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Ultra-processed foods (UPFs) like pastries, packaged snacks, fast foods, and sweetened beverages have become dominant in the modern food supply and are strongly associated with numerous public health concerns. While the physical health consequences of UPF intake have been well documented (e.g., increased risks of cardiometabolic conditions), less empirical discussion has emphasized the mental health consequences of chronic UPF consumption. Notably, the unique characteristics of UPFs (e.g., artificially high levels of reinforcing ingredients) influence biological processes (e.g., dopamine signaling) in a manner that may contribute to poorer psychological functioning for some individuals. Importantly, gold-standard behavioral lifestyle interventions and treatments specifically for disordered eating do not acknowledge the direct role that UPFs may play in sensitizing reward-related neural functioning, disrupting metabolic responses, and motivating subsequent UPF cravings and intake. The lack of consideration for the influences of UPFs on mental health is particularly problematic given the growing scientific support for the addictive properties of these foods and the utility of ultra-processed food addiction (UPFA) as a novel clinical phenotype endorsed by 14-20% of individuals across international samples. The overarching aim of the present review is to summarize the science of how UPFs may affect mental health, emphasizing contributing biological mechanisms. Specifically, the authors will (1) describe how corporate-sponsored research and financial agendas have contributed to contention and debate about the role of UPFs in health; (2) define UPFs and their nutritional characteristics; (3) review observed associations between UPF intake and mental health conditions, especially with depression; (4) outline the evidence for UPFA; and (5) describe nuanced treatment considerations for comorbid UPFA and eating disorders., Competing Interests: The authors declare no conflicts of interest.

Background: Weight suppression has been defined as diet-induced weight loss, traditionally operationalized as the difference between one's highest and current weight. This concept has been studied in the context of eating disorders, but its value in predicting treatment outcomes has been inconsistent, which may be partially attributed to its calculation., Method: The current study operationalizes a novel weight suppression score, reflecting the midpoint between the lowest and highest adult weights among adults (N = 287, ages 21-75, 73.9% women) seeking outpatient treatment for disordered eating. This report compared the traditional weight suppression calculation to the novel weight suppression score in a simulated dataset to model their differential distributions. Next, we analyzed shared and distinct clinical correlates of traditional weight suppression versus the novel weight suppression score using clinical intake data., Results: The novel weight suppression score was significantly associated with meeting criteria for both eating disorders and ultra-processed food addiction and was more sensitive to detecting clinically relevant eating disorder symptomatology. However, the novel weight suppression score (vs. traditional weight suppression) was associated with fewer ultra-processed food addiction symptoms., Conclusion: The novel weight suppression score may be particularly relevant for those with eating disorders and ultra-processed food addiction, with more relevance to individual eating disorder compared to ultra-processed food addiction symptoms. Consideration of the novel weight suppression score in future research on eating behaviors should extend beyond just those with diagnosed eating disorders., (© 2024. The Author(s).)

Adverse childhood experiences (ACEs) have been associated with poor mental health outcomes in adulthood. Childhood maltreatment is related to both depressive and anxiety symptoms. Our objective was to investigate these associations among low-income, mostly Black and Latino men who have sex with men (MSM), as these may be a particularly vulnerable population group. Data come from a longitudinal study of MSM with varied substance use behaviors (n = 321) collected between August 2014 and April 2022. Cumulative, childhood maltreatment ACEs, and the single ACE of childhood sexual abuse were investigated as potential predictors of self-reported depressive and anxiety symptoms in mixed-effects logistic and ordinal regression models. There was no evidence of a dose-response relationship between the number of ACEs and the predicted probability of depressive and anxiety symptoms. Compared to MSM reporting fewer than five ACEs, those with five or more ACEs had approximately double the odds ratio of reporting depressive (OR = 1.93; 95% CI: 1.04-3.60) and anxiety symptoms (OR = 2.21; 95% CI: 1.05-4.68). The dimension of childhood maltreatment had a more robust prediction of depressive symptoms than the dimension of household dysfunction across all models. The association between childhood sexual abuse history and depressive symptoms remained after adjustment for the other nine ACEs (OR = 2.27; 95% CI: 1.11-4.68). The ordinal logistic model suggested that cumulative ACEs more than triple the odds of being in a higher anxiety category (OR = 3.12; 95% CI: 1.58-6.14), with associations reported for childhood maltreatment ACEs (OR = 1.31; 95% CI: 1.06-1.66) and childhood sexual abuse (OR = 1.93; 95% CI: 0.89-4.21). Childhood maltreatment ACEs, particularly childhood sexual abuse, are salient predictors of depressive and anxiety symptoms among adult urban MSM. Mitigating the impact of childhood maltreatment requires understanding the additional burden of social distress often faced by MSM throughout the life course., (© 2023. The Author(s).)

Background: Adverse childhood experiences (ACEs) have been shown to be associated with drug use in adulthood. The single ACE of household substance use history (part of the household dysfunction category) has frequently been associated with drug use. Resilience factors such as perceived social support appear to buffer the association between ACEs and drug use and may be particularly relevant for urban men who have sex with men (MSM). The current study of low-income mostly Black and Latino MSM aims to investigate whether the cumulative ACE score predicts self-reported drug use in a dose-response manner and whether this potential association differs by perceived social support., Methods: Data was utilized from a longitudinal study of MSM (mean age=34; SD=7.1) with varied substance use behaviors (n = 321) collected between August 2014 and April 2022. Cumulative, household dysfunction ACEs, and the single ACE of household substance use history were investigated as predictors of self-reported drug use (methamphetamine, ecstasy, cocaine/crack, heroin/fentanyl, party drugs [GHB, special K, mushrooms, LSD/acid], other drugs [bath salts, PCP]) during the past six months in mixed-effects logistic regression models, with moderation analyses by perceived social support (measured by the Multidimensional Scale of Perceived Social Support) across all models using stratified analysis and one model of multiplicative interaction., Results: There was no suggestion of a dose-response relationship between the number of ACEs and the predicted probability of self-reported drug use. Cumulative ACEs did not predict the outcome overall (aOR=1.99; 95% CI: 0.86-4.59), however, a positive association was estimated for individuals reporting lower levels of perceived social support (aOR=2.80; 95% CI: 0.97-8.06). The dimension of household dysfunction had a positive association with drug use (aOR=1.32; 95% CI: 1.00-1.74) whereas the dimension of childhood maltreatment did not. The association between household dysfunction and drug use was moderated by the perception of social support, with those reporting lower levels having greater odds of reporting drug use (aOR=2.94; 95% CI: 1.04-8.31). The association between household substance use history and self-reported drug use was similarly moderated by perceived social support in a multiplicative interaction model (p = .02)., Conclusion: Perceived social support emerged as a potential buffering factor for any reported drug use, particularly for the single ACE of household substance use history. Given that the association between ACEs and drug use was weak among those with higher levels of perceived social support, promotion of social ties in the community may help reduce the burden of substance use among MSM exposed to ACEs., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Food addiction, specifically ultra-processed food addiction, has been discussed in thousands of peer-reviewed publications. Although 20% of adults meet criteria for this condition, food addiction is not a recognized clinical diagnosis, leading to a dearth of tested treatment protocols and published outcome data. Growing numbers of clinicians are offering services to individuals on the basis that the food addiction construct has clinical utility. This audit reports on clinical teams across three locations offering a common approach to programs delivered online. Each team focused on a whole food low-carbohydrate approach along with delivering educational materials and psychosocial support relating to food addiction recovery. The programs involved weekly sessions for 10-14 weeks, followed by monthly support. The data comprised pre- and post- program outcomes relating to food addiction symptoms measured by the modified Yale Food Addiction Scale 2.0, ICD-10 symptoms of food related substance use disorder (CRAVED), mental wellbeing as measured by the short version of the Warwick Edinburgh Mental Wellbeing Scale, and body weight. Sample size across programs was 103 participants. Food addiction symptoms were significantly reduced across settings; mYFAS2 score -1.52 (95% CI: -2.22, -0.81), CRAVED score -1.53 (95% CI: -1.93, -1.13) and body weight was reduced -2.34 kg (95% CI: -4.02, -0.66). Mental wellbeing showed significant improvements across all settings; short version Warwick Edinburgh Mental Wellbeing Scale 2.37 (95% CI: 1.55, 3.19). Follow-up data will be published in due course. Further research is needed to evaluate and compare long-term interventions for this complex and increasingly burdensome biopsychosocial condition., Competing Interests: Authors HG, CK, MP, FS, CS, and DW have fee paying clients with food addiction. Author DW was employed at Nutrition in Recovery LLC. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Unwin, Delon, Giæver, Kennedy, Painschab, Sandin, Poulsen and Wiss.)

In addition to its immediate negative consequences, childhood sexual abuse is associated with lifelong deleterious mental and physical health outcomes. This review employs a biopsychosocial perspective to better understand pathways from childhood sexual abuse to eating disorders, food and drug addictions, and obesity across the life course. Guided by an updated conceptual model, this review delineates how the biological embedding of childhood sexual abuse triggers a cascade of interrelated conditions that often result in failed attempts at weight suppression and eventually obesity. Such biological embedding involves pathways such as inflammation, allostatic load, reward sensitivity, activation of the hypothalamic-pituitary-adrenal axis, epigenetics, and structural and functional changes in the brain. These pathways are in turn theorized to lead to food addiction, substance use disorder, and eating disorders-each with potential pathways toward obesity over time. Predisposing factors to childhood sexual abuse including gender, culture, and age are discussed. This model calls into question the longstanding "protective measure" theory that purports individuals exposed to sexual abuse will deliberately or subconsciously gain weight in attempt to prevent future victimization. A more comprehensive understanding of the mechanisms by which childhood sexual abuse becomes biologically embedded may help clinicians and survivors normalize and/or address disordered eating and weight-related outcomes, as well as identify intervention strategies.Level of evidence: Level V: opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objectives: The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Design: Longitudinal observational cohort study., Setting: Academic Level 1 trauma center., Patients/participants: One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018., Intervention: Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion., Results: Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures., Conclusions: The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion., Level of Evidence: Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To compare and stratify the healing rates after our index nonunion surgery using contemporary methods of fixation, report the prevalence of recalcitrant non-union, and identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Design: Retrospective analysis of a prospectively collected database., Setting: Academic Level 1 Trauma Center., Patients/participants: Two hundred twenty-two tibial nonunions treated with internal fixation by a single surgeon., Intervention: Bivariate and multivariate regression analysis were performed to compare healing rates by the type of fixation and graft augmentation and to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Results: Of the 222 patients, 162 (73%) healed as intended and 51 (23%) required 1 or more subsequent interventions to achieve union (96%). Nine fractures (4%) failed to unite. The 60 fractures (27%) that required a subsequent intervention(s) or failed to consolidate were defined as recalcitrant nonunions. There were no statistically significant differences in the recalcitrant rate when we compared plates versus nails or types of bone graft. Risk factors for developing a recalcitrant nonunion were multifactorial and included grade III open fractures, compartment syndrome, deep infection, and 2 or more prior surgical procedures., Conclusions: Internal fixation remains a successful method of treatment for most tibial nonunions. However, 27% of patients required a subsequent intervention because of failure to heal our index nonunion procedure. Factors that are associated with recalcitrant nonunions were a grade III open fracture, compartment syndrome, deep infection, and 2 or more or more prior surgical procedures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To understand the relationship between drug use, food insecurity (FI) and mental health among men who have sex with men (MSM)., Design: Cohort study (2014-2019) with at least one follow-up., Setting: Visits at 6-month intervals included self-assessment for FI and depressive symptoms. Urine testing results confirmed drug use. Factors associated with FI were assessed using multiple logistic regression with random effects for repeated measures. General structural equation modelling tested whether FI mediates the relationship between drug use and depressive symptoms., Participants: Data were from HIV-positive and high-risk HIV-negative MSM in Los Angeles, CA (n 431; 1192 visits)., Results: At baseline, FI was reported by 50·8 % of participants, depressive symptoms in 36·7 % and 52·7 % of urine screening tests were positive for drugs (i.e. marijuana, opioids, methamphetamine, cocaine and ecstasy). A positive drug test was associated with a 96 % increase in the odds of being food insecure (95 % CI 1·26, 3·07). Compared to those with high food security, individuals with very low food security have a nearly sevenfold increase in the odds of reporting depressive symptoms (95 % CI 3·71, 11·92). Findings showed 14·9 % of the association between drug use (exposure) and depressive symptoms (outcome) can be explained by FI (mediator)., Conclusion: The prevalence of FI among this cohort of HIV-positive and high-risk HIV-negative MSM was high; the association between drug use and depressive symptoms was partially mediated by FI. Findings suggest that enhancing access to food and nutrition may improve mood in the context of drug use, especially among MSM at risk for HIV transmission.

Objective: While organisational change in substance use disorder (SUD) treatment has been extensively studied, there is no research describing facility-wide changes related to nutrition interventions. This study evaluates staff-perceived barriers to change before and after a wellness initiative., Design: A pre-intervention questionnaire was administered to participating staff prior to facility-wide changes (n 40). The questions were designed to assess barriers across five domains: (1) provision of nutrition-related treatment; (2) implementation of nutrition education; (3) screening, detecting and monitoring (nutrition behaviours); (4) facility-wide collaboration and (5) menu changes and client satisfaction. A five-point Likert scale was used to indicate the extent to which staff anticipate difficulty or ease in implementing facility-wide nutrition changes, perceived as organisational barriers. Follow-up questionnaires were identical to the pre-test except that it examined barriers experienced, rather than anticipated (n 50)., Setting: A multisite SUD treatment centre in Northern California which began implementing nutrition programming changes in order to improve care., Participants: Staff members who consented to participate., Results: From pre to post, we observed significant decreases in perceived barriers related to the provision of nutrition-related treatment (P = 0·019), facility-wide collaboration (P = 0·036), menu changes and client satisfaction (P = 0·024). Implementation of nutrition education and the domain of screening, detecting and monitoring did not reach statistical significance., Conclusions: Our results show that staff training, food service changes, the use of targeted curriculum for nutrition groups and the encouragement of discussing self-care in individual counselling sessions can lead to positive shifts about nutrition-related organisational change among staff.

The purpose of this communication is to provide an overview as well as the strengths and weaknesses of Overeaters Anonymous (OA) as an intervention for binge eating disorder treatment. Binge eating disorder is associated with low remission rates, high relapse rates, treatment dissatisfaction, and high rates of failure to receive treatment attributed to stigma, misconceptions, lack of diagnosis, access to care, and inadequate insurance coverage. New interventions are needed that can overcome these barriers. OA is a twelve-step program and established fellowship for individuals who self-identify as having problematic relationships with food or eating. OA can be referred clinically or sought out by an individual confidentially, without a diagnosis, and free of charge. OA's Nine Tools, Twelve Steps, and Twelve Traditions can provide structure, social support, and open, anonymous sharing that fosters a sense of connection and belonging. This may provide benefit to individuals who value structure and social support in their recovery. The tradition of anonymity may also create some challenges for conducting research and may explain the shortage of empirical support. This commentary reviews existing research findings on the effectiveness of twelve-step interventions and OA. Common misunderstandings about and within OA are also addressed and OA's limitations are discussed. Overall, OA provides a promising option for binge eating disorder treatment that warrants clinical research on its feasibility and efficacy in a way that respects and protects its tradition of anonymity.

Background: Clavicle nonunions often result after nonoperative treatment for the acute fracture. Those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. The aims of the present study were to (1) determine healing rates of clavicle nonunions after plate osteosynthesis using either a conventional or locked plate, (2) compare iliac crest bone graft vs. bone morphogenetic protein on nonunion healing, and (3) identify risk factors for the development of a recalcitrant nonunion., Methods: We performed a retrospective analysis of a prospectively collected database of 78 clavicle nonunions treated with open reduction and plate fixation with or without graft augmentation by a single surgeon over 25 years. Seventy-one patients over the age of 18 with at least 12 months of follow-up comprised the study group. We analyzed healing rates after the index clavicle nonunion surgery comparing plate type and graft technique as well as identifying risk factors for developing a recalcitrant nonunion., Results: A total of 62 patients (87.3%) healed after their index nonunion surgery at our institution. Three patients (4.2%) required additional surgery but healed, and 6 patients (8.5%) remain un-united; these 9 patients (12.7%) were defined as recalcitrant. There was no statistically significant difference in healing rates between plate type (P = .633) or type of bone graft (P = .157). There were no identifiable risk factors for the development of a recalcitrant nonunion., Conclusions: Plate fixation of clavicle nonunions remains a successful method of treatment. The type of plate or the method of bone graft did not produce different results. There were no demographic, patient, or injury characteristics associated with the development of a recalcitrant nonunion., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The role of stress, trauma, and adversity particularly early in life has been identified as a contributing factor in both drug and food addictions. While links between traumatic stress and substance use disorders are well documented, the pathways to food addiction and obesity are less established. This review focuses on psychosocial and neurobiological factors that may increase risk for addiction-like behaviors and ultimately increase BMI over the lifespan. Early childhood and adolescent adversity can induce long-lasting alterations in the glucocorticoid and dopamine systems that lead to increased addiction vulnerability later in life. Allostatic load, the hypothalamic-pituitary-adrenal axis, and emerging data on epigenetics in the context of biological embedding are highlighted. A conceptual model for food addiction is proposed, which integrates data on the biological embedding of adversity as well as upstream psychological, social, and environmental factors. Dietary restraint as a feature of disordered eating is discussed as an important contextual factor related to food addiction. Discussion of various public health and policy considerations are based on the concept that improved knowledge of biopsychosocial mechanisms contributing to food addiction may decrease stigma associated with obesity and disordered eating behavior.

Adverse childhood experiences (ACEs) can become biologically embedded leaving a lasting signature on multiple body systems. ACE scores have been used to associate childhood adversity to a wide range of adverse health conditions over the life course, most notably substance-related disorders. Multiple studies have shown that the presence of elevated ACE scores predicts obesity in adulthood. However, a gap exists in the literature elucidating the pathways from childhood adversity to increased BMI in adulthood. We systematically reviewed these mechanisms as well as discuss novel plausible pathways. We searched PubMed, PsycInfo, Embase, and Web of Science and after applying exclusion criteria identified 18 articles for qualitative analysis. The most commonly cited mechanisms linking ACEs to obesity are social disruption, health behaviors, and chronic stress response. Ten observational studies (n=118,691) were quantitatively summarized and demonstrated a positive association between ACE and adult obesity with a pooled odds ratio of 1.46 (CI=1.28, 1.64) with moderate heterogeneity (I 2 =70.8%). Our results found a 46% increase in the odds of adult obesity following exposure to multiple ACEs. Based on our qualitative synthesis and review of the most recent relevant literature, we propose biologically plausible explanations for the significant positive relationship between ACEs and adult obesity. Reducing exposure to ACEs, improved screening and detection of trauma, better access to trauma-informed care, and improvements to the food environment are likely to improve downstream health outcomes related to eating behavior., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion., Methods: We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Results: One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures., Conclusions: Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

With the rising prevalence of type 2 diabetes mellitus (T2DM), there is debate regarding biological and psychosocial risk factors. While it is well established that alcohol lowers glycohemoglobin (HbA1c) levels, it is less clear whether alcohol consumption is protective of T2DM. It is also unclear how gender and ethnicity influence the utility of HbA1c screening as a tool for T2DM diagnosis, particularly in the context of alcohol use. This cross-sectional study utilized the National Health and Nutrition Examination Survey 2013-2014 dataset and was restricted to adults 20 years and older, nonpregnant, and not on antihypertensive medication ( n  = 4299) to evaluate the relationship between alcohol use and HbA1c. A multilinear regression model controlled for gender, ethnicity, education level, body mass index, and age. After controlling for covariates, both moderate ( β  = -0.073; p  = 0.033) and heavy drinking ( β  = -0.167; p  < 0.001) are associated with reduced HbA1c levels. Additionally, female gender is a significant negative predictor of HbA1c ( β  = -0.052; p  = 0.024) and all ethnic groups have higher levels of HbA1c compared with non-Hispanic whites. Plausible biological mechanisms are discussed. The clinical utility of HbA1c as a screening tool for T2DM without considering alcohol use, gender, and ethnicity may lead to diagnostic errors. Individualized approaches and focused efforts toward health equity are needed to address rising rates of T2DM., Competing Interests: No competing financial interests exist., (© David A. Wiss 2019 Published by Mary Ann Liebert, Inc.)

The opioid crisis has reached epidemic proportions in the United States with rising overdose death rates. Identifying the underlying factors that contribute to addiction vulnerability may lead to more effective prevention strategies. Supply side environmental factors are a major contributing component. Psychosocial factors such as stress, trauma, and adverse childhood experiences have been linked to emotional pain leading to self-medication. Genetic and epigenetic factors associated with brain reward pathways and impulsivity are known predictors of addiction vulnerability. This review attempts to present a biopsychosocial approach that connects various social and biological theories related to the addiction crisis. The emerging role of nutrition therapy with an emphasis on gastrointestinal health in the treatment of opioid use disorder is presented. The biopsychosocial model integrates concepts from several disciplines, emphasizing multicausality rather than a reductionist approach. Potential solutions at multiple levels are presented, considering individual as well as population health. This single cohesive framework is based on the interdependency of the entire system, identifying risk and protective factors that may influence substance-seeking behavior. Nutrition should be included as one facet of a multidisciplinary approach toward improved recovery outcomes. Cross-disciplinary collaborative efforts, new ideas, and fiscal resources will be critical to address the epidemic.

The objective of this study was to determine the prevalence of nutrition services and utilization of registered dietitian nutritionists at substance use disorder treatment centers in Los Angeles. This cross-sectional descriptive study utilized phone interviews with facilities within a 25-mile radius of the Los Angeles metropolitan area using the Substance Abuse and Mental Health Services Administration Treatment Services Locator to identify facilities that included a listing of substance abuse as primary focus of care (n = 128). Facilities were asked if they offered any kind of nutrition services, the type of services that were offered, and the credential of the professional providing the services. We compared facilities that offered a residential level of care to those offering outpatient services only. The Fisher's exact test was used to determine statistical significance. The study showed that only 39 sites (30.5%) offered any type of nutrition services on site, and the odds of a residential level of care offering nutrition services was 2.7 times higher than outpatient only facilities (p = 0.02). Of the 39 facilities offering nutrition services, only 8 (20.5%) utilized a registered dietitian nutritionist. Overall fewer than 7% of the facilities utilized the services of a dietitian. Recovery programs for substance use disorder should consider using a registered dietitian nutritionist as a member of the treatment team, which may contribute to better clinical outcomes.

The obesity epidemic has been widely publicized in the media worldwide. Investigators at all levels have been looking for factors that have contributed to the development of this epidemic. Two major theories have been proposed: (1) sedentary lifestyle and (2) variety and ease of inexpensive palatable foods. In the present review, we analyze how nutrients like sugar that are often used to make foods more appealing could also lead to habituation and even in some cases addiction thereby uniquely contributing to the obesity epidemic. We review the evolutionary aspects of feeding and how they have shaped the human brain to function in "survival mode" signaling to "eat as much as you can while you can." This leads to our present understanding of how the dopaminergic system is involved in reward and its functions in hedonistic rewards, like eating of highly palatable foods, and drug addiction. We also review how other neurotransmitters, like acetylcholine, interact in the satiation processes to counteract the dopamine system. Lastly, we analyze the important question of whether there is sufficient empirical evidence of sugar addiction, discussed within the broader context of food addiction.

It is well established that obesity has reached pandemic proportions. Over the last four decades the prevalence of obesity and morbid obesity have risen substantially in both men and women worldwide. Although there are many causative factors leading to excessive weight gain including genetics and sedentary lifestyle, the transformation of the food environment has undoubtedly contributed to the dangerously high rates of obesity. The current food landscape is inundated with food engineered to contain artificially high levels of sugar and fat. Overconsumption of these types of food overrides the homeostatic mechanisms, which under normal circumstances regulate appetite and body mass, leading to hedonic eating. Evidence from the animal literature has illustrated nutrition-influenced perturbations that occur within the mesolimbic dopamine pathway, as well as maladaptive behavioral responses that result from chronic ingestion of highly palatable foods. These neurobehavioral adaptations are similar to what is observed in drugs of abuse. Recent evidence also supports that maternal exposure to these foods is capable of provoking neurobehavioral alterations in offspring. Therefore the purpose of this review is to summarize the current developments on the addictive potential of highly palatable foods, as well as illuminate the impact of maternal hyperphagia and obesity on the reward-related neurocircuitry and addiction-like behaviors in the offspring., (Published by Elsevier Ltd.)

Although not formally recognized by the DSM-5, food addiction (FA) has been well described in the scientific literature. FA has emerged as a clinical entity that is recognized within the spectrum of disordered eating, particularly in patients with bulimia nervosa, binge-eating disorder and/or co-occurring addictive disorders and obesity. Integrating the concept of FA into the scope of disordered eating has been challenging for ED treatment professionals, since there is no well-accepted treatment model. The confusion surrounding the implications of FA, as well as the impact of the contemporary Westernized diet, may contribute to poor treatment outcomes. The purpose of this review is twofold. The first is to briefly explore the relationships between EDs and addictions, and the second is to propose a new model of conceptualizing and treating EDs that incorporates recent data on FA. Since treatment for EDs should vary based on individual assessment and diagnosis, the Disordered Eating Food Addiction Nutrition Guide (DEFANG) is presented as a tool for framing treatment goals and helping patients achieve sustainable recovery.

Because the spectrum of injuries to the tibia is so great, no single method of treatment is applicable to all nonunions. Therefore, it is important for surgeons who treat tibial nonunions to be skilled in several different methods of treatment. In patients with significant deformities, electrical stimulation, isolated fibular osteotomy, and bone grafts alone are unsatisfactory treatment options. In aseptic nonunions, the use of intramedullary nailing or compression plating appears to have many advantages. In previously closed and selected grade I and grade II open fractures, reamed intramedullary nailing is a safe and effective method of treatment. Because of the risk of infection, reamed nailing is not recommended after external fixation of open fractures. In these cases as well as others, the authors prefer plate osteosynthesis. With few exceptions, the plate should be placed, under tension, on the convex side of the tibia. Used in this fashion, the plate can assist in correction of any deformity and can also provide stable internal fixation. Half-pin external fixation is used primarily in the management of infected fractures. Ilizarov and other small-wire circular fixators have proved effective in treating complex-composite deformities associated with sepsis, bone loss, shortening, angulation, or malrotation. Amputation may be warranted if a functional limb cannot be achieved.

One hundred thirty-four acute unstable fractures of the tibia were treated with a reamed intramedullary nail with locking capabilities. There were 101 closed and 33 open fractures (20 Grade 1 fractures, 12 Grade 2 fractures, and 1 fracture from a gunshot wound). Patients were seen in followup for an average of 16 months after nailing. The time to fracture union averaged 28 weeks in closed fractures and 39 weeks in open fractures. Delayed union (> 6 months) developed in 14 fractures (8%): 11 closed (11%) and 3 open (9%) fractures. Eleven of the 14 delayed unions healed spontaneously, or after dynamization of statistically locked nails. Seven fractures (5%) were not healed by 9 months and were classified as nonunion (2 closed, 5 open). All fractures required major additional procedures to obtain union. Infection developed in 13 fractures (10%). In closed fractures, there were 2 superficial (2%) and 3 deep (3%) infections; in open fractures there was 1 superficial (3%) and 7 deep (21%) infections. The authors conclude that reamed intramedullary nails should be restricted to unstable, closed tibial shaft fractures. Its use in open fractures even on a delayed basis cannot be recommended because of unacceptably high infection rates.

In a nonrandomized prospective study, 178 comminuted or length unstable femur fractures were treated with a statically locked, slotted, titanium alloy interlocking nail. Patients were divided into two groups based on the number of distal interlocking screws that were used. The patients were followed up for an average of 17 months to determine if the use of a single distal screw provided adequate fracture stability without loss of fracture fixation.

This article is an overview of the management of femoral shaft fractures resulting from gunshot wounds. It deals with the initial patient evaluation, operative techniques of fracture stabilization and wound care, associated complications, and the postoperative rehabilitation of these complex fractures. The recommendations are based upon a large patient experience in an urban trauma center.

Sixteen patients who had undergone hip arthrodesis utilizing an anteriorly placed compression plate were evaluated at an average of 4.5 years after surgery. The technique was designed to facilitate future conversion to a total hip arthroplasty by preserving the abductor musculature. Of the 11 patients who underwent primary fusions, 5 failed to unite (45%). Nonunion occurred in all five (100%) patients undergoing refusion for a failed surgical arthrodesis. The authors conclude that an anterior compression plate alone in patients with limited bone stock does not provide adequate fixation and predisposes the patient to failure of fixation and nonunion.

Forty-seven tibial nonunions were treated with a reamed intramedullary nail. Initially, there were 14 (30%) closed and 33 (70%) open tibial fractures. The initial fracture management consisted of casts in 12 (26%) patients, Ender or Lottes nails in nine (19%), and external fixation in 26 (55%). The time from injury to nailing averaged 31.5 weeks. All but one fracture was nailed using a closed technique (98%). Twenty-six patients were initially managed with external fixation. Duration of fixation averaged 11 weeks, and the time from fixator removal to nailing averaged 24 weeks. Patients were followed for an average of 18.7 months after nailing. Forty-two of the 47 (89%) nonunions united uneventfully. Infection developed in six (13%) patients, five of which occurred in previously open fractures treated with external fixation. After one or more procedures, these nonunions consolidated without apparent infection. Reamed intramedullary nailing is a safe and effective method of treatment for tibial nonunions of previously closed fractures and prior open fractures that have been treated with Ender or Lottes nails. Because of the risk of infection, we do not recommend its use after external fixation of open fractures.

In a retrospective study, 58 patients with 60 tibial plafond fractures were treated by internal fixation and reviewed over an average follow-up period of 2.5 years. There were three Reudi Type I, 27 Reudi Type II, and 30 Reudi Type III fractures. Twelve fractures were open, and 60% of the fractures were the result of high-energy trauma. Results were evaluated based on a subjective and objective rating system. There were 15 good and excellent (25%), 15 fair (25%), and 30 poor results (50%). The deep infection rate in Reudi Types I and II fractures was 0%, and in Type III fractures it was 37%. The deep infection rate statistically correlated with the presence of a postoperative wound dehiscence or skin slough but not with the presence of an open fracture. Overall clinical rating correlated with the Reudi classification, quality of reduction, and the presence of a postoperative wound infection. The ankle fusion rate for Reudi Types I and II fractures was 10%, whereas that in Reudi Type III fractures was 26%. The results of this study show that operative treatment of complex intraarticular fractures of the distal tibia remain fraught with difficulty and that the complication rates and need for further reconstructive surgery remains high. If anatomic reduction without soft-tissue complications cannot be predicted preoperatively, consideration should be given to alternative types of treatment.

The management of severe open fractures of the tibia remains one of the more challenging problems facing the orthopedic surgeon. Patients who sustain high-energy injuries with loss of soft tissue in conjunction with displaced comminuted fractures face high rates of delayed union, nonunion, infection, and in some instances, amputation. This article discusses materials, methods, and surgical techniques.

Forty-one adult patients with displaced olecranon fractures were treated with open reduction internal fixation in a prospective, randomized study comparing tension band wiring (TBW) and plate fixation (PF). Plate fixation required longer operative time, but did not lead to an increased complication rate. Range of elbow motion at six months did not differ significantly between the two groups. Symptomatic metal prominence was frequently observed after TBW (42%), although true Kirschner wire (K-wire) migration was seen in only one patient. Postoperative loss of reduction, leading to a significant articular step-off or gap, was more frequent after TBW (53%) than after PF (5%). Tension band wiring resulted in 37% good clinical and 47% good roentgenographic results, as compared with PF, which resulted in 63% good clinical and 86% good roentgenographic results. Plate fixation should be carefully considered when planning open reduction and internal fixation of displaced olecranon fractures.

Ninety-five subtrochanteric femoral fractures were treated with an interlocking nail. There were 69 closed and 26 open fractures. This injury was the result of high-energy trauma in 77% of the cases. The average time to healing was 25 weeks. There were three delayed unions, one nonunion, and six malunions. Essentially all nonpathologic, subtrochanteric femur fractures can be stabilized by interlocking nailing, regardless of the fracture pattern or degree of comminution. Favorable mechanical characteristics of interlocking nails have eliminated the requirement of surgically reconstituting the medial femoral cortex. Closed interlocking nailing is the preferred treatment for subtrochanteric fractures of the femur resulting from trauma.

Fifty non-unions of the tibia that were present in forty-nine patients after external fixation and immobilization in a cast for a high-energy fracture were subsequently treated by compression plating. Initially, there were forty-six open fractures and four closed fractures with a compartment syndrome. Twenty-two non-unions (44 per cent) had early soft-tissue reconstruction (thirteen rotational and nine free flaps). The duration of external fixation averaged ten weeks, and the mean time from injury to plating was eight months. None of the non-unions were infected at the time of plating. The average preoperative deformity in the sagittal (anterior-posterior) plane was 8 degrees and in the frontal (medial-lateral) plane, 9 degrees; after plate fixation, the residual angulation averaged 3 and 2 degrees. Autogenous bone graft was used in thirty-nine of the fifty non-unions. The patients were followed for an average of twenty-four months. Forty-six (92 per cent) of the non-unions united, in an average of seven months, without further intervention. In four patients (8 per cent), the plate broke, necessitating re-plating in three and external fixation in one (the latter patient had an infected non-union). A deep infection developed in three patients (6 per cent). Ultimately, forty-eight non-unions (96 per cent) healed without evidence of infection. Plate osteosynthesis is an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and immobilization in a cast.

Thirty-four patients with ipsilateral fractures of the femur and tibia with intraarticular extension into the knee of at least one fracture were reviewed at an average follow-up of 38 months. Joint involvement was present in 22 (65%) femoral fractures and 23 (68%) tibial fractures. In 11 (32%) patients, both fractures were intraarticular. In 71% of the patients, there were major associated injuries. Open fractures were common, occurring in 21 (62%) extremities. Associated vascular injuries were seen in seven (21%) cases. Ninety percent of the fractures were surgically stabilized. The average time to healing was 39 and 37.5 weeks for the femur and tibia, respectively. The average flexion of the knee was 96 degrees (5-140 degrees) with flexion contractures occurring in five (15%) knees. Results were graded according to criteria established by Karlström and Olerud. Only eight (24%) patients had good or excellent results. Complications were frequent, with deep infections occurring in 11 (32%) extremities, leading to above-knee amputations in three (9%) patients. This subgroup of floating knee injuries appears to be associated with a higher degree of systemic trauma, a higher percentage of open injuries, and a much graver prognosis.

Thirty-three patients with ipsilateral intracapsular femoral neck and shaft fractures were treated with antegrade reamed intramedullary (IM) nails and cancellous screw fixation of the femoral neck. The shaft fractures were fixed prior to definitive neck stabilization. A "reversed" nail construct was used in 13 patients, a conventional interlocked nail was used in 6, and a reconstruction nail was used in the remaining 14. Thirty-one (94%) of the femoral shaft fractures healed primarily. In two patients, the shaft fracture failed to unite and was bone grafted and plated, respectively; the fractures subsequently healed. However, only 27 (82%) of the femoral neck fractures healed after initial fixation. In six patients (18%), a symptomatic varus nonunion developed, requiring a valgus osteotomy. Five of the six femoral neck non-unions and all of the osteotomy sites united; however, two of these patients later developed osteonecrosis of their femoral heads. Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of high rates of varus nonunion of the femoral neck fracture.

Fifty-six patients who had a fracture of the femur due to a low-velocity gunshot injury were treated with interlocking nailing with the Grosse-Kempf nail. Patients who had an isolated fracture were treated by intravenous administration of antibiotics followed by delayed interlocking nailing. Ninety-three per cent of the fractures had Grade-III or IV comminution. At an average duration of follow-up of sixteen months (range, twelve to twenty-nine months), the results of closed interlocking nailing were excellent. All of the fractures united an average of twenty-three weeks (range, fourteen to forty weeks) after the nailing. There were no apparent infections in the entire series. There were two delayed unions and seven malunions. Five patients had a serious associated vascular injury; four of these five had interlocking nailing immediately after vascular repair. The fractures united without any residual vascular insufficiency.

Fifteen patients with Type III avulsion fractures of the tibial tubercle treated surgically were reviewed at an average of 9.6 years after injury. Six patients had a history of Osgood-Schlatter disease, and two patients had Type I osteogenesis imperfecta. Associated injuries to the meniscus were found and repaired in three patients. Two of these patients had also avulsed the origin of the tibialis anterior muscle, leading to a compartment syndrome in one. All but one fracture healed. There was one refracture. Five patients developed bursitis over prominent screw heads, which required screw removal. All but two patients were asymptomatic and participated in sports. A full range of knee motion without instability was present in all patients. Thigh and calf circumferences were equal to the opposite side. Radiographs showed normal knee joints in all but one asymptomatic patient, who showed signs of an early arthrosis. No patient developed angular or recurvatum deformities. However, a leg-length discrepancy of 1.0-1.8 cm was noted in four patients (two overgrowth, two undergrowth).

Seventy-nine nonconsecutive patients with subtrochanteric femur fractures were divided into three groups based on the method of fracture fixation. Group I consisted of 21 patients treated with a Zickel nail, Group II comprised 25 patients treated with a 95 degrees blade plate, and Group III included 33 patients treated with an interlocking nail. All patients in Group I and Group II had open reduction and internal fixation of their fractures. Ninety-four percent of the patients in Group III were treated by closed intramedullary nailing. The average operating times for Groups I, II, and III were 212, 272, and 181 min, respectively, while blood loss averaged 900, 1,500, and 600 ml for each group, respectively. Group I had one infection, ten malunions, and one nonunion. Group II had one infection, six malunions, and two nonunions. Group III had no infections, two malunions, and one nonunion. We conclude that closed interlocking nailing is the treatment of choice for acute nonpathologic subtrochanteric femur fractures in adults. There is decreased blood loss, reduced operating time, and fewer complications than with either the Zickel nail or the 95 degrees blade plate regardless of the fracture pattern or the degree of fracture comminution.

Twenty-one adults who had a fracture of the middle of the humeral shaft and an injury of the ipsilateral brachial plexus were followed for an average of twenty-eight months. Only two of these patients showed evidence of neurological improvement. Of the eleven patients who had an associated traumatic injury to the brain, eight were treated non-operatively and three, operatively. The presence of a fracture of the humerus in a flail extremity has been found to delay rehabilitation markedly and to result in prolonged hospitalization. Eleven fractures were treated non-operatively with a brace or cast, and there were five non-unions, two delayed unions, and two malunions. Of the ten fractures that were treated operatively, three that were treated by compression-plating all united. Two fractures were treated by external fixation; one had a delayed union and one, a malunion. In the remaining five patients, who were treated with an intramedullary rod, there were two non-unions, one delayed union, and one malunion.