(2024) 24:551
Suzuki et al. BMC Pediatrics
https://doi.org/10.1186/s12887-024-05024-2

BMC Pediatrics

RESEARCH

Open AccessBody weight and eating attitudes influence
improvement of depressive symptoms
in children and pre‑adolescents with eating
disorders: a prospective multicenter cohort
study
Yuichi Suzuki1*, Shinichiro Nagamitsu2, Nobuoki Eshima3,4, Takeshi Inoue5, Ryoko Otani5, Ryoichi Sakuta5,
Toshiyuki Iguchi6, Ryuta Ishii7, Soh Uchida8, Ayumi Okada9, Shinji Kitayama10, Kenshi Koyanagi11, Yuki Suzuki12,
Yoshino Sumi13, Shizuo Takamiya14, Chikako Fujii15 and Yoshimitsu Fukai16

Abstract
Background Pediatric patients with eating disorders in a multicenter joint study on 11 facilities were enrolled
and prospectively investigated to determine whether improvement in body weight, eating attitudes, and psychosocial factors in children with eating disorders would also improve depressive symptoms.
Methods In this study, 91 patients were enrolled between April 2014 and March 2016. The severity of underweight
was assessed using the body mass index-standard deviation score (BMI-SDS), eating behavior was assessed using
the children’s eating attitude test (ChEAT26), the outcome of childhood eating disorders was assessed using the childhood eating disorder outcome scale, and depressive symptoms were assessed using the Children’s Depression Inventory (CDI) score.
Results After 12 months of treatment, depressive symptoms were evaluated in 62 of the 91 cases where it
was evaluated at the initial phase. There was no difference in background characteristics between the included
patients and the 29 patients who dropped out. A paired-sample t-test revealed a significant decrease in CDI scores
after 12 months of treatment (p < 0.001, 95% CI: 2.401–7.373) and a significant increase in the BMI-SDS (p < 0.001, 95%
CI: − 2.41973–1.45321). Multiple regression analysis revealed that BMI-SDS and ChEAT26 scores at the initial phasewere beneficial in CDI recovery. In addition, BMI-SDS at the initial phase was useful for predicting BMI-SDS recovery
after 12 months of treatment.
Conclusions Depressive symptoms in children with eating disorders improved with therapeutic intervention
on body weight and eating attitudes.
Trial registration The Clinical Trial Number for this study is UMIN000055004.
Keywords Eating disorders, Anorexia nervosa, Body mass index-standard deviation score, Eating attitudes, Children’s
depression inventory*Correspondence:
Yuichi Suzuki
susan@fmu.ac.jp
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as longas you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article orparts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicatedotherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
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Suzuki et al. BMC Pediatrics(2024) 24:551

Background
Eating disorders are chronic illnesses that develop duringchildhood and adolescence, and they are syndromes thatnecessitate physical, psychological, and social support.
These disorders have a high comorbidity with psychiatricconditions such as depression, anxiety, attention deficit/
hyperactivity disorder, obsessive compulsive disorder,
and personality disorders [1]. Depression and anxiety are
the most common comorbid symptoms of eating disorders [2–5]. Thus, evaluating psychopathology is important when determining the onset, duration, and prognosisof eating disorders. These disorders are poorly understood and often manifest as hyperactivity despite malnutrition, making it challenging to evaluate depression
superficially. According to a systematic review, patientswith anorexia nervosa (AN) have a higher rate of depression than the general population [6–8]. It is important tounderstand depression in patients with eating disorders
because long-term depression has been linked to suicide[9, 10]. Previous studies have reported eating disorders
and depression in adolescents; however, their existence inyounger children (pre-pubertal to adolescent) has rarely
been reported. Furthermore, although a systematic scoping review revealed that comorbid depression and eating disorder has a negative impact on weight gain [11],another reports suggested that low body weight due tomalnutrition does not affect depression [12]. It is important to understand depression at the onset of childhood
eating disorders and evaluate treatment options, but it
remains unclear whether treatment improves depressive
symptoms in children with eating disorders.
In Japan, the prevalence of eating disorders among
junior and senior high school students is ~ 0.5%, whichis comparable to that in Western societies [13]. Eating disorder subclassifications differ between children
and adults, with AN and avoidance/restrictive foodintake disorders (ARFID) accounting for > 50% and22.5% ~ 25.8% of childhood eating disorders, respectively[14, 15]. In other words, many other eating disorders
such as ARFID or unspecified feeding exist in children
and differ from AN in terms of age of onset, body weight,
eating attitude, and extent of anxiety. In a previous study,
individuals with ARFID were younger, reported earlier
age of onset, and had higher percent median body massindex (BMI) than those with AN [16]. A retrospective
study that categorized different eating disorders including AN and ARFID, among younger individuals foundthat patients with ARFID had higher rates of comorbidities such as anxiety disorders, separation anxiety disorder, pervasive developmental disorders, attention deficit/hyperactivity disorder, and learning disabilities [12, 17].
However, no prospective studies have been conducted on
the depressive course of childhood eating disorders.

Page 2 of 9This study aimed to evaluate body weight, eating attitudes, psychosocial factors, and depression in children
with eating disorders at the initial phase and determine whether depressive symptoms improve prospectively with changes in weight and eating behavior after
treatment.

Methods
A prospective cohort study of Japanese children
and pre‑adolescents with eating disorders

This is a prospective multicenter cohort study (J-PED
study) that was established in 2014 to develop a new
childhood eating disorder outcome scale. Eleven medical
institutions from the north to the south of Japan participated in the study. All J-PED members were trained bya child psychiatrist on how to use the Mini-International
Neuropsychiatric Interview [18] to assess comorbid psychiatric disorders.
Enrollment and participants

The registration period lasted two years, from April 2014
to March 2016. Patients with eating disorders under theage of 16 were enrolled, and consent was obtained after
the study protocol was explained to the patient and theirguardians in the research manual. Eating disorders werediagnosed using the Diagnostic and Statistical Manualof Medical Disorders, Fifth Edition (DSM-5) [19]. Eating disorders are not limited to AN but also include othereating disorders. The study included both untreated firstvisit patients and patients referred from other hospitals.
Patients who did not provide informed consent to participate in this study were excluded.
The Children’s Depression Inventory (CDI) score wasobtained from 91 patients with eating disorders at theinitial phase. After a 12-month follow-up, 14 patientsrefused to return to the clinic. Nine patients had missing data. Three patients were referred to psychiatry
for suicidal behavior, major depressive symptoms, andother behavioral issues. In addition, three patients had
recovered before the 12-month follow-up. Ultimately,
62 patients were able to be evaluated for depression
after 12 months (follow-up group; completer), while 29
patients dropped out of enrolment (dropout group) up
to 12 months of treatment (Fig. 1). Since the numberof dropouts reached up to 30% of the total number ofpatients at the initial phase, the difference in backgroundcharacteristics was investigated (Table 1).
Study protocol

At the initial phase, age, sex, body mass index-standard
deviation score (BMI-SDS), blood test, disease type, neurodevelopmental complications, children’s eating attitude test (ChEAT26) score, outcome scale score, andSuzuki et al. BMC Pediatrics(2024) 24:551

Page 3 of 9parenteral nutrition, enteral nutrition via a nasogastrictube, psychotherapy, behavioral therapy, and drug therapy were all recommended, with the attending physician
at each institution deciding on the best combinations.
Changes in BMI-SD, ChEAT26, outcome scale, and CDI
were assessed after 12 months of treatment.
Assessment items
Underweight indicators
Fig. 1 Patient flow diagram for this study

Table 1 Comparison of background characteristics at the initial
visit between patients in12-month-follow-up and dropout
groupsAll patients(n = 91)

Follow-up
group(n = 62)

Dropoutgroup(n = 29)P

Age at onset(years)12.9 ± 2.1

13.0 ± 2.2

12.8 ± 2.0

1.00
0.619

In the DSM-5 definition of eating disorders, the BMI isused to designate disease severity as follows: moderate(BMI: 16–16.99 kg/m2), severe (BMI: 15–15.99 kg/m2),
and extreme (BMI < 15 kg/m2) [19]. However, BMI is notrecommended as a measure of adolescent underweightbecause development-related variability can bias theresults [21, 22]. Therefore, the BMI-SDS [21] standardized by age and sex was used in this study.
ChEAT26

Outcome scale

15.7 ± 4.5

15.6 ± 4.7

16.0 ± 4.1

0.923

CDI score(points)

17.5 ± 8.5

17.2 ± 9.0

18.2 ± 7.2

0.865

ChEAT26 was standardized to the Japanese version [23],which is the pediatric version of the eating attitude test
modified by Garner and Garfinkle [24]. The ChEAT26
consists of 26 items designed to screen for and assess
symptoms and characteristics of eating disorders in children and pre-adolescents. It is appropriate for students inthe fourth grade of elementary school to the third gradeof junior high school (approximately 10 to 15 years old).
The cutoff value was set at 18 points (the sensitivity was
69% and the specificity was 93%).

Total CDI scoreabove 23/24,% (n)24.2 (22)22.6 (14)27.6 (8)0.874Childhood eating disorder outcome scale

Female (%)

93.4

95.2

89.7

BMI (kg/m2)

13.5 ± 1.6

13.5 ± 1.4

13.5 ± 2.0

1.00

BMI-SDS− 3.5 ± 1.7− 3.5 ± 1.6− 3.5 ± 1.9

0.981

Free T3(pg/mL)

1.67 ± 0.84

1.63 ± 0.82

1.74 ± 0.91

0.847

AN, % (n)70.3 (64)74.2 (46)62.1 (18)0.503

ASD, % (n)12.1 (11)12.9 (8)10.3 (3)0.883

ChEAT26

20.7 ± 15.5

21.8 ± 15.7

18.4 ± 15.1

0.729

Background characteristics at the baseline and 12-month follow-up werecompared using independent-sample t-test, whereas chi-squared test wasused to compare the groups regarding sex, AN and ASD comorbidities, and CDI
positive rate
BMI body mass index, BMI-SDS body mass index standard deviation score, T3
tri-iodothyronine, AN anorexia nervosa, ASD autism spectrum disorder, ChEAT26
Children’s version of the Eating Attitude Test-26 items, outcome scale Childhood
eating disorder outcome scale, CDI Children’s Depression Inventory, M ± SD
mean ± standard deviation

CDI score were obtained. According to the pediatric eating disorder treatment protocol published by the Japanese Society of Psychosomatic Pediatrics [20], they weretreated with combined family and individual therapy
involving disease education, physical treatment, medical nutrition, medication, supportive psychotherapy, andbehavioral therapy according to their needs. Patientswere treated as either inpatients or outpatients. Total

Members of the J-PED study discussed the outcome scale
items and, as a result of factor analysis, the core symptoms of eating disorders (eating attitudes (EA), fear of
being fat (FF), body image distortion (BD)), and thebiopsychosocial factors, which covered items in physical and psychological areas based on environmental
factors specific to children (body weight change, menstruation (ME), perception of physical condition, school
attendance (SA), disease recognition of school (RS), family functioning (FA), disease recognition by parent (RP),social adaption (SA), and relationships with friends (RF)).
After that, an outcome scale was developed by excluding
ME, RS, and RP, which had small loadings as a result offactor analysis [25]. The childhood eating disorder outcome scale has total scores ranging from 0 to 36, with
36 being the worst. There was a significant negative correlation between change in the outcome scale score andchange in BMI-SDS (r =  − 0.562, p < 0.001).

Suzuki et al. BMC Pediatrics(2024) 24:551

CDI score

The CDI score was used to evaluate depression. It is thestandard depression assessment tool in children andadolescents, developed by Kovacs [26]. The Japanese
CDI score was standardized by Ozono et al. in 2019[27]. The CDI’s target age ranges from 6 to 17 years. It
consists of 27 items that are based on the child’s life,
such as questions about school and friendships. Each
item has three choices, each worth 0 to 2 points (theworst score is 54 points). The CDI consists of five factors (A: negative mood, B: interpersonal problems, C:ineffectiveness, D: anhedonia, and E: negative selfesteem). The total score cutoff for the detection ofdepression was set at 24 points [27].
Statistical analysis and ethical statement

The Statistical Package for the Social Sciences (SPSS)
software, Version 26.0 (IBM SPSS Statistics for Windows, Armonk, NY, USA: IBM Corp.) was used for data
analysis. Descriptive analyses were conducted to assessthe distribution of the basic clinical and demographic
variables among all participants. As the continuous variables in the groups were non-normally distributed, theWilcoxon signed-rank test and Mann-Whitney U test
were used to compare them. However, categorical variables were compared between groups using Fisher’s exact
test. Finally, the analysis of covariance (ANCOVA) wasused to control for potential confounding variables. A
paired t-test was used to analyze changes on a continuous scale, while a multiple regression analysis was used
to analyze multiple explanatory variables that affect CDI
improvement.
The study’s design and procedures for obtaining
informed consent were approved by the medical ethics
committee of Kurume University School of Medicine(approval no. 13211) after applying to the medical review
committees of the participating medical institutions.

Results
Comparison of 12‑month‑follow‑up and dropout patients’characteristics at the initial visit (Table 1)

At the initial visit, the participants of 91 children andadolescents aged 7- 15 years. The average age of the
91 patients with eating disorders was 12.9 years (SD:2.1). The male-to-female ratio was 8:83, with females
accounting for 93.4% of the cohort. The average BMIPage 4 of 9

was 13.5 (SD: 1.6), and the average BMI-SDS was − 3.5(SD: 1.7). The free T3 levels, which reflect nutritional
status, were low at 1.67 pg/mL (SD: 0.84). The prevalence of AN was 70.3% (64/91); the other 29.7% (27/91)
were cases of ARFID, and the autism spectrum disorder comorbidity diagnosed based on DSM-5 criteria
was 12.1% (11/91). The average ChEAT26 score was
20.7 points (SD: 15.5), and the outcome score was
15.7 points (SD: 4.5). The average CDI score was 17.5
points (SD: 8.5), with 24.2% of the cases exceeding thecutoff value (23/24) for Japanese children. Among the91 patients with eating disorders who had CDI at theinitial visit (all patients), 62 patients who had CDI after
12 months of treatment (the follow-up group), and29 patients who dropped out during the observation
period (the dropout group), there were no significant
differences in age at the initial visit, male-to-female
ratio, BMI, and BMI-SDS, free T3 levels, the prevalenceof AN and autism spectrum disorder comorbidity, the
ChEAT26 score, the outcome scale score, and the CDI
score.
Changes in CDI score, BMI‑SDS, ChEAT26 score,and outcome scale from the initial phase to the 12‑monthfollow‑up

In 62 patients, the average CDI score was 17.2 points(SD: 9.0) at the initial visit and 12.6 points (SD: 8.3)
after 12 months of treatment. A paired t-test revealed
that therapeutic intervention significantly reduced
the CDI score (p < 0.001, confidence interval (CI):2.401–7.373; Fig. 2a). In addition, the average BMI-SDS
was − 3.5 (SD: 1.6) at the initial visit and − 1.5 (SD: 1.8)
after 12 months of treatment, indicating that therapeutic intervention significantly increased BMI-SDS(p < 0.001, CI: − 2.41937– − 1.45321; Fig. 2b). Moreover,
the average ChEAT26 score was 21.7 (SD: 15.9) at theinitial visit and 8.7 (SD: 9.6) after 12 months of treatment, with the ChEAT26 score decreasing significantlywith therapeutic intervention (p < 0.001, CI: 9.284–
16.683; Fig. 2c). Furthermore, the average outcome
scale scores at the initial visit and after 12 months oftreatment were 15.6 (SD: 4.7) and 9.4 (SD: 5.7), respectively, indicating that therapeutic intervention significantly decreased the outcome scale (p < 0.001, CI:
4.472–7.915; Fig. 2d).

Suzuki et al. BMC Pediatrics(2024) 24:551

Page 5 of 9

Fig. 2 Changes in assessment items from the initial phase to the 12-month follow-up. a The CDI score was significantly decreased after 12 monthsof treatment (p < 0.001). b The BMI-SDS was significantly increased after 12 months of treatment (p < 0.001). CDI, Children’s Depression Inventory;BMI-SDS, body mass index-standard deviation score. c The ChEAT26 score was significantly decreased after 12 months of treatment (p < 0.001). d
The outcome scale score was significantly increased after 12 months of treatment (p < 0.001). ChEAT26, children’s version of the Eating Attitude
Test-26 items

the BMI-SDS as the physical severity score, the ChEAT26
score as the child’s eating attitude score, and the outcome
scale as the score of eating disorder core symptoms
and the biopsychosocial factors. There was a positive
correlation with BMI-SDS and a negative correlation
with ChEAT26 at the initial visit. On the other hand,
to identify the factors at the initial visit that affect the

Prognostic factors at the initial visit and their effects
on CDI score and BMI‑SDS improvement (Tables 2 and 3)

To identify the factors at the initial visit that influence
the prediction of CDI score changes after 12 months oftreatment, a multiple regression analysis was performed
using each item of the explanatory variables, which wereTable 2 Multiple regression analysis of the effect of prognostic factors on CDI improvement
Outcome judgment criteria
Differences in CDI score

Prognostic factors

R2

BMI-SDS

0.248

β

SE

t

P

0.243

0.113

2.144

0.036

ChEAT26− 0.429

0.113− 3.786< 0.001

Outcome scale− 0.0350.134− 0.262

0.795

CDI Children’s Depression Inventory, BMI-SDS body mass index standard deviation score, ChEAT26 Children’s version of the Eating Attitude Test-26 items, Outcome scaleChildhood eating disorder outcome scale, R2 R Squared, β Beta Coefficient, SE Standard Error, t t-Statistic, P P-Value
Using a model selection procedure, the BMI-SDS and ChEAT26 scores were selected, whereas the outcome scale was excluded. The F value was 10.880, with degrees of
freedom (3,58), p < 0.001

Suzuki et al. BMC Pediatrics(2024) 24:551

Page 6 of 9

Table 3 Multiple regression analysis of the effect of prognostic factors on BMI-SDS improvement
Outcome judgment criteria
Differences in BMI-SDS

Prognostic factors

R2

BMI-SDS

0.294

β

SE

t

P

− 0.553

0.109− 5.094< 0.001

ChEAT26− 0.105

0.124− 0.8460.401

Outcome score

0.184

0.110

1.667

0.101

BMI-SDS body mass index standard deviation score, ChEAT26 Children’s version of the Eating Attitude Test-26 items, Outcome scale Childhood eating disorder outcome
scale, R2 R Squared, β Beta Coefficient, SE Standard Error, t t-Statistic, P P-Value
Using a model selection procedure, the BMI-SDS was selected, whereas ChEAT26 and outcome scores were excluded. The F value was 25.947, with degrees of freedom(3,58), p < 0.001

prediction of changes in BMI-SDS, an index of physicalimprovement, after 12 months of treatment, a multiple
regression analysis was performed using each score at
the initial visit as an explanatory variable, and only BMISDS at the initial visit revealed a negative correlation.

Discussion
In this study, we revealed that children and pre-adolescents with eating disorders showed improvements in CDI
scores with therapeutic intervention. Among 91 patientswith eating disorders, 22 patients (24.2%) exceeded thedepression cutoff value; however, the CDI score significantly decreased after 12 months of treatment (9.7%, n6/62). In addition, therapeutic intervention promoted
weight recovery along with improvement of depressive
symptoms. Body weight and ChEAT26 score at the initial visit had an effect on the improvement of depressive
symptoms. This suggests that early intervention, before
the occurrence of psychophysical deterioration, may
enhance outcomes in children and pre-adolescents witheating disorders. Specifically, addressing the factors contributing to nutritional status during the course of treatment may be crucial in improving depression outcomes.
Several studies have shown a link between patient bodyweight and depression in ED, with both positive andnegative results. In a study involving 147 patients with
AN, Marzola et al. reported that patients with higher
depressive and anxious temperament scores had lower
lifetime BMI [28]. Furthermore, in a study including
217 ED patients without comorbidity, 32 with comorbid anxiety, 86 with comorbid depression, and 36 withcomorbid anxiety and depression, Hughes et al. reported
that ED patients with comorbid depression showed complex and severe presentations in weight/shape concerns[29]. Tanaka et al. investigated the relationship between
nutritional status and physical and/or mental status at
the initial visit in 45 ED patients aged ≥ 18 years and 39
age-matched healthy controls. They found that depression assessed using the Beck’s Depression Inventory(BDI) correlated with harm avoidance and self-directedness assessed using the Temperament and Character Inventory-125 in both groups, but BMI showed nocorrelation with TCI-125 subscales in either group [30].
Based on these reports, although there is no direct relationship between BMI and BDI, our study on children
and pre-adolescents with eating disorders revealed theimportance of weight gain for improvement of depressive
symptoms.
In a previous study, we demonstrated a significant negative correlation between the outcome scale and BMISDS, and changes in outcome scale scores from baseline
to 12 months were significantly associated with improvement in BMI-SDS [25]. To the best of our knowledge,
this is the first scale that can statistically analyze outcome measure in children with eating disorders. Threeoutcomes (EA, FF, and BD) based on DSM-5 AN criteria
were included as disease-specific factors [19]. Moreover, psychosocial factors (e.g., FA, RF, and SA), which areoften considered for the recovery of children with eating
disorders, were included. However, statistical analysis
revealed that the outcome score at the initial visit cannot
predict both CDI and BMI-SDS improvement. As thisstudy’s scale did not include psychiatric disorders such as
depression, these disorders may have been excluded fromthe statistical analysis. On the other hand, some patientsused medications. Antidepressants were used in 8 out of
62 cases, and antipsychotics were used in 10 out of 62
cases. There was no significant difference in the change
in CDI values 12 months after treatment between thegroups that used each drug and those that did not (datanot shown).
A systematic review that investigated whether neuropsychological impairments in patients with AN are
influenced by BMI, anxiety disorders, or depression
revealed that none of these factors were associated withaltered central coherence (a tendency to focus on details
rather than the overall picture when processing information) and set-shifting (cognitive flexibility, refers to
the ability to shift thoughts or actions according to situational demands) in individuals with AN in most studies[31]. In other words, in addition to BMI or depression,
there are other factors that contribute to AN pathology. According to a study investigating the relationship between body image perception and symptoms ofSuzuki et al. BMC Pediatrics(2024) 24:551

depression and anxiety during outpatient psychotherapy
in 242 women with AN aged 18–56 years, body image
perceptions were significantly associated with symptoms
of depression and anxiety at all treatment stages [32].
Thus, prevention of persistent body image disturbance in
AN may have resulted in the recovery of depression andanxiety with treatment. Based on these studies, it is necessary to recover not only the physical state of AN but
also the cognitive distortion to achieve mental and physical recovery. Our study’s findings indicated that BMI-SDS
and ChEAT26 score were factors affecting CDI recovery
at the initial visit, indicating the need for comprehensive
support for EA.
Several studies have argued regarding the importanceof family function in the recovery process of children
with AN [33–38]. In a meta-analysis of 19 randomized
controlled trials from 8 different countries on the effects
of nonpharmacological interventions on BMI, body dissatisfaction, depression, and anxiety among individuals
with AN, behavioral family system therapy was found to
improve BMI, while conjoint family therapy was more
effective in ameliorating depression [39]. This review
demonstrated the impact of multidisciplinary family therapy on physical and psychological recovery. Our
study patients were treated at multiple facilities in Japanin accordance with the Japanese Society of Psychosomatic Pediatrics guidelines [20], which are based on
expert consensus on the importance of a biopsychosocial
approach. Our study treatment involved physical therapy
provided by a pediatrician and supportive and/or behavioral therapy centered on family support provided by amultidisciplinary team. The J-PED study revealed that theoutcome scale can assess the severity of eating disorders,and changes in this score through therapeutic interventions can reflect improvement in BMI-SDS [25]. In thisreview, therapeutic interventions led to an improvementof eating disorder pathology, resulting in a decrease in
CDI scores.
This study had some limitations. First, one-third of the
91 patients at the initial visit had dropped out during the
12 months leading up to the analysis. The dropout analysis revealed that there were no significant differences inbackground characteristics of patients among the threegroups (91 patients at the initial visit, 62 patients after
12 months of treatment, and 29 patients who droppedout) and that dropout patients had no distinguishing
characteristics. Furthermore, while the 12-month followup period enabled the evaluation of medium-term outcomes, it may not sufficiently capture long-term recovery
and sustainability of treatment effects. Future researchshould consider extending the follow-up duration to better assess the long-term stability of the therapeutic benefits. It is necessary to examine these dropout cases inPage 7 of 9

the future. Second, despite the presence of psychiatriccomorbidities (autism spectrum disorder, depression,and obsessive compulsive disorder) among the study
patients were not included as weighting factors in theoutcome score. The severity of comorbidities may vary
between diseases or patients, and the presence of comorbidities was not included in our outcome scale. Finally,
the use of antidepressants and antipsychotics was not
subject to specific criteria and was left to the discretionof the attending physician. Because these conditions were
not included in the outcome scale, I think this explains
why the coefficients of determination (R2) were low.
These comorbidities are believed to have a significant
negative impact on the prognosis of eating disorders andmay be evaluated as prognostic factors in future studies.

Conclusions
In our study, the therapeutic intervention improved
CDI score and BMI-SDS after 12 months of treatment.
Furthermore, patient body weight and eating attitudes
were useful for predicting improvement of depressive
symptoms.
Abbreviations
AN	Anorexia nervosa
ARFID	Avoidance/restrictive food intake disorders
DSM-5	The Diagnostic and Statistical Manual of Medical Disorders,
Fifth Edition
CDI	The Children’s Depression Inventory
BMI-SDS	Body mass index-standard deviation score
ChEAT26	Children’s eating attitude test
Outcome Scale	Childhood eating disorder outcome scale
EA	Eating attitudes
FF	Fear of being fat
BD	Body image distortion
ME	Menstruation
SA	School attendanceRS	Disease recognition of school
FA	Family functioningRP	Disease recognition by parent
SA	Social adaption
RF	Relationships with friends
SPSS	The Statistical Package for the Social Sciences
Acknowledgements
We would like to thank all participants and their families who participated in
the study.
Authors’ contributions
All authors reviewed the manuscript, approved it in its current form, andapproved the authorship order. All authors (Yuichi Suzuki, Shinichiro Nagamitsu, Takeshi Inoue, Ryoko Otani, Ryoichi Sakuta, Toshiyuki Iguchi, Soh
Uchida, Ayumi Okada, Shinji Kikayama, Kenshi Koyanagi, Yuki Suzuki, YoshinoSumi, Shizuo Takamiya, Chikako Fujii, and Yoshimitsu Fukai) except Nobuoki
Eshima collected patient data. Yuichi Suzuki and Shinichiro Nagamitsu compiled the manuscript. Shinichiro Nagamitsu, Yoshimitsu Fukai, and Soh Uchidaparticipated in the design of this study. Nobuoki Eshima conducted thestatistical analyses and supervised the preparation of the manuscript.
Authors’ information
Yuichi Suzuki. Lecturer in Pediatrics, Fukushima Medical University; specialistin pediatrics, pediatric neurology, and child mental health; board memberof the Japanese Society of Psychosomatic Pediatrics; and a representativeSuzuki et al. BMC Pediatrics(2024) 24:551

Page 8 of 9of the Eating Disorders Working Group, Japanese Society of Psychosomatic
Pediatrics.

5.

Funding
This work was supported by the Ministry of Health, Labour and Welfare
under Grant (#H28Sukoyaka-001 and H29Sukoyaka-005 #29040501) provided
research materials.

6.

Availability of data and materials
The datasets generated and/or analyzed during the current study are available
from the corresponding author upon reasonable request.

7.

8.

Declarations

9.

Ethics approval and consent to participate
All procedures performed in studies involving human participants were inaccordance with the 1964 Helsinki declaration and its later amendments orcomparable ethical standards. Ethical approval was granted by the medical
ethics committee of Kurume University School of Medicine, reference number
13211. Informed consent was obtained from all individual participants
included in the study. Additional informed consent was obtained from allindividual participants for whom identifying information is included in thisarticle. Informed consent was obtained from the parents or legal guardians of
all participants under the age of 16.

10.

Consent for publication
Not applicable.

11.
12.
13.
14.

Competing interests
The authors declare no competing interests.
Author details
1
Department of Pediatrics, Fukushima Medical University School of Medicine,
1 Hikariga‑Oka, Fukushima, Fukushima 960‑1295, Japan. 2 Department of Pediatrics, Fukuoka University Faculty of Medicine, Fukuoka, Japan. 3 Departmentof Pediatrics, Kurume University School of Medicine, Fukuoka, Japan. 4 Center
for Education and Research of Disaster Risk Reduction and Redesign, Oita,
Japan. 5 Child Development and Psychosomatic Medicine Center, Dokkyo
Medical University Saitama Medical Center, Saitama, Japan. 6 Departmentof Pediatrics, Hoshigaoka Maternity Hospital, Aichi, Japan. 7 Departmentof Pediatrics and Child Health, Kurume University School of Medicine,
Fukuoka, Japan. 8 Karamun`S Forest Children`S Clinic, Tokyo, Japan. 9 Department of Pediatrics, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences, Okayama, Japan. 10 Himeji City Centerfor the Disabled, Hyogo, Japan. 11 Nagasaki Prefectural Center of Medicine
and Welfare for Children, Nagasaki, Japan. 12 Department of Pediatrics, National
Hospital Organization Mie National Hospital, Mie, Japan. 13 Mental and Developmental Clinic for Children “Elm Tree”, Hokaido, Japan. 14 Takamiya Psychiatry
Clinic, Hyogo, Japan. 15 Department of Pediatrics/Child Psychosomatic Medicine, Okayama University Hospital, Okayama, Japan. 16 Department of Pediatrics, St. Luke’s International Hospital, Tokyo, Japan.

15.

16.

17.

18.
19.
20.
21.

Received: 13 January 2024 Accepted: 19 August 2024
22.

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