Mechanisms underlying food devaluation after response inhibition to food.

Multiple studies reveal that a requirement to stop a response to appetitive food stimuli causes devaluation of these stimuli. However, the mechanism underlying food devaluation after stopping is still under debate. The immediate-affect theory suggests that an increase in negative affect after stopping a response is the driving force for food devaluation. A competing value-updating theory presumes that food devaluation after stopping occurs through the need to align behavior with goals. The current study assessed how food devaluation after response inhibition is influenced by negative emotional reactivity and behavior-goal alignment on a trial-by-trial basis. The study included 60 healthy participants who completed a Food-Stop-Signal-Emotion task. Participants categorized high vs. low-calorie food stimuli and stopped their response upon encountering a stop signal. Subsequently, participants made subjective negativity ratings of negative- or neutral-valenced emotional images, and rated their desire to eat the previously depicted food. In contrast to predictions made by the immediate-affect account, food devaluation after stopping was not mediated nor moderated via changes in negative emotional reactivity after stopping. In support of the value-updating account, food devaluation was modulated by behavior-goal alignment, indicated by larger food devaluation after successful vs. failed stopping. In agreement with this theory, the findings indicate that devaluation occurs more strongly when performance aligns with the task requirement. This study sheds light on the mechanism that likely underlies food devaluation after stopping. Implications regarding applied use of food-inhibition trainings are discussed.

Early weight gain as a predictor of weight restoration in avoidant/restrictive food intake disorder.

BACKGROUND: Previous research has demonstrated that early weight gain in family-based treatment (FBT) is predictive of remission for adolescents with anorexia nervosa (AN). However, no published data has addressed if early weight gain is also predictive of reaching weight restoration (i.e., 95% EBW) in patients with avoidant/restrictive food intake disorder (ARFID). Furthermore, no studies have evaluated the performance of the statistical models used to predict weight restoration at the end of treatment. This study sought to examine whether early weight gain in ARFID is predictive of weight restoration at 20 weeks using ROC analysis. Additionally, this study assessed how accurately the model classified patients and what types of misclassifications occurred. METHODS: Participants (n = 130, 57.7% cisgender female 70.0% white) received virtual outpatient FBT. Receiver operating characteristics (ROC) were used to predict successful weight restoration at end of treatment, using early weight gain as the predictor. Twenty weeks was considered as the end of treatment, to align with the definition of end of treatment in FBT clinical trials. ROC analyses demonstrated that gaining at least 6.2 pounds by week 5 of treatment was the strongest predictor of achieving 95% EBW at 20 weeks (AUC = 0.72 [0.63, 0.81]). ROC analyses misclassified 35% of patients; the most common misclassification was predicting that a patient would not achieve 95% EBW when they actually did (61.6%). A logistical regression model, which included the patients' %EBW at admission in addition to early weight gain as a predictor, outperformed the ROC analyses (AUC = 0.90 [0.85, 0.95]) and provided additional context by showing the probability that a patient would succeed. CONCLUSION: Taken together, research demonstrates that early weight gain is a useful predictor of 95% EBW at 20 weeks of treatment for patients with ARFID who require weight restoration. Furthermore, results suggest that statistical models need to take into account additional information, such as %EBW at admission, along with early weight gain in order to more accurately predict which patients will reach weight restoration at week 20.

Results from this study indicate that when patients with avoidant/restrictive food intake disorder (ARFID) gain weight steadily at the beginning of treatment, it helps them reach 95% expected body weight (EBW) by week 20 of treatment. The more weight the patients gain each week early on, the better their chances of getting to 95% EBW by week 20. However, there are two important things to consider: how much the patients weigh when they start treatment (starting %EBW) and how much weight they gain each week. Both of these factors affect the chances of reaching 95% EBW by week 20. Thus, this study highlights the goals for gaining weight at the start of treatment need to be different for each person, depending on how much they weigh when they begin. This may help patients with ARFID reach the goal of being at 95% EBW within 20 weeks.

Expressed emotion and early treatment response in family-based treatment for adolescent anorexia nervosa.

This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12-18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced.

Who Responds to an Adaptive Intervention for Adolescents With Anorexia Nervosa Being Treated With Family-Based Treatment? Outcomes From a Randomized Clinical Trial.

OBJECTIVE: Anorexia nervosa (AN) is a serious psychiatric disorder with high morbidity and mortality. The current evidence supports the use of family-based treatment (FBT), but recovery rates are only about 40%. Improving treatment outcomes among adolescents with AN will save lives, improve health, and prevent chronicity. This study examined the relative efficacy of adding intensive parental coaching (IPC) to standard FBT for patients who do not respond by weight gain of 2.4 kg by session 4, a clinical predictor of outcome at the end of treatment, to improve remission rates (>94% of expected mean body mass index). METHOD: The study recruited 107 participants and their families from across the United States; 69 participants failed to respond early and were randomly assigned to continue with standard FBT or to receive 3 sessions of IPC. Participants were adolescents (ages 12-18) meeting DSM-5 criteria for AN; 6.5% were male, and 11% were Hispanic. RESULTS: Main outcomes were mean body mass index >94% expected for age, height, and sex. Secondary outcomes included change in eating-related cognitions. Adding IPC to early nonresponders did not improve outcomes except for participants whose parents demonstrated low parental self-efficacy at baseline (moderator). Early weight gain of 2.4 kg by session 4 was replicated as a predictor of end of treatment remission. CONCLUSION: Parental self-efficacy moderates IPC as an adaptive treatment for adolescents with AN. Baseline parental self-efficacy assessment can be used to identify families most likely to benefit from adding IPC to FBT. Future studies should consider earlier interventions to improve early response rates. PLAIN LANGUAGE SUMMARY: Anorexia nervosa is a serious psychiatric disorder. While family-based treatment (FBT) has the largest evidence base for adolescents with anorexia, recovery rates are only about 40%. This study investigated the addition of 3 sessions of intensive parental coaching intervention (IPC) to FBT among youth with anorexia who did not gain adequate weight early in treatment, a predictor of recovery by the end of treatment. Youth with inadequate weight gain were randomized to either receive FBT with IPC or FBT as usual. Overall, adding IPC did not improve outcomes among youth with anorexia. However among those whose parents demonstrated low parental self-efficacy at baseline, youth who received FBT with IPC had higher remission rates than youth who received FBT alone. CLINICAL GUIDANCE: Intensive parental coaching shows promise for improving outcomes among youth with anorexia whose parents report low parental self-efficacy. CLINICAL TRIAL REGISTRATION INFORMATION: Adaptive Treatment for Adolescent Anorexia Nervosa; https://clinicaltrials.gov/; NCT03097874.

Family-based treatment (FBT) for loss of control (LOC) eating in youth: Current knowledge and future directions.

Loss of control (LOC) eating in youth is a common disordered eating behavior and associated with negative health and psychological sequalae. Family-based treatment (FBT) is an efficacious treatment for adolescent anorexia nervosa and bulimia nervosa (BN) but has not been formally evaluated for adolescents with LOC eating. This study is a secondary data analysis from a randomized controlled clinical trial (NCT00879151) testing FBT for 12-18-year-olds with BN. Data were reanalyzed to examine outcomes for LOC eating episodes, regardless of episode size. Abstinence rates, defined as zero LOC eating episodes (objective or subjective binge episodes) in the previous month, were calculated at the end-of-treatment (EOT), 6-month, and 12-month follow-up time points. Among 51 adolescent participants (M + SD: 15.94 + 1.53 y; 92% female; 23.5% Hispanic; 76.5% Caucasian), FBT significantly reduced LOC eating episodes, with 49% achieving LOC eating abstinence at EOT. At 6-month follow-up, 41% achieved LOC eating abstinence. Of those providing 12-month follow-up data, 73% achieved abstinence. This preliminary exploration suggests that FBT may be effective for youth with LOC eating, regardless of episode size. Additional research is needed to replicate these findings and extend treatments with developmental adaptations for younger children with LOC eating.

A randomized trial of two group-delivered transdiagnostic eating disorder treatments: Dissonance-based treatment versus interpersonal psychotherapy.

OBJECTIVE: Test whether a group-delivered dissonance-based transdiagnostic eating disorder treatment, Body Project Treatment (BPT), produces greater reductions in eating disorder symptoms and higher abstinence from eating disorder behaviors and remittance from eating disorder diagnoses than group-delivered transdiagnostic interpersonal psychotherapy (IPT). METHOD: Women with a range of eating disorders (N = 73) were randomized to 8-week group-implemented BPT or IPT and completed surveys and masked diagnostic interviews at pretest, posttest, and 6-month follow-up. RESULTS: Participants randomized to BPT versus IPT showed significantly greater reductions in eating disorder symptoms (d = -.75), pursuit of the thin ideal (d = -.87), anxiety symptoms (d = -.76), and social impairment (d = -.59) through 6-month follow-up. By end of treatment, participants randomized to the BPT versus IPT did not significantly differ on abstinence from binge eating and purging (49% vs. 40%, respectively) or remittance from eating disorder diagnoses (54% vs. 40%, respectively). Participants randomized to BPT versus IPT did not differ significantly in average session attendance (5.8 vs. 6.9, respectively) or average homework assignments completed (4.6 vs. 5.6, respectively). The within-condition reductions in eating disorder symptoms for BPT did not significantly differ when implemented in person versus via synchronous video telepsychiatry (d = -1.39 vs. -1.09, respectively), though these effects should be considered preliminary because of the small cell sizes. CONCLUSIONS: The evidence that BPT produces greater reductions in eating disorder symptoms, pursuit of the thin ideal, anxiety symptoms, and social impairment than IPT is encouraging because it provides some assurance that the effects are present equating for the effects of expectancies, demand characteristics, and nonspecific factors. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The assessment of caregiver self-efficacy in a virtual eating disorder setting.

BACKGROUND: Caregiver self-efficacy is thought to be a key component for successful family-based treatment (FBT) for individuals with eating disorders. As such, interventions aimed at enhancing caregiver self-efficacy, often measured via the Parents Versus Anorexia scale, have been a focal point of FBT literature. However, studies looking at the relationship between caregiver self-efficacy and treatment outcomes have been mixed. We aimed to better understand the influence of caregiver self-efficacy on eating disorder treatment outcomes during FBT. METHODS: Caregiver self-efficacy was measured using the Parents Versus Eating Disorders (PVED) scale, an adapted version of the Parents Versus Anorexia scale, in a sample of 1051 patients with an eating disorder and 1528 caregivers (patients can have more than one caregiver) receiving virtual FBT. Across two multilevel models, we tested how caregiver self-efficacy changed over time and its association with changes in eating disorder symptoms and weight over the first 16 weeks of treatment. RESULTS: Over treatment, PVED scores increased (b = 0.79, SE = 0.04, CI [0.72, 0.86]) and starting PVED scores were predictive of improved eating disorder symptoms (b = - 0.73, SE = 0.22, CI [- 1.15, - 0.30]), but not weight (b = - 0.96, SE = 0.59, CI [- 2.10, 0.19]). We also found that PVED change-from-baseline scores were predictive of weight (b = - 0.48, SE = 0.03, CI [- 0.53, - 0.43]) such that patient weight was lower when caregiver reports of PVED were higher. Likewise, the association between caregiver change in PVED scores and weight varied as a function of treatment time (b = 0.27, SE = 0.01, CI [0.24, 0.29]). Results were consistent when isolating patients with anorexia nervosa. CONCLUSIONS: Caregiver self-efficacy during FBT improved over time but was not robustly associated with treatment outcomes. This may, in part, be due to psychometric properties of the PVED scale. We describe these issues and illustrate the need for development of a new measure of self-efficacy for caregivers supporting their loved ones through eating disorder treatment.

In family-based treatment (FBT) for eating disorders, caregivers play a central role in helping their child recover. Specifically, a caregiver's self-efficacy, or their confidence in their ability to cope with the challenges their child faces during treatment, is believed to be a key to successful treatment outcomes. However, research on the impact caregiver self-efficacy has on patient treatment outcomes is mixed. Using the Parent vs. Eating Disorder (PVED) scale, we looked at the association between caregiver self-efficacy and eating disorder symptoms and weight changes over time in a sample of 1051 patients receiving virtual FBT. Caregiver self-efficacy had little to no significant impact on treatment outcomes. We offer explanations about why our findings challenge existing research that supports the association between caregiver self-efficacy and outcomes. Namely, the PVED scale appears to measure caregiver perceptions of their role in the treatment process (and not self-efficacy). We believe a new measurement tool must be developed and tested for the field to move forward in its understanding of the role caregiver self-efficacy plays in FBT.

An orexigenic subnetwork within the human hippocampus.

Only recently have more specific circuit-probing techniques become available to inform previous reports implicating the rodent hippocampus in orexigenic appetitive processing1-4. This function has been reported to be mediated at least in part by lateral hypothalamic inputs, including those involving orexigenic lateral hypothalamic neuropeptides, such as melanin-concentrating hormone5,6. This circuit, however, remains elusive in humans. Here we combine tractography, intracranial electrophysiology, cortico-subcortical evoked potentials, and brain-clearing 3D histology to identify an orexigenic circuit involving the lateral hypothalamus and converging in a hippocampal subregion. We found that low-frequency power is modulated by sweet-fat food cues, and this modulation was specific to the dorsolateral hippocampus. Structural and functional analyses of this circuit in a human cohort exhibiting dysregulated eating behaviour revealed connectivity that was inversely related to body mass index. Collectively, this multimodal approach describes an orexigenic subnetwork within the human hippocampus implicated in obesity and related eating disorders.

Human habit neural circuitry may be perturbed in eating disorders.

Circuit-based mechanisms mediating the development and execution of habitual behaviors involve complex cortical-striatal interactions that have been investigated in animal models and more recently in humans. However, how human brain circuits implicated in habit formation may be perturbed in psychiatric disorders remains unclear. First, we identified the locations of the sensorimotor putamen and associative caudate in the human brain using probabilistic tractography from Human Connectome Project data. We found that multivariate connectivity of the sensorimotor putamen was altered in humans with binge eating disorder and bulimia nervosa and that the degree of alteration correlated with severity of disordered eating behavior. Furthermore, the extent of this circuit aberration correlated with mean diffusivity in the sensorimotor putamen and decreased basal dopamine D2/3 receptor binding potential in the striatum, consistent with previously reported microstructural changes and dopamine signaling mediating habit learning in animal models. Our findings suggest a neural circuit that links habit learning and binge eating behavior in humans, which could, in part, explain the treatment-resistant behavior common to eating disorders and other psychiatric conditions.

Aberrant reward-related neural activation: Dimensional correlate of binge-eating severity or categorical marker of binge eating?

Binge eating (BE) is characterized by consuming an objectively large amount of food in a short period of time and experiencing loss of control over one's eating. The neural underpinnings of monetary reward anticipation and their association with BE severity remain poorly understood. Fifty-nine women aged 18 to 35 (M = 25.67, SD = 5.11) with a range of average weekly BE frequency (M = 1.96, SD = 1.89, range = 0-7) completed the Monetary Incentive Delay Task during fMRI scanning. Mean percent signal change within the left and right nucleus accumbens (NAc) during anticipation of monetary gain (versus non-gain) was extracted from a priori-defined functional 5 mm spheres and correlated with average weekly BE frequency. Exploratory voxel-wise whole-brain analyses examined the association between neural activation during anticipation of monetary reward and average weekly BE frequency. Body mass index and depression severity were covariates of non-interest in analyses. Mean percent signal change in the left and right NAc inversely correlated with average weekly BE frequency. Whole-brain analysis revealed no significant associations between neural activation during reward anticipation and average weekly BE frequency. In exploratory case-control analyses, mean percent signal change in the right NAc was significantly lower in women with BE (n = 41) versus women without BE (n = 18), but whole-brain analyses revealed no significant group differences in neural activation during reward anticipation. Decreased right NAc activity during monetary reward anticipation may distinguish women with and without BE.

Efficacy of virtual delivery of a dissonance-based eating disorder prevention program and evaluation of a donation model to support sustained implementation.

OBJECTIVE: Evaluate whether the Body Project prevention program reduces eating disorder risk factors and symptoms when implemented via synchronous video telepsychiatry, which could markedly increase the reach of this intervention and test whether a pay-it-forward donation model could support sustained implementation of this intervention. METHOD: Young women at high risk for eating disorders because of body image concerns (N = 75; age range 16-27) were randomized to Body Project groups delivered virtually by peer educators or a waitlist control condition; participants who completed the Body Project for free because of past donations were encouraged to donate money so that this intervention could be provided for free to others. RESULTS: Participants randomized to virtually delivered Body Project groups showed significantly or marginally greater pretest-to-posttest reductions in pursuit of the thin ideal, body dissatisfaction, dieting, negative affect, and eating disorder symptoms than controls. The average effect was large (d = .79), which was 49% larger than the average effect observed previously for in-person peer-educator-delivered Body Project groups (d = .53; [.76-.53 = .23/.53 = 49%]). However, only 3.6% of participants donated money to support future implementation of this intervention. CONCLUSIONS: The evidence that the Body Project produced large reductions in eating disorder risk factors and symptoms when implemented virtually and that the effects were larger than for in-person Body Project groups suggests it would be useful to implement this prevention program virtually, which could expand the reach of this intervention. Future studies should evaluate alternative methods for supporting sustained implementation of this prevention program. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Understanding outcomes in family-based treatment for adolescent anorexia nervosa: a network approach.

BACKGROUND: Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa (AN). Yet, remission is not achieved for about half of adolescents with AN receiving FBT. Understanding patient- and parent-level factors that predict FBT response may inform treatment development and improve outcomes. METHODS: Network analysis was used to identify the most central symptoms of AN in adolescents who completed the Eating Disorder Examination (EDE) prior to FBT (N = 409). Bridge pathways between adolescent AN and parental self-efficacy in facilitating their child's recovery from AN were identified in a subset of participants (n = 184). Central and bridge symptoms were tested as predictors of early response (⩾2.4 kg weight gain by the fourth session of FBT) and end-of-treatment weight restoration [⩾95% expected body weight (EBW)] and full remission (⩾95% EBW and EDE score within 1 standard deviation of norms). RESULTS: The most central symptoms of adolescent AN included desiring weight loss, dietary restraint, and feeling fat. These symptoms predicted early response, but not end-of-treatment outcomes. Bridge symptoms were parental beliefs about their responsibility to renourish their child, adolescent discomfort eating in front of others, and adolescent dietary restraint. Bridge symptoms predicted end-of-treatment weight restoration, but not early response nor full remission. CONCLUSIONS: Findings highlight the prognostic utility of core symptoms of adolescent AN. Parent beliefs about their responsibility to renourish their child may maintain associations between parental self-efficacy and AN psychopathology. These findings could inform strategies to adapt FBT and improve outcomes.

Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth.

Barriers limit access to eating disorder treatment. Evidence-based treatment delivered using telemedicine could expand access. This study determined the effectiveness of enhanced Family-Based Treatment (FBT+) delivered using telemedicine for children and adolescents with eating disorders. Participants had a confirmed eating disorder diagnosis, lived in states where treatment was available, and lived with a family member willing to participate. Virtual FBT+ was administered by a five-person team including a therapist, dietitian, medical provider, peer mentor, and family mentor for up to 12 months. Measures were recorded at baseline and varying frequencies throughout treatment. Weight was self-reported. Eating disorder symptoms were assessed with the Eating Disorder Examination-Questionnaire Short Form (EDE-QS) and depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Caregiver burden and self-efficacy were measured using the Burden Assessment Scale, and Parent Versus Eating Disorder scale. The majority of patients (N = 210; 6 to 24 years old [mean 16 · 1 years]) were cisgender female (83%) White, (71%), required weight restoration (78%), and had anorexia nervosa, restricting type (63%). After 16 weeks, patients on weight restoration gained on average 11 · 3 [9 · 86, 12 · 8] pounds and the average change in EDE-QS score was -6 · 31 [-8 · 67, -4 · 10] points. Similar reductions were seen for depression (-2 · 62 [-4 · 24, -1 · 04]), anxiety (-1 · 44 [-1 · 12, 0 · 78]), and caregiver burden (-4 · 41 [2 · 45, 6 · 31]). Caregiver self-efficacy increased by 4 · 56 [3 · 53, 5 · 61] points. Patients and caregivers reported satisfaction with treatment. Virtual FBT+ for eating disorders can transcend geographical and psychosocial treatment barriers, expanding access to evidence-based eating disorder treatment.

Predictors of family-based treatment for adolescent eating disorders: Do family or diagnostic factors matter?

OBJECTIVE: Misconceptions around which patients will and will not benefit from family-based treatment (FBT) for adolescent eating disorders (EDs) limit referrals and access to this treatment modality. The present study explored whether common demographic and clinical factors that may prevent referral to FBT predict treatment outcomes in adolescent anorexia nervosa (AN) and bulimia nervosa (BN). METHOD: The following predictors of treatment outcomes were assessed: baseline family and diagnostic factors (socioeconomic status, comorbidity, illness duration, parent feelings of self-efficacy, family status, prior treatment, sex and prior hospitalizations) in a combined sample of adolescents receiving FBT compared to those randomized to other treatment conditions, across six clinical trials in the United States and Canada (total n = 724, ages 12-18, 90% female across both diagnoses). AN and BN samples were examined separately. RESULTS: Any prior ED treatment emerged as the only predictor of outcome in AN and BN, such that having no prior treatment predicted better outcomes in FBT for AN, and in both FBT and other treatment modalities for BN. No other sociodemographic or clinical variables predicted outcomes for AN or BN in FBT or in other evidence-based treatment modalities. CONCLUSIONS: The findings of this exploratory analysis suggest that commonly assumed factors do not predict outcome in FBT. Specifically socioeconomic and demographic factors or clinical variability in families seeking treatment do not predict treatment outcomes in FBT, or other evidence-based treatment modalities, with the exception of prior treatment. Providers should consider referring to FBT even when these factors are present. PUBLIC SIGNIFICANCE: This manuscript reports that commonly assumed family, sociodemographic and diagnostic factors do not predict outcome in FBT or other evidence-based treatment modalities, with the exception of prior treatment. This data may be helpful for providers when considering referrals to FBT in the context of variability in these variables.

Evaluating differences in setting expected body weight for children and adolescents in eating disorder treatment.

OBJECTIVE: Weight restoration or weight gain is a common goal in eating disorder treatment. However, approaches to determine expected body weight (EBW) vary. A standardized approach based on normative data for a patient's age and gender uses weight associated with median BMI (mBMI). An individualized approach predicts EBW based on a patient's individual growth trajectory. Little research has examined differences in these approaches. METHOD: Weight and clinical data were collected from patients ages 6-20 enrolled in virtual eating disorder treatment. EBW associated with mBMI was compared with EBW using the individualized approach. Linear mixed effects models examined differences in weight, eating disorder symptoms, depression, and anxiety, and whether EBW approach varied by patient characteristics. RESULTS: Patients (N = 609) were on average age 15.6 (2.29), 85% were cisgender female, and predominantly diagnosed with anorexia nervosa (83.1%). The individualized approach led to significantly higher EBW on average (mean difference = 8.4 lbs [SE: .75]; p < .001) compared to mBMI; 70% of patients had a higher EBW using the individualized approach. Notably, EBW varied based on gender and diagnosis and it took longer on average to achieve individualized EBW. Time was the strongest predictor of changes in psychosocial outcomes and there were no significant differences by EBW approach. DISCUSSION: Results from this study indicate that an individualized approach led to significantly higher EBWs compared with using mBMI. As underestimation of EBW may lead to higher risk of relapse, eating disorder professionals should consider using an individualized approach for setting EBW. PUBLIC SIGNIFICANCE: For eating disorder patients who need to gain weight, accurately estimating target body weight for eating disorder treatment is critical to recovery and preventing relapse. An individualized, patient-centered approach to estimating target body weight more accurately estimated target body weight than the standardized, median body mass index approach. Using an individualized approach to treatment may improve a patient's likelihood of full recovery.

Protocol for a randomized clinical trial for Avoidant Restrictive Food Intake Disorder (ARFID) in low-weight youth.

Background Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder recently added to the Diagnostic and Statistical Manual, 5th Edition (DSM-5) that involves nutritional, developmental, and/or psychosocial impairment, and often presents with a lack of interest in eating, sensory-related eating concerns, and/or fear of adverse consequences related to eating. There is limited evidence on treatments for ARFID, and in particular, treatments for children in the outpatient setting. Pilot data suggest that Family-Based Treatment (FBT) modified for ARFID is efficacious, and that improvements in parental self-efficacy may be the mechanism behind its success. This manuscript describes a study protocol seeking to confirm these preliminary findings through an adequately powered, randomized clinical trial (RCT). METHODS: This trial will randomize 100 children ages 6-12 years old who meet DSM-5 criteria for ARFID and their families to receive either 14 telehealth sessions of FBT-ARFID (n = 50) or a manualized Psychoeducational Motivation Therapy (PMT) treatment (n = 50), an individual therapy addressing the child's understanding of the problems ARFID is causing and promoting non-behavioral motivation and exploration of changing their eating patterns. Masked assessments will be conducted at baseline, one and two months within treatment, end-of-treatment, and six-month follow-up. Primary outcomes include change in body weight, parental self-efficacy, and parent feeding behaviors between baseline and end-of-treatment. CONCLUSIONS: The results of this RCT will advance our understanding of effective treatments for low-weight ARFID in youth.

Pilot study of responsive nucleus accumbens deep brain stimulation for loss-of-control eating.

Cravings that precede loss of control (LOC) over food consumption present an opportunity for intervention in patients with the binge eating disorder (BED). In this pilot study, we used responsive deep brain stimulation (DBS) to record nucleus accumbens (NAc) electrophysiology during food cravings preceding LOC eating in two patients with BED and severe obesity (trial registration no. NCT03868670). Increased NAc low-frequency oscillations, prominent during food cravings, were used to guide DBS delivery. Over 6 months, we observed improved self-control of food intake and weight loss. These findings provide early support for restoring inhibitory control with electrophysiologically-guided NAc DBS. Further work with increased sample sizes is required to determine the scalability of this approach.

Study protocol for training providers in private practice in family-based treatment for adolescents with anorexia nervosa: A randomized controlled feasibility trial.

BACKGROUND: Private practice clinicians make up approximately 50% of US mental health outpatient providers and treat a high number of eating disorder patients. While family-based treatment (FBT) is a first-line treatment for adolescent anorexia nervosa (AN), private practice clinicians experience difficulties receiving training in evidence-based treatments such as FBT. This report outlines the study protocol for a randomized control trial (RCT) training private practice clinicians in FBT for adolescent AN (NCT04428580). METHODS: In this study, we intend to recruit 140 private practice mental health practitioners and randomize them to complete either a standard webinar-based online training or an enhanced online training that incorporates additional modules related to the putative mechanisms of treatment effect in FBT (i.e., use of externalization and agnosticism). Following the training, participants will begin expert case consultation for an adolescent with AN using FBT from their private practice. CONCLUSION: Based on preliminary studies suggesting the importance of enhanced skills related to agnosticism and externalization, we hypothesize that feasibility data will support a larger randomized clinical trial (RCT) and that the enhanced training arm will significantly improve FBT knowledge and skills compared to the standard webinar training arm. We also expect that patient weight gain early in treatment will be associated with clinician fidelity to the inventions used in FBT regardless of training type.

Aberrant impulse control circuitry in obesity.

The ventromedial prefrontal cortex (vmPFC) to nucleus accumbens (NAc) circuit has been implicated in impulsive reward-seeking. This disinhibition has been implicated in obesity and often manifests as binge eating, which is associated with worse treatment outcomes and comorbidities. It remains unclear whether the vmPFC-NAc circuit is perturbed in impulsive eaters with obesity. Initially, we analyzed publicly available, high-resolution, normative imaging data to localize where vmPFC structural connections converged within the NAc. These structural connections were found to converge ventromedially in the presumed NAc shell subregion. We then analyzed multimodal clinical and imaging data to test the a priori hypothesis that the vmPFC-NAc shell circuit is linked to obesity in a sample of female participants that regularly engaged in impulsive eating (i.e., binge eating). Functionally, vmPFC-NAc shell resting-state connectivity was inversely related to body mass index (BMI) and decreased in the obese state. Structurally, vmPFC-NAc shell structural connectivity and vmPFC thickness were inversely correlated with BMI; obese binge-prone participants exhibited decreased vmPFC-NAc structural connectivity and vmPFC thickness. Finally, to examine a causal link to binge eating, we directly probed this circuit in one binge-prone obese female using NAc deep brain stimulation in a first-in-human trial. Direct stimulation of the NAc shell subregion guided by local behaviorally relevant electrophysiology was associated with a decrease in number of weekly episodes of uncontrolled eating and decreased BMI. This study unraveled vmPFC-NAc shell circuit aberrations in obesity that can be modulated to restore control over eating behavior in obesity.