Age dependency of body mass index distribution in childhood and adolescent inpatients with anorexia nervosa with a focus on DSM-5 and ICD-11 weight criteria and severity specifiers

Christian Engelhardt¹, Manuel Föcker², Katharina Bühren³, Brigitte Dahmen³, Katja Becker^{4

5}, Linda Weber⁴, Christoph U Correll^{6

7

8}, Karin Maria Egberts⁹, Stefan Ehrlich^{10

11}, Veit Roessner¹¹, Christian Fleischhaker¹², Alexander von Gontard¹³, Freia Hahn¹⁴, Ekkehart Jenetzky^{15

16}, Michael Kaess^{17

18}, Tanja Legenbauer¹⁹, Tobias J Renner²⁰, Ulrike M E Schulze²¹, Judith Sinzig^#²², Ida Wessing^{2

23}, Gisela Antony²⁴, Beate Herpertz-Dahlmann³, Triinu Peters^#²⁵, Johannes Hebebrand^#¹

Affiliations

¹ Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Essen (AöR), University of Duisburg-Essen, Wickenburgstrasse 21, 45147, Essen, Germany.
² Department of Child and Adolescent Psychiatry, University Hospital Muenster, Schmeddingstraße 50, 48149, Münster, Germany.
³ Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany.
⁴ Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine, Phillips-University and University Hospital Marburg, Hans-Sachs-Str. 6, 35039, Marburg, Germany.
⁵ Center for Mind, Brain and Behavior (CMBB), University of Marburg and Justus Liebig University Giessen, Giessen, Germany.
⁶ Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353, Berlin, Germany.
⁷ Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
⁸ Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.
⁹ Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany.
¹⁰ Division of Psychological and Social Medicine and Developmental Neurosciences, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.
¹¹ Translational Developmental Neuroscience Section, Eating Disorder Research and Treatment Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
¹² Department of Child and Adolescent Psychiatry and Psychotherapy, University Freiburg, Hauptstraße 8, 79104, Freiburg, Germany.
¹³ Department of Child and Adolescent Psychiatry, Saarland University Hospital, Kirrberger Straße 1, 66421, Homburg, Germany.
¹⁴ Department of Child and Adolescent Psychiatry and Psychotherapy, LVR-Klinik Viersen, Horionstr. 14, 41749, Viersen, Germany.
¹⁵ Department of Child and Adolescent Psychiatry Und Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
¹⁶ Faculty of Health, School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
¹⁷ University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Stöckli, 3000, Bern 60, Switzerland.
¹⁸ Section for Translational Psychobiology, Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany.
¹⁹ LWL University Hospital Hamm for Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Ruhr University-Bochum, Heithofer Allee 64, 59071, Hamm, Germany.
²⁰ Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University of Tübingen, Osianderstraße 14-16, 72076, Tübingen, Germany.
²¹ Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, University of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany.
²² Department of Child and Adolescent Psychiatry, LVR-Klinik Bonn, Kaiser-Karl-Ring 20, 53111, Bonn, Germany.
²³ Institute for Biomagnetism and Biosignalanalysis, University Hospital Münster, Malmedyweg 15, 48149, Münster, Germany.
²⁴ Central Information Office, CIO Marburg GmbH, Struthweg 1, 35112, Fronhausen, Germany.
²⁵ Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Essen (AöR), University of Duisburg-Essen, Wickenburgstrasse 21, 45147, Essen, Germany. triinu.peters@uni-due.de.

^# Contributed equally.

PMID: 32666204
PMCID: PMC8295075
DOI: 10.1007/s00787-020-01595-4

Age dependency of body mass index distribution in childhood and adolescent inpatients with anorexia nervosa with a focus on DSM-5 and ICD-11 weight criteria and severity specifiers

Christian Engelhardt et al. Eur Child Adolesc Psychiatry. 2021 Jul.

. 2021 Jul;30(7):1081-1094.

doi: 10.1007/s00787-020-01595-4. Epub 2020 Jul 14.

Authors

Affiliations

¹ Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Essen (AöR), University of Duisburg-Essen, Wickenburgstrasse 21, 45147, Essen, Germany.
² Department of Child and Adolescent Psychiatry, University Hospital Muenster, Schmeddingstraße 50, 48149, Münster, Germany.
³ Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany.
⁴ Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine, Phillips-University and University Hospital Marburg, Hans-Sachs-Str. 6, 35039, Marburg, Germany.
⁵ Center for Mind, Brain and Behavior (CMBB), University of Marburg and Justus Liebig University Giessen, Giessen, Germany.
⁶ Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353, Berlin, Germany.
⁷ Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
⁸ Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.
⁹ Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany.
¹⁰ Division of Psychological and Social Medicine and Developmental Neurosciences, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.
¹¹ Translational Developmental Neuroscience Section, Eating Disorder Research and Treatment Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
¹² Department of Child and Adolescent Psychiatry and Psychotherapy, University Freiburg, Hauptstraße 8, 79104, Freiburg, Germany.
¹³ Department of Child and Adolescent Psychiatry, Saarland University Hospital, Kirrberger Straße 1, 66421, Homburg, Germany.
¹⁴ Department of Child and Adolescent Psychiatry and Psychotherapy, LVR-Klinik Viersen, Horionstr. 14, 41749, Viersen, Germany.
¹⁵ Department of Child and Adolescent Psychiatry Und Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
¹⁶ Faculty of Health, School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
¹⁷ University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Stöckli, 3000, Bern 60, Switzerland.
¹⁸ Section for Translational Psychobiology, Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany.
¹⁹ LWL University Hospital Hamm for Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Ruhr University-Bochum, Heithofer Allee 64, 59071, Hamm, Germany.
²⁰ Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University of Tübingen, Osianderstraße 14-16, 72076, Tübingen, Germany.
²¹ Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, University of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany.
²² Department of Child and Adolescent Psychiatry, LVR-Klinik Bonn, Kaiser-Karl-Ring 20, 53111, Bonn, Germany.
²³ Institute for Biomagnetism and Biosignalanalysis, University Hospital Münster, Malmedyweg 15, 48149, Münster, Germany.
²⁴ Central Information Office, CIO Marburg GmbH, Struthweg 1, 35112, Fronhausen, Germany.
²⁵ Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Essen (AöR), University of Duisburg-Essen, Wickenburgstrasse 21, 45147, Essen, Germany. triinu.peters@uni-due.de.

^# Contributed equally.

PMID: 32666204
PMCID: PMC8295075
DOI: 10.1007/s00787-020-01595-4

Abstract

Both DSM-5 and ICD-11 have provided weight cut-offs and severity specifiers for the diagnosis of anorexia nervosa (AN) in childhood, adolescence and adulthood. The aims of the current study focusing on inpatients aged < 19 years were to assess (1) the relationship between age and body mass index (BMI; kg/m²), BMI-centiles, BMI-standard deviation scores (BMI-SDS) and body height-SDS at referral, (2) the percentages of patients fulfilling the DSM-5 and ICD-11 weight criteria and severity categories for AN, and (3) the validity of the AN severity specifiers via analysis of both weight related data at discharge and inpatient treatment duration. The German Registry for Anorexia Nervosa encompassed complete data sets for 469 female patients (mean age = 15.2 years; range 8.9-18.9 years) with a diagnosis of AN (n = 404) or atypical AN (n = 65), who were ascertained at 16 German child and adolescent psychiatric hospitals. BMI at referral increased up to age 15 to subsequently plateau. Approximately one tenth of all patients with AN had a BMI above the fifth centile. The ICD-11 specifier based on a BMI-centile of 0.3 for childhood and adolescent AN entailed two equally sized groups of patients. Discharge data revealed limited validity of the specifiers. Height-SDS was not correlated with age thus stunting had no impact on our data. We corroborate the evidence to use the tenth instead of the fifth BMI-centile as the weight criterion in children and adolescents. Weight criteria should not entail major diagnostic shifts during the transition from adolescence to adulthood. The severity specifiers based on BMI or BMI-centiles do not seem to have substantial clinical validity.

Keywords: Atypical anorexia nervosa; BMI-SDS; BMI-centile; Early onset anorexia nervosa; Weight criterion.

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Conflict of interest statement

Dr. Correll has been a consultant and/or advisor to or has received honoraria from: Alkermes, Allergan, Angelini, Boehringer-Ingelheim, Gedeon Richter, Gerson Lehrman Group, Indivior, IntraCellular Therapies, Janssen/J&J, LB Pharma, Lundbeck, MedAvante-ProPhase, Medscape, Merck, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Servier, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva. He has provided expert testimony for Bristol-Myers Squibb, Janssen, and Otsuka. He served on a Data Safety Monitoring Board for Boehringer-Ingelheim, Lundbeck, Rovi, Supernus, and Teva. He received royalties from UpToDate and grant support from Janssen and Takeda. He is also a shareholder of LB Pharma. Dr. Herpertz-Dahlmann and Dr Hebebrand: research grants by German Research Society (HD, JH), German Federal Ministry for Education and Research (HD, JH), EU (HD), ERA-NET (HD), Ministry of Labour, Health and Social Policies of North-Rhine-Westfalia (HD), Innovationsfond of German health insurances (JH), Christina Barz Foundation (JH) and the University Hospital of Essen (JH); speaker’s fees by Ferring (HD). Platform Ernährung und Bewegung (JH), Novo-Nordisk (JH)). Dr. Becker has received research grants by German Research Society, German Federal Ministry for Education and Research, Philipps-University Marburg, von Behring-Röntgen Foundation, German Ministry for Health, University Hospital Gießen and Marburg, Rhön Klinikum AG. She receives honorary from Georg Thieme Publisher, and received speakers´ honorary (independent lecture content) by Shire during the last 5 years. The other authors declare that they have no conflict of interest.

Figures

**Fig. 1**
Scatterplot for age and BMI at referral (T0) of 469 inpatients with Anorexia Nervosa (AN; differentiated according to restricting or binge eating/purging type) or atypical AN including local regression (loess) in relationship to the ICD-11 specifier of BMI ≥ 14 or < 14 kg/m² (straight line)

**Fig. 2**
Age dependency of mean correlations (Spearman’s) and 95% confidence intervals between age and BMI at referral (T0) of 404 inpatients with Anorexia Nervosa for four age groups. Correlation coefficients were calculated on a cross-sectional basis per age group

**Fig. 3**
Scatterplot for age and BMI-SDS at referral (T0) of 469 inpatients with Anorexia Nervosa (AN; differentiated according to restricting or binge eating/purging type) or atypical AN including local regression in relationship to the ICD-11 specifier of BMI-centile ≥ 0.3 or < 0.3, which corresponded to BMI-SDS across the age range that skewed between 3.40 and 3.48

**Fig. 4**
Scatterplot for age and body height-SDS of 469 inpatients with Anorexia Nervosa including local regression (loess). Linear correlation r = 0.009, P = 0.844

See this image and copyright information in PMC

References

1. American Psychiatric Association, Diagnostic and statistical manual of mental disorders (DSM-5®). 2013, Washington, DC: American Psychiatric Pub.
1. Hebebrand J, et al. Use of percentiles for the body mass index in anorexia nervosa: diagnostic, epidemiological, and therapeutic considerations. Int J Eat Disord. 1996;19(4):359–369. doi: 10.1002/(SICI)1098-108X(199605)19:4<359::AID-EAT4>3.0.CO;2-K. - DOI - PubMed
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Age dependency of body mass index distribution in childhood and adolescent inpatients with anorexia nervosa with a focus on DSM-5 and ICD-11 weight criteria and severity specifiers

Affiliations

Age dependency of body mass index distribution in childhood and adolescent inpatients with anorexia nervosa with a focus on DSM-5 and ICD-11 weight criteria and severity specifiers

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

LinkOut - more resources

Full Text Sources