can verbally assess behaviors. Screening and monitoring for depression and eating disorders as part of obesity treatment facilitates opportunistic identification of a high-risk group that infrequently accesses health services. Identification of adolescents at risk may enable clinicians to facilitate access to mental health services, resulting in the provision of additional support. Initiating treatment of potential triggers or contributors to obesity may also support weight management attempts or improve treatment outcomes. It is important to ensure that clinicians can interpret self-report questionnaires and use them to guide clinical decision making. Additionally, the time, resources, and availability of services are important considerations in evaluating feasibility of conducting universal screening and monitoring in a clinical setting.
Strengths and Limitations
Our study has several strengths. This was the first, to our knowledge, in-depth study of depression and eating-disorder symptoms in treatment-seeking, culturally diverse, Australian adolescents with obesity and concurrent complications. Structured screening and monitoring procedures were used with evidence-based, predefined cutpoints.
This study also has limitations. Data presented are secondary analyses using self-report measures, therefore, results should be interpreted with caution. Two of the 4 subscales within the EDE-Q relate to body dissatisfaction, which is elevated in adolescents with obesity, and a third includes dietary restriction, which is a component of the intervention. Adolescents also reported misunderstanding questions on the EDE-Q. For example, participants reported occasions of overeating based on consuming a somewhat larger portion size at main meals compared with other family members or peers. Questions related to vomiting were sometimes misunderstood, eg, vomiting due to migraines or gastroesophageal reflux were reported but were not self-induced vomiting. Although the EDE-Q is validated for use in adolescents, a youth-specific version of this questionnaire or more recently validated short eating-disorder assessments for youth, may improve screening in future trials. The trial was mainly undertaken during the COVID-19 pandemic. Therefore, an increase in self-reported depression and disordered eating during this time could be due to the intervention or the COVID-19 pandemic and differentiation between these is not possible.
Conclusions
In this randomized clinical trial, adolescents with obesity who were seeking treatment self-reported symptoms of depression, eating disorders, and/or binge eating. Symptoms reduced for most adolescents, concurrent with BMI reduction, highlighting a potential dual role of obesity treatment in improving mental as well as physical health. A subgroup of adolescents were identified as needing additional support for depression or disordered eating with some experiencing increased symptoms during the intervention. Approaches to screening and monitoring using a combination of questionnaires and clinician assessment appear important. Treatment practitioners should have mechanisms in place for identification and management of changes in psychopathology in adolescents seeking obesity treatment. Although obesity services may present an opportune time to support adolescent mental health, appropriate training, time, and resourcing is needing to implement this into practice.
Trial Protocol.
Trial Protocol Amendments.
Statistical Analysis Plan.
eMethods. Screening
eTable 1. The Center for Epidemiologic Studies Depression Scale–Revised 10-Item Version for Adolescents Cut Points Based on the Scoring Described by Haroz et al
eFigure 1. CONSORT Figure
eTable 2. Proportion of Adolescents With Symptoms of Depression, Eating Disorders, and Binge Eating and Change Over Time by Group
eFigure 2. Proportion of Adolescents Meeting Depression Screening Criteria Over Time, All Participants Combined
eFigure 3. Proportion of Adolescents Meeting Eating Disorder Screening Criteria Over Time, All Participants Combined
eFigure 4. Proportion of Adolescents Meeting Binge Eating Scale Criteria Over Time, All Participants Combined
eReferences
Data Sharing Statement.
References
- 1.Jebeile H, Cardel MI, Kyle TK, Jastreboff AM. Addressing psychosocial health in the treatment and care of adolescents with obesity. Obesity (Silver Spring). 2021;29(9):1413-1422. doi: 10.1002/oby.23194 [DOI] [PubMed] [Google Scholar]
- 2.Rawana JS, Morgan AS. Trajectories of depressive symptoms from adolescence to young adulthood: the role of self-esteem and body-related predictors. J Youth Adolesc. 2014;43(4):597-611. doi: 10.1007/s10964-013-9995-4 [DOI] [PubMed] [Google Scholar]
- 3.Natsuaki MN, Biehl MC, Ge X. Trajectories of depressed mood from early adolescence to young adulthood: The effects of pubertal timing and adolescent dating. J Res Adolesc. 2009;19(1):47-74. doi: 10.1111/j.1532-7795.2009.00581.x [DOI] [Google Scholar]
- 4.Slane JD, Klump KL, McGue M, Iacono WG. Developmental trajectories of disordered eating from early adolescence to young adulthood: a longitudinal study. Int J Eat Disord. 2014;47(7):793-801. doi: 10.1002/eat.22329 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Neumark-Sztainer D, Wall M, Larson NI, Eisenberg ME, Loth K. Dieting and disordered eating behaviors from adolescence to young adulthood: findings from a 10-year longitudinal study. J Am Diet Assoc. 2011;111(7):1004-1011. doi: 10.1016/j.jada.2011.04.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Wang S, Chen L, Ran H, et al. Depression and anxiety among children and adolescents pre and post COVID-19: a comparative meta-analysis. Front Psychiatry. 2022;13:917552. doi: 10.3389/fpsyt.2022.917552 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Ludwig-Walz H, Dannheim I, Pfadenhauer LM, Fegert JM, Bujard M. Increase of depression among children and adolescents after the onset of the COVID-19 pandemic in Europe: a systematic review and meta-analysis. Child Adolesc Psychiatry Ment Health. 2022;16(1):109. doi: 10.1186/s13034-022-00546-y [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Miskovic-Wheatley J, Koreshe E, Kim M, Simeone R, Maguire S. The impact of the COVID-19 pandemic and associated public health response on people with eating disorder symptomatology: an Australian study. J Eat Disord. 2022;10(1):9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.McLean CP, Utpala R, Sharp G. The impacts of COVID-19 on eating disorders and disordered eating: a mixed-studies systematic review and implications. Front Psychol. 2022;13:926709. doi: 10.3389/fpsyg.2022.926709 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Chang TH, Chen YC, Chen WY, et al. Weight gain associated with COVID-19 lockdown in children and adolescents: a systematic review and meta-analysis. Nutrients. 2021;13(10):3668. doi: 10.3390/nu13103668 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Hayes JF, Fitzsimmons-Craft EE, Karam AM, Jakubiak J, Brown ML, Wilfley DE. Disordered eating attitudes and behaviors in youth with overweight and obesity: implications for treatment. Curr Obes Rep. 2018;7(3):235-246. doi: 10.1007/s13679-018-0316-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.McMaster CM, Paxton SJ, Maguire S, et al. The need for future research into the assessment and monitoring of eating disorder risk in the context of obesity treatment. Int J Eat Disord. 2023;56(5):914-924. doi: 10.1002/eat.23898 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Jebeile H, Kelly AS, O’Malley G, Baur LA. Obesity in children and adolescents: epidemiology, causes, assessment, and management. Lancet Diabetes Endocrinol. 2022;10(5):351-365. doi: 10.1016/S2213-8587(22)00047-X [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Lister NB, Baur LA, Felix JF, et al. Child and adolescent obesity. Nat Rev Dis Primers. 2023;9(1):24. doi: 10.1038/s41572-023-00435-4 [DOI] [PubMed] [Google Scholar]
- 15.Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640. doi: 10.1542/peds.2022-060640 [DOI] [PubMed] [Google Scholar]
- 16.Jebeile H, Gow ML, Baur LA, Garnett SP, Paxton SJ, Lister NB. Treatment of obesity, with a dietary component, and eating disorder risk in children and adolescents: a systematic review with meta-analysis. Obes Rev. 2019;20(9):1287-1298. doi: 10.1111/obr.12866 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Jebeile H, Gow ML, Baur LA, Garnett SP, Paxton SJ, Lister NB. Association of pediatric obesity treatment, including a dietary component, with change in depression and anxiety: a systematic review and meta-analysis. JAMA Pediatr. 2019;173(11):e192841. doi: 10.1001/jamapediatrics.2019.2841 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Moustafa AF, Quigley KM, Wadden TA, Berkowitz RI, Chao AM. A systematic review of binge eating, loss of control eating, and weight loss in children and adolescents. Obesity (Silver Spring). 2021;29(8):1259-1271. doi: 10.1002/oby.23185 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.King JE, Jebeile H, Garnett SP, Baur LA, Paxton SJ, Gow ML. Physical activity–based pediatric obesity treatment, depression, self-esteem, and body image: a systematic review with meta-analysis. Ment Health Phys Act. 2020;19:100342. doi: 10.1016/j.mhpa.2020.100342 [DOI] [PubMed] [Google Scholar]
- 20.Gow ML, Tee MSY, Garnett SP, et al. Pediatric obesity treatment, self-esteem, and body image: A systematic review with meta-analysis. Pediatr Obes. 2020;15(3):e12600. doi: 10.1111/ijpo.12600 [DOI] [PubMed] [Google Scholar]
- 21.House ET, Gow ML, Lister NB, et al. Pediatric weight management, dietary restraint, dieting, and eating disorder risk: a systematic review. Nutr Rev. 2021;79(10):1114-1133. doi: 10.1093/nutrit/nuaa127 [DOI] [PubMed] [Google Scholar]
- 22.Hoare JK, Jebeile H, Garnett SP, Lister NB. Novel dietary interventions for adolescents with obesity: a narrative review. Pediatr Obes. 2021;16(9):e12798. doi: 10.1111/ijpo.12798 [DOI] [PubMed] [Google Scholar]
- 23.Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later? J Am Diet Assoc. 2006;106(4):559-568. doi: 10.1016/j.jada.2006.01.003 [DOI] [PubMed] [Google Scholar]
- 24.Alman KL, Lister NB, Garnett SP, Gow ML, Aldwell K, Jebeile H. Dietetic management of obesity and severe obesity in children and adolescents: a scoping review of guidelines. Obes Rev. 2021;22(1):e13132. doi: 10.1111/obr.13132 [DOI] [PubMed] [Google Scholar]
- 25.Gow ML, Pham-Short A, Jebeile H, Varley BJ, Craig ME. Current perspectives on the role of very-low-energy diets in the treatment of obesity and type 2 diabetes in youth. Diabetes Metab Syndr Obes. 2021;14:215-225. doi: 10.2147/DMSO.S238419 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Lister NB, Jebeile H, Truby H, et al. Fast track to health—intermittent energy restriction in adolescents with obesity: a randomized controlled trial study protocol. Obes Res Clin Pract. 2020;14(1):80-90. doi: 10.1016/j.orcp.2019.11.005 [DOI] [PubMed] [Google Scholar]
- 27.Lister NB, Baur LA, House ET, et al. Intermittent energy restriction for adolescents with obesity: the Fast Track to Health randomized clinical trial. JAMA Pediatr. Published online August 26, 2024. doi: 10.1001/jamapediatrics.2024.2869 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Cole TJ, Lobstein T. Extended international (IOTF) body mass index cutoffs for thinness, overweight, and obesity. Pediatr Obes. 2012;7(4):284-294. doi: 10.1111/j.2047-6310.2012.00064.x [DOI] [PubMed] [Google Scholar]
- 29.Eaton WW, Smith C, Ybarra M, Muntaner C, Tien A. Center for Epidemiologic Studies Depression Scale: review and revision (CESD and CESD-R). In: Maruish ME, ed. The Use of Psychological Testing for Treatment Planning and Outcomes Assessment: Instruments for Adults. 3rd Ed. Lawrence Erlbaum Associates Publishers; 2004:363-377. [Google Scholar]
- 30.Haroz EE, Ybarra ML, Eaton WW. Psychometric evaluation of a self-report scale to measure adolescent depression: the CESDR-10 in 2 national adolescent samples in the US. J Affect Disord. 2014;158:154-160. doi: 10.1016/j.jad.2014.02.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994;16(4):363-370. doi: [DOI] [PubMed] [Google Scholar]
- 32.Gormally J, Black S, Daston S, Rardin D. The assessment of binge eating severity among obese persons. Addict Behav. 1982;7(1):47-55. doi: 10.1016/0306-4603(82)90024-7 [DOI] [PubMed] [Google Scholar]
- 33.Rø Ø, Reas DL, Stedal K. Eating Disorder Examination Questionnaire (EDE-Q) in Norwegian adults: discrimination between female controls and eating disorder patients. Eur Eat Disord Rev. 2015;23(5):408-412. doi: 10.1002/erv.2372 [DOI] [PubMed] [Google Scholar]
- 34.Decaluwé V, Braet C. Assessment of eating disorder psychopathology in obese children and adolescents: interview vs self-report questionnaire. Behav Res Ther. 2004;42(7):799-811. doi: 10.1016/j.brat.2003.07.008 [DOI] [PubMed] [Google Scholar]
- 35.Goldschmidt AB, Doyle AC, Wilfley DE. Assessment of binge eating in overweight youth using a questionnaire version of the Child Eating Disorder Examination With Instructions. Int J Eat Disord. 2007;40(5):460-467. doi: 10.1002/eat.20387 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.House ET, Lister NB, Seidler AL, et al. Identifying eating disorders in adolescents and adults with overweight or obesity: a systematic review of screening questionnaires. Int J Eat Disord. 2022;55(9):1171-1193. doi: 10.1002/eat.23769 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ. Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behav Res Ther. 2004;42(5):551-567. doi: 10.1016/S0005-7967(03)00161-X [DOI] [PubMed] [Google Scholar]
- 38.Mond JM, Myers TC, Crosby RD, et al. Screening for eating disorders in primary care: EDE-Q vs SCOFF. Behav Res Ther. 2008;46(5):612-622. doi: 10.1016/j.brat.2008.02.003 [DOI] [PubMed] [Google Scholar]
- 39.Hoddy KK, Kroeger CM, Trepanowski JF, Barnosky AR, Bhutani S, Varady KA. Safety of alternate day fasting and effect on disordered eating behaviors. Nutr J. 2015;14(1):44. doi: 10.1186/s12937-015-0029-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Vizthum D, Katz SE, Pacanowski CR. The impact of time restricted eating on appetite and disordered eating in adults: a mixed-methods systematic review. Appetite. 2023;183:106452. doi: 10.1016/j.appet.2023.106452 [DOI] [PubMed] [Google Scholar]
- 41.Vidmar AP, Naguib M, Raymond JK, et al. Time-limited eating and continuous glucose monitoring in adolescents with obesity: a pilot study. Nutrients. 2021;13(11):3697. doi: 10.3390/nu13113697 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Andela S, Burrows TL, Baur LA, Coyle DH, Collins CE, Gow ML. Efficacy of very low-energy diet programs for weight loss: a systematic review with meta-analysis of intervention studies in children and adolescents with obesity. Obes Rev. 2019;20(6):871-882. doi: 10.1111/obr.12830 [DOI] [PubMed] [Google Scholar]
- 43.da Luz FQ, Hay P, Gibson AA, et al. Does severe dietary energy restriction increase binge eating in overweight or obese individuals: a systematic review. Obes Rev. 2015;16(8):652-665. doi: 10.1111/obr.12295 [DOI] [PubMed] [Google Scholar]
- 44.Stice E, Van Ryzin MJ. A prospective test of the temporal sequencing of risk factor emergence in the dual pathway model of eating disorders. J Abnorm Psychol. 2019;128(2):119-128. doi: 10.1037/abn0000400 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Kelly AS, Auerbach P, Barrientos-Perez M, et al. ; NN8022-4180 Trial Investigators . A randomized, controlled trial of liraglutide for adolescents with obesity. N Engl J Med. 2020;382(22):2117-2128. doi: 10.1056/NEJMoa1916038 [DOI] [PubMed] [Google Scholar]
- 46.Goossens L, Braet C, Verbeken S, Decaluwé V, Bosmans G. Long-term outcome of pediatric eating pathology and predictors for the onset of loss of control overeating following weight-loss treatment. Int J Eat Disord. 2011;44(5):397-405. doi: 10.1002/eat.20848 [DOI] [PubMed] [Google Scholar]
- 47.Lister NB, Baur LA, Paxton SJ, et al. Eating disorders in weight-related therapy (EDIT) collaboration: rationale and study design. Nutr Res Rev. 2024;37(1):32-42. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Förster LJ, Vogel M, Stein R, et al. Mental health in children and adolescents with overweight or obesity. BMC Public Health. 2023;23(1):135. doi: 10.1186/s12889-023-15032-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Lee AM, Szurek SM, Dilip A, et al. Behavioral weight loss intervention preferences of adolescents with overweight/obesity. Child Obes. 2021;17(3):160-168. doi: 10.1089/chi.2020.0296 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Stewart TM, Martin CK, Williamson DA. The complicated relationship between dieting, dietary restraint, caloric restriction, and eating disorders: is a shift in public health messaging warranted? Int J Environ Res Public Health. 2022;19(1):491. doi: 10.3390/ijerph19010491 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Jennings KM, Phillips KE. Eating Disorder Examination–Questionnaire (EDE–Q): norms for clinical sample of female adolescents with anorexia nervosa. Arch Psychiatr Nurs. 2017;31(6):578-581. doi: 10.1016/j.apnu.2017.08.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Aardoom JJ, Dingemans AE, Slof Op’t Landt MC, Van Furth EF. Norms and discriminative validity of the Eating Disorder Examination Questionnaire (EDE-Q). Eat Behav. 2012;13(4):305-309. doi: 10.1016/j.eatbeh.2012.09.002 [DOI] [PubMed] [Google Scholar]
- 53.Carter JC, Stewart DA, Fairburn CG. Eating disorder examination questionnaire: norms for young adolescent girls. Behav Res Ther. 2001;39(5):625-632. doi: 10.1016/S0005-7967(00)00033-4 [DOI] [PubMed] [Google Scholar]
- 54.Mond J, Hall A, Bentley C, Harrison C, Gratwick-Sarll K, Lewis V. Eating-disordered behavior in adolescent boys: eating disorder examination questionnaire norms. Int J Eat Disord. 2014;47(4):335-341. doi: 10.1002/eat.22237 [DOI] [PubMed] [Google Scholar]
- 55.Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423-2478. doi: 10.1016/S0140-6736(16)00579-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Kwok C, Forward V, Lister NB, Garnett SP, Baur LA, Jebeile H. Considerations of eating disorder risk during obesity treatment in Australia: current practice, attitudes, and barriers. Obes Res Clin Pract. 2023;17(2):151-157. doi: 10.1016/j.orcp.2023.02.008 [DOI] [PubMed] [Google Scholar]
- 57.Accurso EC, Waller G. A brief session-by-session measure of eating disorder psychopathology for children and adolescents: development and psychometric properties of the Eating Disorder-15 for Youth (ED-15-Y). Int J Eat Disord. 2021;54(4):569-577. doi: 10.1002/eat.23449 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Kliem S, Schmidt R, Vogel M, Hiemisch A, Kiess W, Hilbert A. An 8-item short form of the Eating Disorder Examination-Questionnaire adapted for children (ChEDE-Q8). Int J Eat Disord. 2017;50(6):679-686. doi: 10.1002/eat.22658 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Trial Protocol.
Trial Protocol Amendments.
Statistical Analysis Plan.
eMethods. Screening
eTable 1. The Center for Epidemiologic Studies Depression Scale–Revised 10-Item Version for Adolescents Cut Points Based on the Scoring Described by Haroz et al
eFigure 1. CONSORT Figure
eTable 2. Proportion of Adolescents With Symptoms of Depression, Eating Disorders, and Binge Eating and Change Over Time by Group
eFigure 2. Proportion of Adolescents Meeting Depression Screening Criteria Over Time, All Participants Combined
eFigure 3. Proportion of Adolescents Meeting Eating Disorder Screening Criteria Over Time, All Participants Combined
eFigure 4. Proportion of Adolescents Meeting Binge Eating Scale Criteria Over Time, All Participants Combined
eReferences
Data Sharing Statement.