Randomized Controlled Trial Comparing Health Coach-Delivered Smartphone-Guided Self-Help With Standard Care for Adults With Binge Eating.

OBJECTIVE: Cognitive-behavioral therapy (CBT) has shown efficacy in the treatment of eating disorders. The authors conducted a randomized controlled telemedicine trial of CBT-guided self-help (CBT-GSH) assisted with a smartphone app, Noom Monitor, for binge eating with or without purging. They hypothesized that coach-delivered CBT-GSH telemedicine sessions plus Noom Monitor would yield greater reductions in symptoms of binge eating, purging, and eating disorders compared with standard care. METHODS: Fifty-two-week outcomes for CBT-GSH plus Noom Monitor (N=114) were compared with outcomes for standard care (N=111) among members of an integrated health care system in the Pacific Northwest. Patients in the health system who met inclusion criteria were ≥18 years old, had a body mass index ≥18.5, met criteria for DSM-5 binge eating disorder or bulimia nervosa, had 12 months of continuous health care enrollment in Kaiser Permanente Northwest, and had a personal smartphone. Participants received eight CBT-GSH telemedicine sessions over 12 weeks administered by health coaches, and outcomes were assessed at baseline and at weeks 4, 8, 12, 26, and 52. The use of available treatment offered within the Kaiser Permanente health care system was permitted for participants assigned to standard care. RESULTS: Participants who received CBT-GSH plus Noom Monitor reported significant reductions in objective binge-eating days (ß=-0.66, 95% CI=-1.06, -0.25; Cohen's d=-1.46, 95% CI=-4.63, -1.09) and achieved higher rates of remission (56.7% compared with 30%; number needed to treat=3.74) at 52 weeks compared with participants in standard care, none of whom received any eating disorder treatment during the intervention period (baseline and weeks 1-12). Similar patterns emerged for compensatory behaviors (vomiting, use of laxatives, and excessive exercise; 76.3% compared with 56.8%; number needed to treat=5.11), eating disorder symptoms (body shape, weight, eating concerns, and dietary restraint), and clinical impairment (Cohen's d=-10.07, -2.15). CONCLUSIONS: These results suggest that CBT-GSH plus Noom Monitor delivered via telemedicine by routine-practice health coaches in a nonacademic health care system yields reductions in symptoms and impairment over 52 weeks compared with standard care.

Randomized controlled trial comparing smartphone assisted versus traditional guided self-help for adults with binge eating.

OBJECTIVE: Guided self-help treatments based on cognitive-behavior therapy (CBT-GSH) are efficacious for binge eating. With limited availability of CBT-GSH in the community, mobile technology offers a means to increase use of these interventions. The purpose of this study was to test the initial efficacy of Noom Monitor, a smartphone application designed to facilitate CBT-GSH (CBT-GSH + Noom), on study retention, adherence, and eating disorder symptoms compared to traditional CBT-GSH. METHOD: Sixty-six men and women with DSM-5 binge-eating disorder (BED) or bulimia nervosa (BN) were randomized to receive eight sessions of CBT-GSH + Noom (n = 33) or CBT-GSH (n = 33) over 12 weeks. Primary symptom outcomes were eating disorder examination objective bulimic episodes (OBEs), subjective bulimic episodes (SBEs), and compensatory behaviors. Assessments were collected at 0, 4, 8, 12, 24, and 36 weeks. Behavioral outcomes were modeled using zero-inflated negative-binomial latent growth curve models with intent-to-treat. RESULTS: There was a significant effect of treatment on change in OBEs (ß = -0.84, 95% CI = -1.49, -0.19) favoring CBT-GSH + Noom. Remission rates were not statistically different between treatments for OBEs (ßlogit = -0.73, 95% CI = -1.86, 3.27; CBT-GSH-Noom = 17/27, 63.0% vs. CBT-GSH 11/27, 40.7%, NNT = 4.5), but CBT-GSH-Noom participants reported greater meal and snack adherence and regular meal adherence mediated treatment effects on OBEs. The treatments did not differ at the 6-month follow-up. DISCUSSION: Smartphone applications for the treatment binge eating appear to have advantages for adherence, a critical component of treatment dissemination.

Reducing eating disorder risk factors: A pilot effectiveness trial of a train-the-trainer approach to dissemination and implementation.

OBJECTIVE: Impediments limit dissemination and implementation of evidence-based interventions (EBIs), including lack of sufficient training. One strategy to increase implementation of EBIs is the train-the-trainer (TTT) model. The Body Project is a peer-led body image program that reduces eating disorder (ED) risk factors. This study examined the effectiveness of a TTT model at reducing risk factors in Body Project participants. Specifically, this study examined whether a master trainer could train a novice trainer to train undergraduate peer leaders to administer the Body Project such that individuals who received the Body Project (i.e., participants) would evidence comparable outcomes to previous trials. We hypothesized that participants would evidence reductions in ED risk factors, with effect sizes similar to previous trials. METHOD: Utilizing a TTT model, a master trainer trained a novice trainer to train undergraduate peer leaders to administer the Body Project to undergraduate women. Undergraduate women aged 18 years or older who received the Body Project intervention participated in the trial and completed measures at baseline, post-treatment, and five-month follow-up. Primary outcomes included body dissatisfaction, thin ideal internalization, negative affect, and ED pathology. RESULTS: Participants demonstrated significant reductions in thin ideal internalization, ED pathology and body dissatisfaction at post-treatment and 5-month follow-up. At 5 months, using three different strategies for managing missing data, effect sizes were larger or comparable to earlier trials for 3 out of 4 variables. DISCUSSION: Results support a TTT model for Body Project implementation and the importance of utilizing sensitivity analyses for longitudinal datasets with missing data.

Testing the disgust conditioning theory of food-avoidance in adolescents with recent onset anorexia nervosa.

Anorexia nervosa is characterized by chronic food avoidance that is resistant to change. Disgust conditioning offers one potential unexplored mechanism for explaining this behavioral disturbance because of its specific role in facilitating food avoidance in adaptive situations. A food based reversal learning paradigm was used to study response flexibility in 14 adolescent females with restricting subtype anorexia nervosa (AN-R) and 15 healthy control (HC) participants. Expectancy ratings were coded as a behavioral measure of flexibility and electromyography recordings from the levator labii (disgust), zygomaticus major (pleasure), and corrugator (general negative affect) provided psychophysiological measures of emotion. Response inflexibility was higher for participants with AN-R, as evidenced by lower extinction and updated expectancy ratings during reversal. EMG responses to food stimuli were predictive of both extinction and new learning. Among AN-R patients, disgust specific responses to food were associated with impaired extinction, as were elevated pleasure responses to the cued absence of food. Disgust conditioning appears to influence food learning in acutely ill patients with AN-R and may be maintained by counter-regulatory acquisition of a pleasure response to food avoidance and an aversive response to food presence. Developing strategies to target disgust may improve existing interventions for patients with AN.

Stress and addiction.

Appetitive behaviors such as substance use and eating are under significant regulatory control by the hypothalamic-pituitary adrenal (HPA) and hypothalamic pituitary gonadal (HPG) axes. Recent research has begun to examine how these systems interact to cause and maintain poor regulation of these appetitive behaviors. A range of potential molecular, neuroendocrine, and hormonal mechanisms are involved in these interactions and may explain individual differences in both risk and resilience to a range of addictions. This manuscript provides a commentary on research presented during the International Society of Psychoneuroendocrinology's mini-conference on sex differences in eating and addiction with an emphasis on how HPG and HPA axis interactions affect appetitive behaviors in classic addictions and may be used to help inform the ongoing debate about the validity of food addiction.

Reducing self-objectification: are dissonance-based methods a possible approach?

BACKGROUND: Previous research has documented that self-objectification is associated with numerous negative outcomes including body shame, eating disorder (ED) pathology, and negative affect. This exploratory open study investigated whether or not an evidence-based body image improvement program that targets thin-ideal internalization in university women also reduces self-objectification. A second aim of the study was to determine if previous findings showing that body shame mediated the relationship between self-objectification and eating disorder pathology at a single time point (consistent with self-objectification theory) but did not mediate longitudinally (inconsistent with self-objectification theory) would be replicated in a new sample under novel conditions. METHODS: Ninety-six university women completed a peer-led dissonance-based intervention, along with assessment measures at pre-, post-intervention, 8-week and 8-month follow-up. To address the open trial nature of this study, a planned manipulation check was included to make sure that peer-led dissonance decreased thin-ideal internalization, body dissatisfaction, eating disorder pathology, and negative affect with effect sizes being similar to past randomized controlled trials. We hypothesized that all three subscales of the Objectified Body Consciousness Scale (i.e., self-surveillance, body shame, and appearance control beliefs) would be reduced. In addition, we hypothesized that body shame would mediate the relationship between self-objectification (i.e., self-surveillance) and eating disorder pathology at a both at a single time point and longitudinally. RESULTS: The planned manipulation check supported the interpretation that peer-led dissonance in this study largely yielded comparable changes to past controlled trials. In terms of changes in dependent variables, results supported all hypotheses with the exception of body shame, which remained unchanged. With regards to the mediation analyses, our first (cross-sectional) hypothesis but not our second (longitudinal) was supported. CONCLUSIONS: Findings provide preliminary support for the use of dissonance interventions in reducing self-surveillance and body control beliefs. Results for body shame and the mediation analyses suggest that greater scrutiny of the body shame construct is warranted.

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders.

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Eating disorders in youth: diagnostic variability and predictive validity.

OBJECTIVE: The primary aim was to examine the utility of DSM-IV criteria in predicting treatment outcome in a sample of adolescents with eating disorders. METHOD: We (a) descriptively compared the baseline rates of anorexia nervosa (AN) and bulimia nervosa (BN) across multiple reference points for diagnostic criteria, (b) using ROC curve analyses, assessed the sensitivity and specificity of each diagnostic criterion in predicting clinical outcome, and (c) with logistic regression analyses, examined the incremental predictive value of each criterion. RESULTS: Results show a high degree of variability in the baseline diagnostic profiles as a function of the information used to inform each DSM-IV criterion. For AN, Criterion A yielded the best predictive validity, with Criteria B-D providing no significant incremental value. For BN, none of the measures had a significant AUC, and results from logistic regression analyses showed that none of the indicators were robust in predicting outcome. DISCUSSION: For AN, the existing Criterion A is appropriate for children and adolescents, and is sufficient to predict outcome in the context of active refusal to maintain a normal weight as well as multiple informants and behavioral indicators of the psychological aspects of AN. For BN, predictive validity could not be established.

Family-based treatment of a 17-year-old twin presenting with emerging anorexia nervosa: a case study using the "Maudsley method".

This article describes the successful application of family-based treatment (FBT) for a 17-year-old identical twin presenting with a 4-month history of clinically significant symptoms of anorexia nervosa (AN). FBT is a manualized treatment that has been studied in randomized controlled trials for adolescents with AN. This case study illustrates the administration of this evidence-based intervention in a clinical setting, highlighting how the best available research was used to make clinical decisions at each stage of treatment delivery.

Defining body deception and its role in peer based social comparison theories of body dissatisfaction.

The purpose of the current study was to operationalize the phenomenon of body deception, describe its theoretical importance, and validate its existence in an experimental paradigm. The definition of body deception includes the intentional misrepresentation of information about appearance to others. The present study examined body deception in a controlled experimental study of male and female same-sex peer groups using a series of hierarchical linear models. Ninety male and 90 female undergraduates were randomized to an experimental same-sex peer group or individual control condition. The results suggested that both men and women used body deception among peers, but men's body deception was muscularity driven whereas women's was thinness driven. Body dissatisfaction was significantly predictive of the degree of body deception used by both genders and it was significantly related to peer group membership. An integrated model for the role of body deception in body image disturbance is proposed.