WEBINAR: Eating Disorders in Weight-Related Therapy: A Consultation Process Exploring Complex Risk factors
PRESENTER: Dr Hiba Jebeile
DATE: 26 July 2022



Prof Rachel Skinner [00:00:01] Welcome everybody to July's Wellbeing, Health & Youth NHMRC Centre of Research Excellence in Adolescent Health Seminar Series. First off, I just want to acknowledge the funding support that we have from the NHMRC, and the contributions of our research partners in universities across Australia. And for those of you who don't know me, I'm Professor Rachel Skinner and I am Deputy Director of Wellbeing, Health& Youth Centre of Research Excellence.  
Prof Rachel Skinner [00:00:44] I'd like to acknowledge the traditional owners of country throughout Australia and recognise their continuing connection to land, waters and culture. And we pay our respects to their Elders past, present and emerging. And I'd just like to say that I'm joining you from Gadigal country today, so you might like to share the countries that you're joining from in the chat. And to remind you that we have a website which has lots and lots of really great resources, and it's our Community of Practice, it's a place where researchers, clinicians and policymakers and young people come together to share ideas and exchange information. So please check it out if you haven't or take another look to see what else is new there. 
Prof Rachel Skinner [00:01:37] Just to orient you, we have a chat function, your microphone will be muted, you can't actually ask questions verbally, but you can post them in the chat function down the bottom right hand, you can pop them in, and at the end, we will highlight the questions and we'll go through the questions. So please do that as you go, as you think of the question, please pop it in the chat. 
Prof Rachel Skinner [00:02:10] Today, we are really lucky to have Dr Hiba Jebeile, an early career researcher and dietician at the University of Sydney. Her research examines the effect of obesity interventions on eating behaviours and mental health. And Hiba is a co-lead and program manager of the Eating Disorders in Weight Related Therapy EDIT Collaboration, aIndividual E\eating disorder risk during obesity treatment in adolescents and adults. Thank you very much.  I'm going to hand it over to you now. 
Dr Hiba Jebeile [00:02:54] Thanks, Rachel. And thanks for having us today to present on our Collaboration on the work that we've done so far. So first, I'd just like to acknowledge the Darug people as the traditional custodians of the land that I'm presenting from today here in Western Sydney and pay my respects to Elders past, present and emerging.
Dr Hiba Jebeile [00:03:15] Today, I'm going to be talking about the consultation process that we've done as part of the work on the eating disorders in weight related therapy collaboration or the EDIT  Collaboration. I'll start with a bit of background as to how the Collaboration was formed, what our overarching aims are, and then talk a bit about our consultation process so far. 
Dr Hiba Jebeile [00:04:07] Okay. So eating disorders are really a complex group of psychiatric illnesses which often present as disordered eating behaviours, and they can have significant co-morbidity and mortality as well. Eating disorders generally can take several years to develop or develop over time. And they may begin here with a broad number of people who might have eating disorders. Risk factors such as disordered eating, attitudes and behaviours, have some body dissatisfaction. Overvaluation of weight in shape will be engaging in dieting behaviours. Things like depression, anxiety and having low self-esteem are also risk factors for eating disorders. For a group of people that may progress to having more subclinical eating disorder symptoms so where they may engage in more extreme disordered eating behaviours, but not quite reach the frequency or threshold for a clinical diagnosis. So for example, they might have more infrequent binge eating episodes or engage in some irregular compensatory behaviours and then for a smaller  number of people that may progress to a clinical eating disorder. 
Dr Hiba Jebeile [00:05:24] On the other hand, obesity,  the prevalence of which has been increasing over the last few decades, and pre-COVID in developed countries that was starting to plateau but was continuing to increase in low and middle income countries. And now during COVID, particularly in younger children, we are seeing an increase again. 
Dr Hiba Jebeile [00:05:44]Obesity is associated with a range of co-morbidities and complications which can progress into young adulthood, affecting virtually every body system. We do need both effective and safe treatments for obesity in young people. While eating disorders and obesity were historically considered to be on opposing ends of a wide spectrum, there is actually quite some overlap between the two conditions. For example, there are several areas where they have shared risk factors. So if we consider the environment or environmental risk factors, things like weight, teasing, internalised ideals of beauty ideas and media exposure, particularly social media, are risk factors for both weight gain and disordered eating. They also shape cognitive risk factors such as weight concern and body dissatisfaction and behavioural risk factors. Engaging in unhealthy weight control behaviours such as binge eating or loss of control eating contribute to both disordered eating and the risk of developing an eating disorder, but also to further weight gain. There are also components that are commonly part of weight management in different interventions that are eating disorder risk factors. So for example, weight loss or aiming to attempt weight loss, having more extended or large amounts of weight loss is a risk factor for eating disorders and is one of the diagnostic criteria, for example, for anorexia nervosa. Dietary restraint or dietary restriction or dieting is a risk factor across the eating disorders, as well as weighing and monitoring behaviours. Monitoring weight, calorie counting, and particularly when they become a bit more obsessive and more frequent, are also red flags and risk factors for eating disorders. So really over the last decade or two, this has raised some concerns about the role of weight management interventions and treatments for obesity in terms of eating disorder risk. 
Dr Hiba Jebeile [00:08:00] So a few years ago now, our team wanted to really look into this issue and have a look at what the impact was of management interventions on eating disorder risk, but also on psychosocial health more broadly. So we conducted a series of systematic reviews that had the overarching aim to assess the impact of weight management interventions. We focused on interventions with a dietary component because we were really interested in that dieting aspect of interventions conducted in children and adolescents with overweight or obesity. We have three main reviews that we've published looking at eating disorder risk, depression and anxiety and body image and self-esteem. And across the series of reviews, we reviewed about 110 unique studies. 
Dr Hiba Jebeile [00:08:48] I'm going to just briefly present the results of each of these reviews. The first of the reviews looked at eating disorder risk and we looked at several different outcomes. We looked at global eating disorder risk, binge eating, bulimic symptoms, using compensatory behaviours such as self-induced vomiting, emotional eating, drive for thinness, eating concern. And really across studies, when we looked at the main change over time, we found that there was either no change or a small reduction in risk of both post intervention and follow up time points. There were some studies with follow up at 12, 24 and 36 months. There were some studies that had a look at whether people move to above or below predefined cut points. So, high risk if you're above a particular cutpoint. And there were some studies that reported a reduction in the number of participants who were above the cut point, where people were moving to being below the cut point, particularly for binge eating and bulimic symptoms. 
Dr Hiba Jebeile [00:09:52] There were three studies, though, that did report on individual participants, and in those studies they report very small numbers of people who had a worsening in their eating disorder risk. So, for example, there was a study that reported three people had developed a binge eating disorder and a six year follow up time point. In another study, there were seven people who moved to being from below the risk cut point to above the risk cut point. And then another study which reported the onset of binge eating behaviours in four people. Now, it's important to note that in this review and across our reviews, there were very few studies that were RCT, which included a no treatment control, so we weren't able to really have a look at changing risk compared to a group that didn't receive a weight management intervention or not receiving treatment. 
Dr Hiba Jebeile [00:10:44] When we looked at some of these other psychosocial health outcomes, which are also risk factors for eating disorders, we saw a similar pattern across the board where symptoms of depression and anxiety tended to reduce, so there were improvements in those symptoms. And we saw that body image and self-esteem tended to improve as well at both post intervention and follow up. 
Dr Hiba Jebeile [00:11:10] In another follow up to these reviews, we wanted to really explore the role of dieting a little bit more. What we did in studies that had reported a subscale of dieting or dietary restraint, we really had a look at what this change was compared to changes in the other markers of eating disorder risk. So I know this table is a little bit busy, but what I've listed here are the studies that had an increase in dietary restraint or dieting behaviours in at least one of the intervention arms. They're listed just here on the left. In the yellow, you can see their dieting or dietary restraint scores as having increased in at least one arm. There were some arms that had no change. And then across the table, you can see the change in other eating disorder outcomes. In green there is body image and self-esteem and they tend to improve or remain unchanged. And then in between, there are some of the other disordered eating outcomes were binge eating, emotional eating and global eating disorder risk. And really, again, they tended to either not change or have a small reduction. So, in this context of weight management, we saw that even if the dietary restraint of the dieting score increases, some of the other eating disorder markers either didn't change or reduced. That showed that perhaps in this context, markers of dieting or dietary restraint are not necessarily good indicators of eating disorder risk. 
Dr Hiba Jebeile [00:12:48] From these systematic reviews, we really saw that structured weight management interventions on the whole were not associated with an increase in eating disorder risk for most children and adolescents, but that there may be a small subset that do have a worsening of symptoms. But we do need further long term data. At the same time there is quite a strong lived experience voice within the eating disorder community who attribute the development of their eating disorder to weight management and their experiences of weight management, particularly as children. There have also been case reports of adolescents who developed an atypical anorexia nervosa following recommendations to lose weight by a health professional, often in an unsupervised way, but the recommendations were made. And there's also been a couple of other studies that show how to look at adolescents who are presenting to eating disorder services with restrictive eating disorders. And they've found that about 40% of those adolescents report having a history of being overweight or obesity. So there is some link there, and we're hoping to be able to understand what that link is. 
Dr Hiba Jebeile [00:13:55] Really, this research to date had identified two gaps in research questions that we were hoping to address. The first is whether there is a subgroup of individuals who are at risk of developing eating disorders during weight management and whether there is a way that we may be able to identify them early. And then whether there are intervention components that may contribute to eating disorder risk. So we looked at dieting in a bit more detail, but interventions are complex and they contain a large number of different moving parts. We hope to understand if there are particular components that might influence eating disorder risk more than others. 
Dr Hiba Jebeile [00:14:37] We were fortunate to be successful with an NHMRC grant last year to answer these research questions. From that we formed the EDIT  Collaboration, and the Collaboration really has four main aims. The first is to understand which participants are at risk of developing an eating disorder during weight management. We hope to understand which components of weight management interventions may contribute to eating disorder risk. And then hopefully identify predictive pathways for either an increase or decrease in eating disorder risk during weight management. And then develop some resources and recommendations for clinical care. 
Dr Hiba Jebeile [00:15:21] This just provides an overview of the Collaboration. And you can see it's a very large collaboration. We have our study team, which is conducting all of the programs, project management, and research. Our work is overseen by both the Scientific and Stakeholder Advisory Panel, and these panels include people with clinical, research, and lived experience expertise across both eating disorders or obesity or both conditions. And so far, we've had 46 trialists who have agreed to join the Collaboration and share their trial data with us. Our aim is to pull that data together to be able to answer those research questions. 
Dr Hiba Jebeile [00:16:04] This just provides a really broad overview of the work of the Collaboration. What we did is we started by conducting a systematic search to identify trials that have looked at eating disorder risk during weight management interventions. And we have asked all of those trials if they will share their individual participant data to be pulled into a larger dataset to answer these research questions. 
Dr Hiba Jebeile [00:16:28] First up, we conduct a consultation survey, and that's what I'll talk through in a moment. And then with the data that we've collated and the trials, we will be conducting two studies, which is study two and three here on the figure, which are individual participant data meta analysis. And these are really hoping to identify individual predictors or individual risk factors that may predict a worsening of eating disorder risk during weight management interventions. Study Four will be deconstructing those interventions into the individual strategies that may be used, and having a look at whether there are particular strategies that are more likely to increase or decrease eating disorder risk. And we hope to bring the results of studies two, three and four together to conduct some predictive modeling and to really have a look at the interaction between individual characteristics and intervention strategies and whether there are different pathways that might be appropriate for different people. And then hopefully all of that will lead to some recommendations for translation. What I'll be talking about for the rest of this presentation is the consultation survey that we conducted earlier this year. 
Dr Hiba Jebeile [00:17:39] The aims of our consultation survey were to assess opinions on individual characteristics of a person that may contribute to their risk of developing an eating disorder in the context of weight management, and strategies used within weight management interventions which may increase or decrease eating disorder risk. 
Dr Hiba Jebeile [00:18:01] We started by developing an initial list of individual characteristics and intervention strategies that may be relevant to eating disorder risk from the literature. Then with our scientific and Stakeholder Advisory panels, we conducted three workshops to go through those lists and refine them and then to add anything that may be missing from the literature but might be relevant based on their clinical experience or expertise. We then clustered those items into smaller groups and put that together as a cross-sectional survey. The survey was circulated internationally through professional organisations and on Twitter. 
Dr Hiba Jebeile [00:18:42] The survey had three parts. First, was to look at the individual participant characteristics. And so there were six categories that we used or six clusters that we included in that section. Looking at demographics, weight status of the person, their medical and family history, their mental and psychosocial health, eating behaviours at baseline prior to coming into an intervention, and their history of dieting. And we asked participants to rate the relevance of each of these characteristics to eating disorder risk in the context of weight management. 
Dr Hiba Jebeile [00:19:18] The second part had a look in more detail at intervention strategies, and there were five different clusters of intervention strategies. So the overall intervention framing and outcomes and how they were measured, their dietary strategies, how they might address eating behaviours and disordered eating, movement and sleep related strategies and psychosocial health related strategies. And for each of those strategies, we asked people to rate if they were more likely to increase or decrease eating disorder risk or if they had no impact on risk. 
Dr Hiba Jebeile [00:19:52] The final part of the survey looked at different delivery features. So who delivered the intervention, the setting, the mode of delivery, the target population and the support provided, and how important that was to consider an eating disorder risk. 
Dr Hiba Jebeile [00:20:07] Just to give you an idea of the number of different items that we had identified and were included in this survey. So just looking at the individual characteristics, we had 50 different characteristics that we asked people to examine and rate across those different clusters that I previously mentioned. . 
Dr Hiba Jebeile [00:20:27] Similarly with intervention strategies, across the five different categories there are over 100 different strategies that we have identified which may be relevant to eating disorder risk. And  here we have the overarching categories. And then within each category there are again individual clusters of different strategies. And just to give you an idea, within each cluster, there are then several individual strategies that are listed. Here I've included the dietary category as just an example. So within that overarching dietary category, there are five different clusters and within each cluster there are between three and seven individual strategies, really taking it down to a very detailed level. For example, not just asking you if they ask people to monitor their diet, but did they ask them to monitor it using a food based system such as a food diary? Or did they ask them to calorie count using an app and really trying to understand the small details within interventions. 
Dr Hiba Jebeile [00:21:34] Thinking about why we did this survey? Really because this is a very new and emerging area and there are really different views on this interaction between obesity and eating disorders. We wanted to ensure that the work of the Collaboration is really informed by consensus in the field, and we wanted to understand if we could achieve consensus on the different items that we had identified and in particular with relation to the intervention strategies. We wanted to understand if they were more likely to increase or decrease risk and if items within each cluster were likely to move in the same direction or not. So that when we conduct our analysis, we have them grouped correctly. But really, most importantly, we wanted to identify if there were any missing items that we haven't yet considered. And so within each category that I previously mentioned, we asked if there were additional items that we have missed that should be considered in our study. 
Dr Hiba Jebeile [00:22:35] We had 87 people complete the survey, mostly female and mostly from Australia or the US. Most participants were clinicians or researchers, but also we had a really high representation of people with lived experience. So really almost everybody who completed the survey had a lived experience of either being overweight or obese,  or an eating disorder or a carer of somebody with obesity or an eating disorder. And they were 25 out of 87 people who reported a lived experience of both overweight or obese and an eating disorder, which I think is a really good outcome of this survey. 
Dr Hiba Jebeile [00:23:20] I'll talk you through the results now. Starting with the individual characteristics. Looking across the clusters of the individual characteristics, there really was consensus that everything we had identified was relevant to eating disorder risk. So in the light blue there is a rating that each of these items was likely to be relevant to eating disorder risk, which was helpful for us to know. But there were some individual characteristics that were identified as also being relevant that we hadn't picked up. For example, in family history it was suggested that we should consider weight fluctuations- how often weight had fluctuated in the past as well as a history of bariatric surgery. We had previously identified that if, for example, a parent had had bariatric surgery, that was an important risk factor to consider for an adolescent. But it was raised that we should consider if the adolescent themselves or adults have had bariatric surgery as well. From a psychosocial health or eating behaviour point of view, some additional items that were suggested were executive functions. There were some additional mental health items. So considering a history of addiction or self-harm, having considered the parent patient relationship, social media use particularly recently where that's been linked to disordered eating but also to consider risk factors in relation to the personal context of the individual. Somebody might have several risk factors, but if they live in a supportive environment, they're not necessarily going to be at high risk of developing an eating disorder. And somebody who may not have clear risk factors but is not living in that supportive environment might be at higher risk. But really, in this section, the strongest message that came through was that experience of weight stigma from health professionals was a really strong predictor of eating disorder risk. And this, from our point of view in our study, is going to be very difficult to look at. But it's important moving forward to consider this, particularly as clinicians. 
Dr Hiba Jebeile [00:25:23]  I just have some of the comments there that came through. In terms of communication styles from health professionals, it’s suggested that microaggressions and the communication style of the provider contribute to weight stigma, not being able to access medical care for other conditions because of somebody's weight, and also that there is high heterogeneity even with supervised dietary interventions. So even though they may be better than people having to undergo self-directed diets, they may still experience stigma in that context. 
Dr Hiba Jebeile [00:26:00]  We move now to have a look at some of the intervention strategies. Just a reminder that in this section we asked people to rate different strategies used in weight management Interventions that were more likely to increase or decrease eating disorder risk or have no impact. And so I'll be showing this as a series of graphs, and on these graphs the light blue colour represents a decrease in eating disorder risk. Yellow is no impact and the dark blue is an increase in eating disorder risk, with green being not sure. 
Dr Hiba Jebeile [00:26:35] On this first slide, we have a look at the overall framing of the intervention. The theme throughout this whole first category really is that if anything that really overly focuses on weight  and body weight was rated as being more likely to increase eating disorder risk and anything focused more on health was more likely to decrease eating disorder risk. In this first graph, you can see that if the overall intent or framing of the intervention is about weight loss or weight maintenance, it was rated as being more likely to increase risk compared to being framed as improving health and was more likely to decrease risk. Similarly in the different communication strategies used. So if obesity was talked about as being a disease and that we needed to lose weight to improve health, that was more likely to be seen as more likely to increase eating disorder risk. But if we talked about improving health without focusing on weight too much, or that we could improve health without reducing or losing weight, then that was perceived to reduce eating disorder risk. 
Dr Hiba Jebeile [00:27:48] Here we look at different outcomes measured in interventions and how weight is measured. And again, it follows that similar pattern that if an intervention is focusing on measuring weight and encouraging weight loss, it's perceived to be more likely to increase risk where if there's a focus on a range of health outcomes for blood pressure, blood results, mental health, it's more likely to decrease eating disorder risk. 
Dr Hiba Jebeile [00:28:20] Some additional intervention strategies to consider in this category were really around the communication approaches or education style. So from a communication point of view. Focusing on decreasing personal responsibility for weight loss, is perceived to reduce eating disorder risk  and really considering the language and images that are used during interventions from an education point of view. It was suggested that explaining the science of weight and appetite and appetite regulation and the role of weight stigma would decrease eating disorder risk and talking about weight really in terms of health and growth. And from an outcome point of view, it was suggested that the rate of weight loss was important to look at. So how fast somebody might lose weight contributes to eating disorder risk. 
Dr Hiba Jebeile[00:29:18] Next up we have a look at the dietary strategies that may be used during interventions. On the left there, there are the different education strategies that we had included. And really in this section, it was mixed. Across the different dietary strategies or the different nutrition education strategies, there was a mix as to whether they might increase or decrease risk or have no impact, except when it came to prescription. So across all of the dietary prescriptions there on the right it didn't matter what type of diet it was, it was perceived to increase eating disorder risk as well as there on the left, you know, categorisation of foods having good bad foods, focusing on energy and macronutrient content. Really a similar pattern there. 
Dr Hiba Jebeile [00:30:12] Looking at the delivery of the diet, intervention again follows on from the previous slide where anything that was more prescriptive, like using a prescriptive meal plan, using meal replacements were perceived to be more likely to increase eating disorder risk. But then having a flexible approach, having an approach tailored to the individual and a family based approach were more likely to decrease eating disorder risk. Different dietary monitoring strategies just in the bottom left, again, follow on from what we saw earlier where monitoring of foods, focusing on the energy calorie content were all perceived to increase eating disorder risk. And  different behaviour change strategies again were a little bit mixed. So where they may be likely to either increase or decrease risk or have no change. 
Dr Hiba Jebeile [00:31:11] There were some additional dietary strategies to consider.The first is the role of the family and family dynamics in food choice and selection. If the food choices of the individual in the weight management intervention differ from the rest of the household, that was seen as being problematic. It was also suggested that providing education to the family on the risk of eating disorders and the need to be a bit more flexible and not too prescriptive, particularly parents towards children, that that would reduce eating disorder risk overall. And again, communication strategies came up. So how we talk about different dietary strategies, the use of language in talking about foods so good versus bad foods, healthy versus unhealthy foods was considered to be important as well as the dietary prescription which really followed. In terms of the dietary prescription, as we saw in the previous slide, anything that was viewed to be sort of a rigid dietary prescriptions, more likely to increase risk, including behaviours such as weighing and measuring foods. 
Dr Hiba Jebeile [00:33:24] The third category looked at was how an intervention might consider or address eating behaviours and disordered eating. And you can see that across these two clusters, everything's light blue, which means that any form of sort of addressing disordered eating, identifying the behaviours and addressing them or promoting more healthful eating behaviours was perceived to decrease eating disorder risk. 
Dr Hiba Jebeile [00:33:56] Some additional items that were suggested from an eating behaviours point of view. Screening for eating disorders and referral prior to interventions was suggested. But then there was sort of another comment that examining disordered eating behaviours in children may not be appropriate, and whether that may give them some ideas on different strategies to try that they hadn't previously considered. From an education point of view, it was suggested that providing education on excessive energy restriction may lead to hunger and binge eating. So the need for some more flexible restriction and education of a healthy menstrual cycle, and the links with under eating and over exercise so that they were aware of that potential red flag if that occurred. But also the context within which different disordered eating behaviour strategies were used is important. So while we had included some strategies such as mindful eating and intuitive eating as being part of weight management interventions, there were some comments that it was not appropriate to use those within the context of weight management.  
Dr Hiba Jebeile [00:35:13] The fourth category looked at different amusement and sleep related strategies, how interventions promote physical activity or address sedentary behaviour and promote sleep. Really in a similar pattern to the dietary interventions, any sort of more prescriptive exercise plan, so having a formal exercise plan that somebody needed to follow, a more prescriptive plan was perceived to be more likely to increase eating disorder risk. But promoting joyful movement, flexible exercise approaches and really personalised advice was viewed to be more likely to reduce eating disorder risk. 
Dr Hiba Jebeile[00:36:01] Again, the behaviour change strategies related to physical activity were a little bit mixed, a bit like the behaviour change strategies relating to dietary intervention. There wasn't really clear consensus on whether they are more likely to increase or decrease risk. And the same with sedentary time, which is there on the right. There was sort of a bit of a mix between whether it would decrease risk, increase risk or have no impact on eating disorder risk. But for addressing sleep there at the bottom, there was general consensus that it's more likely to decrease risk or have no impact on eating disorder risk, but not increase. 
Dr Hiba Jebeile [00:36:41] There were a few additional items suggested in terms of movement and sleep. In terms of sleep, it was suggested that an intervention should investigate, diagnose and treat sleep apnea, as well as focusing on circadian alignment and total sleep time. And then really in relationship communication, there were some comments about attitudes and beliefs of personal trainers, and how that might influence risk in their communication styles. So if they really overemphasise appearance or weight loss, that would increase eating disorder risk. Whereas if they're focused on healthy habits and quality of life goals as opposed to weight loss, it's more likely to decrease risk. And really, it was suggested that it would be helpful for interventions to explore motivations for exercise and looking at motivations beyond weight. So focusing on the mental health and physical health motivations to exercise rather than focusing on shape, weight and appearance. 
Dr Hiba Jebeile [00:37:45] This final category was looking at psychosocial health related strategies. And again, as with eating behaviours and disordered eating, there was general consensus that these are more likely to decrease risk. If the intervention was based on a psychological framework such as CBT, it's more likely to decrease risk, and if there was some sort of addressing of psychosocial health within the intervention as well.  
Dr Hiba Jebeile [00:38:18] Finally, this looks at addressing mental health more broadly. So if the intervention recognises or diagnoses and addresses different mental health conditions, addresses weight, stigma or addresses body image that was considered to be more likely to decrease eating disorder risk. 
Dr Hiba Jebeile [00:38:38] There were a few items suggested, again, so specifically around different education that could be provided in an intervention. Addressing internalised and externally received weight biases providing some of the health and exercise principals, discussing how undereating might be related to anxiety and depression and concentration, the difficulties with maintaining long term weight loss to really prevent that sense of failure that people might feel down the track and strategies for normalising and addressing shame from carers and young people. And there were some comments about weight stigma that it was not really appropriate to address weight stigma in the context of weight management, and that it's not the responsibility of the individual to manage prejudices from others. And that came from one of the items we had, which was about an intervention, including components to build resilience to weight management. 
Dr Hiba Jebeile [00:39:42] The last part of the survey looked at the specific delivery features used within an intervention. And here in yellow that's just showing that there was consensus that really all of the delivery features are important to consider from an eating disorder point of view. And there were some additional delivery features that were suggested should be considered. The continuity of care, that's really important to be providing long term support because weight regain down the track can lead to self-blame and feelings of failure. Support should be provided during those stages that we need both step up and step down pathways for obesity care and multidisciplinary care. In terms of the mode of delivery, there were some suggestions about telehealth and video conferencing because there has been some recent data following on from COVID, really showing the use of video conferencing and telehealth is associated with body image concerns. 
Dr Hiba Jebeile [00:40:41] And then considering the intervention setting itself things like any environmental contributors, does the service have the right environment and the right set up, appropriate chairs, offering a safe space, and having a good understanding of group rules in group sessions. 
Dr Hiba Jebeile [00:41:02] And then from a health professional point of view, really just saying that health professionals who are providing weight management need to have a good understanding of eating disorders and body image issues so that these risk factors can be picked up early. 
Dr Hiba Jebeile [00:41:16] In the survey, there were also a couple of broad themes that came across that didn't necessarily fit into a specific category. One was that there's likely to be individual variation in response. And so that patient choice should be considered in the selection of different weight management approaches and that there is high heterogeneity with intervention features. Some will have a good experience and others will have a stigmatising and harmful experience with the same intervention. So this quote just shows tha:t
Quote [00:41:48] "I've seen acceptance therapies promote disordered eating behaviours and I've seen body positivity increase people's negative self evaluation, and I've seen them work for others. But these things that are used so often are not the answer for everybody."
Dr Hiba Jebeile [00:42:08] The other broad theme that emerged is really the need to recognise disordered eating, and eating disorders during weight management, often that they're not recognised, clinicians need a greater awareness of eating disorders and resources to be able to address these.  Individuals seeking weight management may have a higher tolerance for risky and unsafe approaches to weight loss. People with a history of an eating disorder or a current eating disorder should not be offered weight management, and risk factors may vary by eating disorders, so we need to consider the different disorders separately. This is another quote that we had:
Quote [00:42:46]” I entered a weight management program with an active eating disorder and then was taught how to refine my eating disorder behaviours." 
Dr Hiba Jebeile [00:42:55] There were just a couple of general comments that came through in the survey as well. One is the role of weight management at all, so that any weight management contributes to eating disorder risk, that it's not possible for this to be safer because it promotes weight bias. That protective factors don't necessarily reduce the risk of eating disorders. We had talked about some protective elements such as CBT, intuitive eating and mindful eating. And there were some comments to say that these won’t reduce the risk associated with weight management interventions. And then some comments about informed consent. About the long term weight maintenance of weight loss and how realistic that is. The risk with weight cycling, if people sort of lose weight and regain weight frequently and then the risk of disordered eating and the role of family in preventing this. 
Dr Hiba Jebeile [00:43:54] Overall, there was consensus that known eating disorder risk factors can be considered in the context of weight management. We did identify some additional complexities, such as the role of weight stigma from health professionals and communication style and approach, and that identifying eating disorders and disordered eating prior to and during interventions is an important future direction. 
Dr Hiba Jebeile [00:44:18] In terms of the EDIT Collaboration, this really highlighted that we need a detailed deconstruction of interventions and we know that interventions are made up of multiple moving parts. So we need to understand what happens when we combine different strategies. If we are combining strategies that may be perceived to increase risk, such as a more prescriptive diet or exercise program with some other strategies that are more protective, such as CBT, what happens in those instances for different people? 
Dr Hiba Jebeile [00:44:48] I'd just like to end there by thanking our broader EDIT Collaboration study team and our Scientific and Stakeholder Advisory Panels that have really informed this work, as well as all of the trialists who have agreed to share their data with us so that we can answer these research questions. Thank you. 
Prof Rachel Skinner [00:45:39]  Excellent. So I’ve  got a couple of questions that have come up. I encourage everybody to ask questions. Now's the time. It was a fabulous presentation, though. Really, really interesting work and so relevant to, you know, our practice in adolescent health. We have a question from Louise. And she asks, "Would you please comment on the comment that people with active eating disorders should not be offered weight management? What if the person has health complications related to obesity or wants to move to a healthier weight for other health related well-being reasons? "
Dr Hiba Jebeile [00:46:26] Yes,  look, that's a good question, Louise, a very controversial area. I mean, I think really it's going to come down to the individual. There have been some studies that have looked at the co-treatment of obesity and particularly binge eating disorder. So having weight loss as part of treatment for binge eating disorder had some fairly good and mixed results. But in terms of the other eating disorders, I don't think there's really much out there, but I'd say it's really an individual, patient centered decision with the providers depending on what their complications are and the priority really in terms of their overall health. There is going to be a panel discussion, at the Eating Disorder Research Society meeting, addressing that exact issue about when we could potentially co-treat, provide weight management and eating disorder treatment. So it's a hot topic. 
Prof Rachel Skinner [00:47:26] From what I can glean from that, you need to consider the multiple components, those protective components of your intervention as well as what it sounds like. And Jonathan has asked, "Is there any data regarding risk of an eating disorder following discharge from a weight loss unit programs?” 
Dr Hiba Jebeile [00:47:55] In the trials that we looked at, there were trials that sort of had followed up people from the end of intervention for one or two years. There were a few trials that have looked at sort of longer follow up for years, five or six years, but with very small numbers. The challenge is that those trials often have high rates of dropout as with any trial. Following people up for several years is really difficult, but that's something we're hoping to look at in more detail as part of EDIT. We do have some trials included in EDIT that have followed up after three or four years from the end of intervention. So we'll be able to have a look at that in a bit more detail at the individual level. There is good data is my answer. The data we have suggests that there isn't really a worsening, that there might you know, there's some individual cases that may have developed binge eating disorder or binge eating, but on the whole there isn't a worsening. But again, studies have a drop out of about 50% and we don't know what happens to those people, which is one of the concerns. 
Prof Rachel Skinner [00:48:58] Thank you. We have another question from Daniel. "Great presentation. I like the approach of utilising data from previous studies to answer new research questions within the ideas grant. Was this an easy thing to achieve and would you have any suggestions for people trying this approach?" 
Dr Hiba Jebeile [00:49:24] Well, the approach that we used, I guess, really, I'll say that the way we designed our studies is based on another study, it's based on a study called the Top Child Collaboration, which is looking at the early prevention of obesity. We really modeled our study on the methods that they've used. But in terms of the Ideas grant, really we sort of started planning these very early and had buy-in from different collaborators early on, started talking about the idea with people. And we also approached trialists before putting the grant in so that we had sort of in-principle agreement from some of the trialists to share their data that we could show in our ideas grant application. But I think there's really no magic answer as to  how these grants are successful, but I think showing the feasibility that you will be able to bring the data together is important. 
Prof Rachel Skinner [00:50:20] Thank you. And Louise, again, related to Daniel's query, "What are some of the practical and ethical considerations to sharing data in this way?" 
Dr Hiba Jebeile [00:50:34] I guess with the ethical considerations first, it can be tricky in terms of the individual trials and if they obtained consent to share data early on during the consenting process. For some of the more recent trials where that is more piece built in a bit more routinely, it's less of an issue to some of the older trials. There is a bit of a process for some trials obtaining a waiver of consent. There are also some practical issues in terms of sharing data, particularly across countries, but also I guess from a practical point of view in terms of bringing the collaboration together and having people trust you enough to share their data with you is probably where most of the work lies, so having really good communication and engagement with trialists so that they feel confident enough to share their data with you. And we're right in the middle of that data sharing process. So while we've had really good engagement so far, it's going to be a lot of work receiving the data. 
Prof Rachel Skinner [00:51:35] Right. Thanks. Very interesting. Miai has asked whether this is a different topic about COVID and the impact of COVID. "Have you noticed an effect on eating disorder trends in young people during COVID?” 
Dr Hiba Jebeile [00:51:56]  I'm not completely across this literature. But I know that there have been some studies coming out of the eating disorder field showing an increase in disordered eating. I've definitely seen papers that have said that there is an increase in presentations to eating disorder services and waiting lists for eating disorder services. So I think there has been an increase during COVID, but I won't comment further. I'm not across everything in that area. 
Prof Rachel Skinner [00:52:28]  I have been reporting increased presentations and certainly anecdotally in our own services, it's much more and maybe it is related to the increased psychosocial distress in general, although we don't entirely understand that. But we do know that young people are experiencing much higher levels of mental health issues, and so that's likely to increase the risk factors as you described. It would be great to find out more on that as time goes on. We have a question from Yasmina. "Are you aware of any studies with adolescents that used risk minimisation factors, i.e. mindful eating, intuitive eating, etc., that have led to unintentional weight loss?” I think you were talking about this.
Dr Hiba Jebeile [00:53:22] There have been trials that have included mindful eating and intuitive eating strategies as part of a weight management intervention, they're sort of incorporated into a weight management intervention where some change in weight is still the goal. We did conduct a systematic review which had just been published recently having a look at if these weight neutral type interventions that really don't focus on weight loss at all, but use some of these mindful intuitive eating strategies in young people and really only identified three very small studies. And with those studies, some led to a small amount of weight loss, others didn't. So not really conclusive at this stage. But from the adult literature, you know, you do tend to see a small amount of weight loss with these strategies as well. 
Prof Rachel Skinner [00:54:20] So not yet evidence to recommend it" 
Dr Hiba Jebeile [00:54:24] Not yet enough evidence. 
Prof Rachel Skinner [00:54:27] So I have a question. While we're waiting to see if anyone else has any questions they'd like to ask because we still have a few minutes. The interventions that you saw that, you know, present risks for young people in developing eating disorders, is that something that specific or that young people and adolescents in particular are more vulnerable to than adults? I mean, is this a specific issue for adolescents? 
Prof Rachel Skinner [00:55:03] I, I don't think it's specific to adolescents. There have been systematic reviews in adults which really show a similar trend. We're looking at those data at the moment of adult weight management trials. And it's really the same sort of trends that for most people there's a reduction in risk. And where trials have looked at this, there's a small number of people, maybe about 5%, who have maybe had the onset of binge eating or have an increase in risk. The challenge is that most of these studies don't look at the individual level. So it's really just been a handful of studies that have reported it. And so I think that's what we're eager to look at with EDIT when we can look at the data across trials and see what the true numbers are. 
Prof Rachel Skinner [00:55:49] Greta,  it will be so impactful, so important to your studies. And I was also interested in the relationship or the perceived relationship between sleep and weight loss, and that programs that focus on sleep can be helpful for weight loss as well as, you know, being safe as well. And what you think the mechanisms might be. If you have any ideas on that.
Dr Hiba Jebeile [00:56:15] I mean, from an eating disorder point of view, I'm not sure what the mechanisms are. I mean, what we tried to do is include really all strategies that may be part of weight management interventions just to be as comprehensive as possible. But Louise might have a better idea on that one. I'm not entirely sure.
Prof Rachel Skinner [00:56:42]  So Louise has popped a reference  in the chat. So that's great. 
Dr Hiba Jebeile [00:56:50] That's the review that we did that looked at the weight neutral interventions in young people, so the mindful eating, intuitive eating type interventions including adolescence. 
Prof Rachel Skinner [00:57:01] Will definitely have a look at that. And I was also interested in the comments from some of the survey respondents that providers are not responsible for weight related stigma that might occur outside the program itself, and whether thinking about the importance of the broader context, as you said, that, you know, when we're implementing various programs for these young people, just provide a little bit more insight into that perception that we're not responsible for the broader impact. 
Dr Hiba Jebeile [00:57:46] What that comment was about is that we had included as one of the intervention strategies that an intervention may provide some training about building resilience towards weight stigma. There have been some trials that are looking at building resilience towards weight stigma and teaching people how they may address weight stigma or communicate in relation to that. And we had another strategy which was teaching communication styles to help people address weight stigma within their own personal circles. And the comments were about not the provider but that the individual person shouldn't be held responsible for addressing that stigma themselves. You know, we need to address stigma at a societal level and with professionals, which we do. But it was saying that it was sort of inappropriate to be teaching those strategies to the individual because it's sort of placing that responsibility on them to address the stigma. That's really what that comment was about. 
Prof Rachel Skinner [00:58:48] Thank you, my misunderstanding, because I would have thought it would be so important. Thank you. Louise has said in the chat that sleep interventions are very important for many aspects of health in young people, including obesity management. And it's incorporated routinely in weight management services, and programs. So that's really great. Yeah. I think we may have come to an end. That was a wonderful presentation, thank you so much Hiba, it was really great. 
Dr Hiba Jebeile [00:59:19] Thanks for having me. 
Prof Rachel Skinner [00:59:19] We wiIsh you all the best for the rest of it. And we would love to have you back when you have the next phase of the data collected and analysed, that would be really wonderful. 
Dr Hiba Jebeile [00:59:34] Definitely. 
Prof Rachel Skinner [00:59:37]  I just wanted to thank everybody for your participation and for joining in and yes, so a big round of applause for Hiba. And we look forward to everyone coming together again in a month's time. I thank you very much and say goodbye.