1. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Eating Disorders do not just disappear: implications of adolescent eating-disordered behaviour for body weight and mental health in young adulthood Results of the mental health module (BELLA-study) of the nationwide German Health Interview and Examination survey for Children and Adolescents (KiGGs) ESCAP MADRID, 22/06/2015 Beate Herpertz-Dahlmann

2. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Disclosure ESCAP Madrid 2015 Since 2012 Vifor Pharma Research Grant German Research Society (DFG) Research Grant German Ministry for Education and Research Grant Research EU FP 7 Research Grant Seite 2

3. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Background High prevalence of eating disorders (DSM-IV) in female adolescents in Western countries (point prevalence) (Machado et al. 2007; Swanson et al. 2011) approx. 3 - 6% Increasing incidence in adolescence ( UK, primary care, 15-19 y. ) (Micali et al. 2013) Increase by 13% from 2000 to 2009 ) 2/1000 girls Second most common new onset mental health disorder in adolescence after depression (UK) (Micali et al. 2013) 11/1000 girls for comparison: Incidence of diabetes mellitus type 1 (UK) 0.4/1000 girls Seite 3

4. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Aim of the BELLA- study to investigate  the stability of eating-disordered behaviour from adolescence to young adulthood;  its effect on the development of over- and underweight;  its contribution to the development of mental disorders, e.g. depression;  but also vice versa: association between adolescent psychopathology and later disordered eating and BMI (Herpertz-Dahlmann et al. 2009; 2015) Seite 4

5. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen BELLA-Study Method Mental health module of the nationwide German Health Interview and Examination survey for Children and Adolescents (KiGGs) KiGGs: Population-based randomly chosen sample of 167 sampling units in cities and communities all over Germany; The final KiGGS study population included 17.641 children and adolescents between birth and the age of 17; BELLA-study: a randomly selected subsample of 2.863 families with children aged 7–17 years Computer-assisted interview with the children and adolescents and one of their parents additional questionnaires sent and returned by mail Seite 5

6. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Populations of first and second wave of the mental health module (BELLA-study) of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) 2003 – 2006 2863 baseline data (7-17 years) (48,5%♀, 51,5%♂) 1734 (60,6% ) assessed (11-17 years) (48,7%♀, 51,3%♂) 2009 – 2013775 (44,7%) Follow-up 2nd wave 771 sufficient data (45,5 %♀, 54,5 %♂) Dropouts:lower SES Relatively more males Slightly lower SCOFF scores (Herpertz-Dahlmann et al., ECAP 2015) Seite 6

7. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Disordered Eating Definition Note: symptoms do not fulfill classification criteria (DSM or ICD) Method of assessment SCOFF – screening questionnaire (conspicuous value: ≥ 2 ) 1) Do you make yourself sick because you feel uncomfortably full? (deliberate vomiting) 2) Do you worry you have lost control over how much you eat ? (loss of control over eating) 3) Have you recently lost more than one stone in a three-month period ? (weight loss) 4) Do you believe yourself to be fat when others say you are thin (body image distortion) 5) Would you say that food dominates your life? (high impact of food on life) Body weight and height of probands measured in person at 1rst wave, at 6-year follow- up by telephone interview, self reported weight and height of the parents Seite 7

8. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Disordered Eating and associated mental disorders Further assessment instruments DepressionCES-DCThe Centre for Epidemiological Studies Depression scale for Children AnxietySCAREDScreen for Anxiety-Related Emotional Disorders questionnaire Depression (in young adults) PHQPatient Health Questionnnaire, depression module Seite 8

9. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Descriptive data on the BELLA- sample at baseline and follow-up MeanSDMin.Max. Age (Baseline) (years)14.32.011.018.0 Age (Follow-up) (years)21.02.217.127.0 BMI (Baseline) kg/m²20.63.913.542.6 BMI (Follow-up) kg/m²22.73.715.346.2 Seite 9 SES (Baseline)% Low18.1 Medium49.2 High32.7

10. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen RESULTS

11. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Stability of ED behaviour and attitudes (n=771) SCOFF ≥ 2 Baseline % SCOFF ≥ 2 follow-up % p = All participants19.313.80.002 Females26.017.60.002 Males11.39.20.41 Seite 11 Note: Decline more pronounced in females and in those with a higher BMI

12. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Course of eating disordered behaviour Relationship between SCOFF/Baseline u. SCOFF/6-year-follow-up Seite 12 Highly significant relationship between eating disordered behaviour in adolescence and young adulthood ( p < 0.0001) ( Poisson regression model after adjusting for age, sex, and baseline BMI)

13. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Association between eating-disordered behaviour (SCOFF-score) at baseline and BMI at follow-up Seite 13 Participants with higher SCOFF scores at baseline were highly likely to become overweight or obese in young adulthood OR.1.58; p= 0.001 Controlled for baseline and parental BMI

14. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Eating-disordered behaviour at baseline (SCOFF-Score) and depression at follow-up Seite 14 Individuals with higher SCOFF-Scores in adolescence have a higher risk for depressive symptoms in young adulthood (p=0.0006)

15. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Association between symptom patterns (single SCOFF items) at baseline and later eating disordered behaviour % Partic. SCOFF Follow-up overweight Follow-up Low weight Follow-up Depression Follow-up PHQ Deliberate vomiting4.50.060.050.020.003 Loss of control over eating 23.3< 0.00010.030.420.0006 Weight loss4.80.050.110.280.48 Body image distortion19.3< 0.00010.020.400.31 High impact of food on life 21.10.00040.220.070.25 Seite 15

16. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Association between depressive symptoms in adolescence and low body weight in early adulthood Seite 16 There is a significant relationship between depressive symptoms In adolescence and very low body weight in early adulthood (< 3. Perzentile) OR=1.13; p=0.02 1rst BMI- Quartile 3rd BMI- Quartile

17. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Summary I: Eating Disorders do not just disappear… 1.There is a decline in disordered eating behavior between adolescence and young adulthood; 2.Disordered eating in adolescence is a significant predictor of disordered eating in young adulthood. 3.Probands with more severe disordered eating have a higher probability to suffer from overweight and obesity in young adulthood (even after controlling for BMI at baseline and parental BMI) 4.Disordered eating in adolescence is significantly associated with depression in young adulthood. Seite 17

18. Bella Study Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Summary II: Eating Disorders do not just disappear… Higher depression scores in adolescence are significantly associated with very low body weight (anorexia nervosa) in young adulthood. There is urgent need for early detection and interventions targeting disordered eating behaviour in adolescence. Seite 18

19. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen Eating Disorders do not just disappear….. Thank you very much for your attention! For further questions: bherpertz@ukaachen.de