Continuous glucose monitoring as an objective measure of meal consumption in individuals with binge-spectrum eating disorders: A proof-of-concept study.

OBJECTIVE: Going extended periods of time without eating increases risk for binge eating and is a primary target of leading interventions for binge-spectrum eating disorders (B-EDs). However, existing treatments for B-EDs yield insufficient improvements in regular eating and subsequently, binge eating. These unsatisfactory clinical outcomes may result from limitations in assessment and promotion of regular eating in therapy. Detecting the absence of eating using passive sensing may improve clinical outcomes by facilitating more accurate monitoring of eating behaviours and powering just-in-time adaptive interventions. We developed an algorithm for detecting meal consumption (and extended periods without eating) using continuous glucose monitor (CGM) data and machine learning. METHOD: Adults with B-EDs (N = 22) wore CGMs and reported eating episodes on self-monitoring surveys for 2 weeks. Random forest models were run on CGM data to distinguish between eating and non-eating episodes. RESULTS: The optimal model distinguished eating and non-eating episodes with high accuracy (0.82), sensitivity (0.71), and specificity (0.94). CONCLUSIONS: These findings suggest that meal consumption and extended periods without eating can be detected from CGM data with high accuracy among individuals with B-EDs, which may improve clinical efforts to target dietary restriction and improve the field's understanding of its antecedents and consequences.

Influence of puberty on relationships between body composition and blood pressure: a cross-sectional study.

BACKGROUND: Fat mass (FM) and fat-free mass (FFM) are positively associated with blood pressure (BP) in youth. Yet, how puberty, independent of age, affects these relationships remains unclear. Given puberty may be a crucial period for cardiometabolic health, we examined how pubertal development moderates the associations of FM/FFM with BP. METHODS: Pubertal development, resting BP, and body composition were assessed in a convenience sample of youth (5.5-17 years). General linear models were conducted to assess if pubertal development moderated the relationships between FM/FFM and systolic/diastolic BP standardized for age, sex, and height (SBPz/DBPz). RESULTS: Among participants (N = 1405; age: M = 13.3 ± 2.9 years; 65.4% female; 53.2% racial/ethnic minority), FM/FFM were positively associated with SBPz and DBPz (ps ≤ 0.02). Pubertal development moderated the associations between FFM and BPz (ps ≤ 0.01), but not FM (ps > 0.43). For early/mid and late pubertal participants, there were positive associations between FFM and BP (DBPz: ßs = 0.10-0.18, ps ≤ 0.01; SBPz: ßs = 0.33-0.43, ps < 0.001); however, these relationships were attenuated, especially for prepubertal DBPz (DBPz: ß = 0.01, p = 0.91; SBPz: ß = 0.24, p = 0.001). CONCLUSIONS: Puberty moderated the relationships between FFM and SBPz/DBPz in analyses that separately modeled the contributions of age and sex. These data suggest that the FFM-DBPz association may potentially be impacted by increasing sex hormone concentrations during puberty. IMPACT: Fat mass (FM) and blood pressure (BP) were positively associated throughout puberty. Fat-free mass (FFM) and BP were positively associated throughout puberty; however, puberty moderated the FFM-BP relationship, such that there was a positive relationship in early/mid and late puberty, but the relationship was attenuated for prepubertal children. These findings contribute further insight into physiological and cardiometabolic changes occurring during puberty. Changes in hormone concentrations may explain the impact puberty has on the FFM-BP relationship. Understanding predictors of BP are important as childhood BP is associated with future cardiometabolic outcomes.

An exploration of homework completion in cognitive behavioral treatments for bulimia-spectrum eating disorders.

The impact of homework completion on outcome from cognitive behavioral therapies (CBTs) for eating disorders (EDs) is unknown. We examined homework completion during two CBTs for bulimia-spectrum EDs and tested the associations among homework and treatment outcomes. After each session, therapists rated the quantity of self-monitoring completed (e.g. tracking food intake and ED symptoms), and degree of completion of the previous week's written (e.g. completing a worksheet) and behavioral (e.g. completing an at-home food exposure, regularly eating) homework on a Likert scale. On average, patients (N = 42) completed 50-100% of self-monitoring homework, moderate completion of written homework, and below-moderate completion of behavioral homework. Average behavioral homework completion, but not self- monitoring or written homework, was related to end-of-treatment symptom cessation. Improving homework completion might enhance the efficacy of CBTs for EDs.

A closer look at homework compliance in behavior therapy for bulimia nervosa: does homework compliance in between-session period prospectively predict session-by-session change in bulimia symptoms?

INTRODUCTION: Homework assignments are considered key components of behavioral treatments for bulimia nervosa (BN), but little is known about whether homework compliance predicts BN symptom improvement. The present study is the first to examine whether session-by-session change in homework compliance predicts session-by-session changes in BN symptoms during behavioral treatment. METHOD: Patients with BN-spectrum eating disorders (n = 42) received 20 sessions of behavioral treatment. Each session, their clinicians completed surveys assessing compliance with self-monitoring, behavioral, and written homework assignments and BN symptom frequency during the previous week. RESULTS: Significant between-persons effects of self-monitoring and behavioral homework compliance were identified, such that patients with greater compliance in the past week experienced greater reductions in binge eating and purging the following week. There were significant within-persons effects of self-monitoring compliance on binge eating and behavioral homework compliance on restrictive eating, binge eating, and purging, such that greater than one's usual compliance predicted greater improvements in BN symptoms the following week. No significant effects of written homework compliance were identified. CONCLUSION: Compliance with self-monitoring and behavioral homework predict improvements in BN symptoms during behavioral treatment. These findings reinforce the importance of self-monitoring and behavioral homework compliance as drivers of change during treatment for BN.

Prefrontal cortex activation by binge-eating status in individuals with obesity while attempting to reappraise responses to food using functional near infrared spectroscopy.

PURPOSE: Difficulty reappraising drives to consume palatable foods may promote poorer inhibition and binge eating (BE) in adults with obesity, but neural underpinnings of food-related reappraisal are underexamined. METHODS: To examine neural correlates of food-related reappraisal, adults with obesity with and without BE wore a portable neuroimaging tool, functional near-infrared spectroscopy (fNIRS). fNIRS measured activity in the prefrontal cortex while participants watched videos of food and attempt to "resist" the food stimuli (i.e., "consider the negative consequences of eating the food"). RESULTS: Participants (N = 32, 62.5% female; BMI 38.6 [Formula: see text] 7.1; 43.5 [Formula: see text] 13.4 y) had a BMI > 30 kg/m2. Eighteen adults (67.0% female; BMI 38.2 [Formula: see text] 7.6) reported BE (≥ 12 BE-episodes in preceding 3 months). The control group comprised 14 adults who denied BE (64.0% female; BMI 39.2 [Formula: see text] 6.6). Among the entire sample, mixed models showed significant, small hyperactivation during crave and resist compared to watch (relax) condition bilaterally in the medial superior frontal gyrus, dorsolateral areas, and middle frontal gyrus (optodes 5, 7, 9, 10, 11, and 12) in the total sample. No statistically significant differences in neural activation were observed between the BE and control group. Moreover, there were no significant group by condition interactions on neural activation. CONCLUSION: Among adults with obesity, BE status was not linked to differential activation in inhibitory prefrontal cortex areas during a food-related reappraisal task. Future research is needed with larger samples, adults without obesity, and inhibition paradigms with both behavioral and cognitive components. LEVEL OF EVIDENCE: Level III: Evidence obtained from well-designed cohort or case-control analytic studies. TRIAL REGISTRATION: # NCT03113669, date April 13, 2017.

Retrieval-induced forgetting in children and adolescents with and without obesity.

BACKGROUND/OBJECTIVES: Previous research indicates that youth with obesity exhibit deficits in executive functioning (EF), which often take the form of impaired response inhibition. One aspect of EF not previously studied in obesity is the adaptive process known as retrieval-induced forgetting (RIF), the suppression/inhibition of intrusive or non-target items by the retrieval of specific items from memory. The present study investigated if child or adolescent obesity disrupts the ability to inhibit retrieval of intrusive memories. SUBJECTS/METHODS: We compared the manifestation of RIF in children (ages 8-12) and adolescents (ages 13-18) as a function of their weight status and sex. We also evaluated the effects of these variables on simple recall of items from episodic memory under conditions where competition from intrusive items was reduced. RESULTS: Children with obesity did not demonstrate significant RIF, whereas RIF was exhibited by preteens without obesity and by teenage participants with- and without obesity (Weight Status × Age Group interaction p = 0.028). This pattern of results did not differ as a function of sex for either age group. No differences in episodic memory were found. Additional analyses using Age as continuous covariate (and not as a nominal group) comparing participants who exhibited RIF with those who did not, found that the no RIF group consumed fast-food meals more frequently (p = 0.024) and had higher percentages of total body adiposity and android fat compared to the RIF group (p's < 0.05). CONCLUSIONS: The findings expand what is known about the effects of childhood obesity on cognitive functioning, identify impaired RIF with specific behavioral and dietary factors and increased adiposity, and suggest the possibility that impairments in the ability to inhibit intrusive memories of food and eating may contribute to poor early-life weight control.

A comparison of negative affect and disinhibited eating between children with and without parents with type 2 diabetes.

BACKGROUND: Children whose parents have type 2 diabetes (T2D) are at high-risk for developing T2D. In youth, negative affect has been shown to predict insulin resistance (IR), and disinhibited-eating behaviors have been linked to IR. It is unknown if youth with a parent with T2D (P-T2D) report greater psychological and behavioral symptoms than those without a P-T2D. OBJECTIVE: To compare youth with and without a P-T2D on symptoms of negative affect and disinhibited-eating. METHODS: Nine-hundred thirty-two youth (13.3 ± 2.6 years; BMIz 1.06 ± 1.06; 67.8% female; 53.6% people of color; 10.7% with a P-T2D) completed questionnaires of anxiety and depressive symptoms, eating in the absence of hunger, and emotional-eating. Loss-of-control (LOC)-eating was assessed by interview. In two separate subsamples, energy intake was explored using laboratory test meals simulating eating in the absence of hunger and LOC-eating, respectively. Analyses were adjusted for age, sex, race/ethnicity. In follow-up analyses, fat mass (kg) and height, and IR were included as covariates, respectively. RESULTS: Adjusting for all covariates including adiposity and IR, compared to youth without a P-T2D, youth with a P-T2D reported more anxiety and depression symptoms, greater eating in the absence of hunger, and emotional-eating (ps < 0.05). No significant differences were found for LOC-eating, or in exploratory analyses of energy intake for either test meal (ps > 0.16). CONCLUSIONS: Self-reported negative affect and disinhibited-eating may be higher among youth with P-T2D compared to those without P-T2D. Prospective studies should examine, among those with a P-T2D, what role such symptoms may play for their subsequent risk for T2D.

Examination of the Interaction between Parental Military-Status and Race among Non-Hispanic Black and Non-Hispanic White Adolescents with Overweight/Obesity.

OBJECTIVES: Adolescent military-dependents experience distinct risk and protective factors, which may necessitate additional clinical considerations. In civilian youth, overweight/obesity is associated with eating, internalizing, and externalizing difficulties, with some studies reporting more difficulties among non-Hispanic White (vs. non-Hispanic Black) youth. It is unknown if these disparities exist among adolescent military-dependents, or between civilian and military-dependent youth. METHODS: Non-Hispanic Black (187 civilian, 38 military-dependent) and non-Hispanic White (205 civilian, 84 military-dependent) adolescents with overweight/obesity (14.7 ± 1.6 years; 73.9% girls; body mass index adjusted for age and sex 1.9 ± 0.5) completed a disordered-eating interview; parents completed a measure assessing their child's internalizing and externalizing difficulties. Multiple linear regressions examined parental military-status as a moderator of the relationship of participant race with eating, internalizing, and externalizing difficulties. RESULTS: White civilian youth with overweight/obesity reported significantly greater disordered-eating than their Black peers (p < .001); there were no other significant racial differences. In all regressions, parental military-status significantly moderated the association between race and each dependent variable (ps < .047). Black military-dependents (vs. civilians) reported more disordered-eating and internalizing difficulties (ps = .01). White military-dependents (vs. civilians) reported fewer externalizing difficulties (p = .01). CONCLUSIONS: Black adolescent military-dependents with overweight/obesity may experience more eating and internalizing difficulties (vs. civilians), a pattern not observed among White participants. Future work should examine if being a military-dependent and a historically marginalized racial group member accounts for these findings. Such data may inform providers of youth with intersecting minority identities.

Eating expectancies and hedonic hunger among individuals with bulimia-spectrum eating disorders who plan binge-eating episodes.

OBJECTIVE: Binge planning (BP; i.e., preparatory thoughts and actions to facilitate future binge-eating episodes) is hypothesized to distract individuals from negative affect and increase the salience of food. Thus, individuals who engage in BP may report greater positive eating expectancies (i.e., beliefs about the outcomes of eating) and hedonic hunger (i.e., desire to eat for pleasure), as BP may increase the likelihood of obtaining these expected outcomes; but empirical tests of this possibility are needed. METHOD: Prior to starting treatment, adults (N = 86) with bulimia-spectrum eating disorders were assessed for engagement in BP and self-reported on eating expectancies and hedonic hunger. RESULTS: Twenty-nine participants (33.7%) reported planning at least one binge-eating episode in the previous 28 days. Compared to individuals who did not report BP, individuals who reported BP had greater expectancies that eating would alleviate negative affect (t = -2.54, p = .013) and boredom (U = 503.50, p = .006). Groups did not differ on levels of hedonic hunger (t = -1.68, p = .096). DISCUSSION: These findings suggest that BP status is linked to expectancies that eating will reduce negative affect. However, more data are needed to determine the temporal relationships among eating expectancies, hedonic hunger and BP. TRIAL REGISTRATION NUMBERS: NCT02716831, NCT03673540.

State negative affect in relation to loss-of-control eating among children and adolescents in the natural environment.

Affect regulation theory proposes that loss-of-control (LOC)-eating is preceded by increases and followed by decreases in negative affect (NA), but empirical tests of this theory among pediatric samples in the natural environment are needed. Using an ecological momentary assessment approach, we conducted post-hoc analyses to examine LOC-eating severity reported during post-meal surveys in relation to the intensity of composite NA and NA components (anger, anxiety, depression, guilt) throughout the day for two weeks in a cohort of healthy children and adolescents. Multilevel models tested the associations among LOC-eating severity and NA components reported at pre-meal surveys (t-1), post-meal surveys (t), and lagged post-meal surveys (t+1). Models were adjusted for sex, age, race/ethnicity, height, fat mass, socioeconomic status, and time between the occurrence and report of eating episodes; post-meal analyses were also adjusted for pre-meal NA. Participants age 8-17 (N = 100; 55% female; 45% male; 12.83 ± 2.73y; 24% with overweight/obesity) recorded 2410 eating episodes. Pre-meal composite NA and NA components were not associated with LOC-eating severity at the subsequent meal. LOC-eating severity was positively associated with post-meal depression (ß = 0.042, 95% CI = 0.007, 0.076) and guilt (ß = 0.056, 95% CI = 0.017, 0.095), but not composite negative affect, anger, or anxiety. The positive association among LOC-eating severity and guilt persisted in lagged post-meal analyses (ß = 0.075, 95% CI = 0.021, 0.128). Contrary to affect regulation theory and laboratory data, but consistent with prior ecological momentary assessment data in children and adolescents, pre-meal NA was not linked to subsequent LOC-eating. Increased guilt following meals may be a mechanism for the development of exacerbated disordered eating. Longitudinal studies may elucidate how NA is implicated in the etiology of pediatric eating disorders.

Mindfulness and acceptance-based behavioral treatment for bulimia-spectrum disorders: A pilot feasibility randomized trial.

OBJECTIVE: Although existing research supports the efficacy of mindfulness- and acceptance-based treatments (MABTs) for eating disorders (EDs), few studies have directly compared outcomes from MABTs to standard CBT. METHOD: Participants (N = 44), treatment-seeking adults with bulimia-spectrum EDs, were screened for eligibility, consented, and randomized to receive 20 sessions of outpatient, individual CBT or MABT treatment. Treatment outcomes (binge eating and compensatory behavior episodes, global ED severity, depressive symptoms, quality of life, emotional awareness/clarity, distress tolerance, values-based decision-making, and emotion modulation) were measured at pre-treatment, post-treatment, and 6-month follow up. Data on feasibility and acceptability are also presented. RESULTS: Treatment and assessment retention rates were comparable between MABT and CBT (p range = .51-.73) and between-group differences on acceptability measures were very small (d range = 0.03-0.19). Both conditions produced notable and generally comparable changes in most treatment outcomes at post-treatment (within group d range = 0.06-1.77). DISCUSSION: The MABT and CBT conditions demonstrated comparable degrees of feasibility, acceptability, and symptom improvement, suggesting that MABTs warrant further evaluation as ED treatments.

Bridging executive function and disinhibited eating among youth: A network analysis.

OBJECTIVE: Poorer executive function (EF) has been linked to disinhibited eating in youth, suggesting poor EF predisposes toward obesity, yet the specific nature and extent of interconnections between facets of these domains is unclear. Network analysis provides a promising framework for elucidating the relationship between poor EF and disinhibited eating, and offers insights into potential maintenance processes. METHOD: Among youth ages 8-17 years, a regularized partial correlation network of EF and disinhibited eating facets was estimated to examine expected influence centrality and bridge expected influence. Computerized neurocognitive tasks assessed EF variables, including decision-making, general and food-related inhibitory control, delayed gratification, cognitive flexibility, and working memory. Disinhibited eating variables included total carbohydrate-fat intake at a laboratory test meal and self-reported eating in the absence of hunger, emotional eating, and loss-of-control eating severity. RESULTS: In the current sample (N = 248; Mage = 12.5; 54.8% female; 43.5% non-Hispanic White; 25.8% non-Hispanic Black; BMI %ile = 65.8 ± 27.8), emotional eating in response to depressive symptoms emerged as a central symptom in the network. Carbohydrate-fat intake had the highest bridge expected influence and was most strongly connected to general inhibitory control (part r = .14). DISCUSSION: The link between general inhibitory control and objective palatable food intake may be particularly salient in maintaining maladaptive eating behavior. Interventions targeting behavioral disinhibition may disrupt associations among a network of disinhibited eating facets in youth and should be targets for longitudinal research.

Food cravings and loss-of-control eating in youth: Associations with gonadal hormone concentrations.

OBJECTIVE: Among youth with overweight, food cravings (FC) are associated with loss-of-control (LOC)-eating, but the impact of sex-associated biological characteristics on this relationship is unknown. We examined whether sex and gonadal hormone concentrations moderated the relationships between FC and LOC-eating severity among healthy boys and girls across the weight strata in natural and laboratory environments. METHOD: Using ecological momentary assessment (EMA), FC, and LOC-eating severity were reported 3-5 times a day for 2 weeks. In the laboratory, participants reported FC, consumed lunch from a buffet test meal designed to simulate LOC-eating, and rated LOC-eating severity during the meal. RESULTS: Eighty-seven youth (13.0 ± 2.7 years, 58.6% female, 32.2% with overweight/obesity) participated. EMA measured general and momentary FC were positively associated with LOC-eating severity (ps < .01), with no differences by sex (ps = .21-.93). Estradiol and progesterone significantly moderated the relationships between FC and LOC-eating such that general FC and LOC-eating severity were only positively associated among girls with greater (vs. lower) estradiol (p = .01), and momentary FC and LOC-eating severity were only positively associated among girls with greater (vs. lower) progesterone (p = .01). Boys' testosterone did not significantly moderate the associations between FC and LOC-eating severity (ps = .36-.97). At the test meal, pre-meal FC were positively related to LOC-eating severity (p < .01), without sex or hormonal moderation (ps = .20-.64). DISCUSSION: FC were related to LOC-eating severity in boys and girls. In the natural environment, gonadal hormones moderated this relationship in girls, but not boys. The mechanisms through which gonadal hormones might affect the relationship between FC and LOC-eating warrant investigation.

Inhibitory control and negative affect in relation to food intake among youth.

Negative affect and poor inhibitory control are related to disinhibited eating behaviors in youth and may contribute to the development and/or maintenance of obesity. Although few studies have jointly examined these constructs in youth, it has been theorized that poor inhibitory control may be driven by negative affect. If supported, impaired inhibitory control, driven by negative affect, could represent a modifiable neurocognitive treatment target for disinhibited eating. The current study examined whether inhibitory control mediates the relationship between negative affect and eating among youth. Youth (8-17 years) participated in a Food Go/No-Go neurocognitive task to measure inhibitory control as the percentage of commission errors. A composite negative affect score was created from self-report measures of anxiety and depression. A laboratory buffet meal modeled to simulate disinhibited eating was used to measure total and snack food intake. Cross-sectional mediation models with bias-corrected bootstrap confidence intervals (CI) were conducted using negative affect as the independent variable, inhibitory control as the mediator, and intake patterns as dependent variables. One-hundred-eighty-one youths (13.2 ± 2.7y; 55% female; BMIz 0.6 ± 1.0) were studied. Total Go/No-Go commission errors mediated the relationship between negative affect and total intake (95%CI = [0.3, 31.6]), but not snack intake (95%CI = [-2.5, 7.3]). Commission errors for Food-Go blocks significantly mediated the relationship between negative affect and total intake (95%CI = [7.7, 44.4]), but not snack intake (95%CI = [-3.4, 9.5]). Commission errors on Neutral-Go blocks did not significantly mediate any of these relationships. Negative affect may lead to poorer inhibitory control as well as a stronger approach tendency toward food, increasing the likelihood of engaging in disinhibited eating. Future research should determine if, in combination with approaches to reduce negative affect, improved inhibitory control could help prevent overeating in youths with depressive or anxiety symptoms.

The application of continuous glucose monitoring technology to eating disorders research: An idea worth researching.

Continuous glucose monitoring (CGM) devices have revolutionized our capacity to measure blood glucose levels in real time using minimally invasive technology, yet to date there are no studies using CGM in individuals with eating disorders (EDs). Preliminary evidence suggests that eating disorder behaviors (EDBs) have substantial and characteristic impacts on blood glucose levels and glucose-related variables (e.g., binge-eating episodes cause rapid spikes in blood glucose levels, purging causes rapid drops in blood glucose to below normal levels). The aims of this article are to describe the benefits of CGM technology over older methods of measuring blood glucose levels and to discuss several specific ways in which CGM technology can be applied to EDs research to (a) improve our ability to identify and predict engagement in EDBs in real time, (b) identify relationships between blood glucose levels and maintenance factors for EDs, and (c) increase our understanding of the physiological and psychological impacts of disordered eating. We also present preliminary acceptability and feasibility data on the use of CGM devices in individuals with EDs. Overall, the article will describe several applications of CGM technology in EDs research with compelling potential to improve research methodologies.

Assessment of loss-of-control eating in healthy youth by interview and questionnaire.

OBJECTIVE: The aim of this study is to evaluate two questionnaires, an updated youth version of the questionnaire on eating and weight patterns (Questionnaire on Eating and Weight Patterns-5 Children/Adolescent [QEWP-C-5]) and the Loss-of-Control (LOC) Eating Disorder Questionnaire (LOC-ED-Q), against the Eating Disorder Examination (EDE) interview to assess the presence of LOC-eating among youth. METHOD: Two-hundred and eighteen youths (12.8 ± 2.7 years) completed the QEWP-C-5, LOC-ED-Q, and EDE, depressive and anxiety questionnaires, and adiposity assessment. Sensitivity, specificity, positive-predictive value, negative-predictive value, and diagnostic accuracy were calculated; Cochran's Q and McNemar's tests were used to compare measures. Receiver operating characteristic area under the curve (AUC) analyses were performed. Mood and adiposity based on LOC-eating presence and absence based on each measure were examined. RESULTS: The QEWP-C-5 and LOC-ED-Q demonstrated poor sensitivity (33%; 30%) and high specificity (95%; 96%) compared with the EDE. The AUCs suggested neither the QEWP-C-5 (0.64) nor the LOC-ED-Q (0.62) demonstrated acceptable diagnostic accuracy. Comparing distributions of LOC-eating presence between assessments, the QEWP-C-5 and EDE did not differ significantly (p = .10), while the LOC-ED-Q and EDE had significantly different distributions (p = .03). LOC-eating presence was associated with higher depressive and anxiety symptoms across all measures (ps < .02). Greater adiposity (ps < .02) was associated with LOC-eating presence on the EDE and LOC-ED-Q, and higher BMI z-score (p = .02) on the LOC-ED-Q. DISCUSSION: Neither the QEWP-C-5 nor the LOC-ED-Q was sensitive for identifying LOC-eating presence as determined by the EDE, although both were associated with greater mood symptoms. Research is needed to improve self-report questionnaires to better screen for LOC-eating presence among pediatric populations.

An exploratory component analysis of emotion regulation strategies for improving emotion regulation and emotional eating.

Emotion-focused treatments are generally efficacious for improving emotion regulation and consequently, improving clinical symptoms across numerous disorders. However, emotion-focused treatment approaches often contain numerous treatment components, limiting our ability to identify which are most efficacious. As such, the current pilot study sought to isolate three components common across a range of emotion-focused treatments (i.e. emotional awareness, emotion down-regulation, and distress tolerance) and test the impact of each component on (1) emotion regulation and (2) emotional eating behavior. Adults (N = 76) who reported four or more emotional eating episodes in the past month were assigned to attend a one-time, three-hour workshop focused on either awareness, down-regulation or tolerance of emotions, and were subsequently evaluated at one-week and two-weeks follow-up. All groups experienced equivalent improvements in emotional eating at two-weeks follow-up (F [1.47, 85.38 ] = 7.60, p < .01). However, groups showed differential patterns of change across facets of emotion regulation. Improvements in access to healthy emotion regulation strategies was moderately related to improvements in emotional eating in Down-Regulation and Distress Tolerance groups (r [18] = 0.40, r [20] = 0.63, respectively). In the Distress Tolerance group, improvements in emotional eating were moderately related to improvements in acceptance of emotions (r[20] = 0.33) and ability to refrain from impulses (r[20] = 0.41). In the Emotional Awareness group, improvements in emotional acceptance (r[20] = 0.30), awareness (r[20] = 0.38) and clarity (r[20] = 0.39) were moderately related to improvements in emotional eating. While several components of emotion-focused treatments may improve outcomes, each component may demonstrate a unique mechanism of action. Further study is needed to isolate these treatment components in fully powered clinical trials to better understand the mechanisms of action for emotion-focused treatments and ultimately develop more efficient and effective treatment approaches.

Just-in-time adaptive interventions: A novel approach for enhancing skill utilization and acquisition in cognitive behavioral therapy for eating disorders.

OBJECTIVE: The most widely researched treatment for bulimia nervosa (BN) and binge-eating disorder (BED) is cognitive behavioral therapy (CBT), a present-focused, active, skill-oriented treatment. However, despite the success of CBT, many patients fail to achieve sufficient rates of skill utilization (i.e., the frequency with which a patient practices or uses therapeutic skills) or adequate skill acquisition (i.e., the ability to successfully perform a skill learned in treatment) by the end of treatment and outcomes suffer as a result. One method for improving skill acquisition and utilization in patients with BN or BED could be the augmentation of in-person treatment with just-in-time adaptive interventions (JITAIs), which use smartphone technology to deliver real-time interventions during app-identified moments of need. The current article discusses how novel JITAI systems that utilize machine learning or other predictive algorithms could be used to detect momentary risk for eating disordered behavior and provide tailored interventions to enhance outcomes. We will consider technologies that may help reduce patient burden and suggest avenues for future research on developing acceptable and effective JITAIs that can be used as an adjunct to CBT protocols.

Youth's energy intake during a laboratory-based loss-of-control eating paradigm: Associations with reported current dieting.

Dieting is theorized as a risk factor for loss-of-control (LOC)-eating (i.e., feeling a sense of lack of control while eating). Support for this association has largely relied on retrospective self-report data, which does not always correlate with objectively assessed eating behavior in youth. We hypothesized that during a laboratory-based LOC-eating paradigm, children and adolescents who reported current (at the time of the visit) dieting would consume meals consistent with LOC-eating (greater caloric intake, and intake of carbohydrates and fats, but less intake of protein). Participants were presented with a buffet-style meal and instructed to "Let yourself go and eat as much as you want." Current dieting (i.e., any deliberate change to the amount or type of food eaten to influence shape or weight, regardless of how effective the changes are) was assessed via interview. General linear models were adjusted for fat mass (%), lean mass (kg), height, sex, protocol, race and ethnicity, pre-meal hunger and minutes since consumption of a breakfast shake. Of 337 participants (Mage 12.8 ± 2.7y; 62.3 % female; 45.7 % non- Hispanic White and 26.1 % non-Hispanic Black; MBMIz 0.78 ± 1.11), only 33 (9.8 %) reported current dieting. Current dieting was not significantly associated with total energy intake (F = 1.63, p = .20, ηp2 = 0.005), or intake from carbohydrates (F = 2.45, p = .12, ηp2 = 0.007), fat (F = 2.65, p = .10, ηp2 = 0.008), or protein (F = 0.39, p = .53, ηp2 = 0.001). Contrary to theories that dieting promotes LOC-eating, current dieting was not associated with youth's eating behavior in a laboratory setting. Experimental approaches for investigating dieting are needed to test theories that implicate dieting in pediatric LOC-eating.

Practical Considerations for Using the Eating Disorder Examination Interview with Adolescents.

Approximately 35 years after its initial publication, the Eating Disorder Examination (EDE) remains one of the most widely used semi-structured interviews for assessing eating disorder diagnoses and symptomatology. Although the interview provides certain advantages over other common measurement approaches (ie, questionnaires), there are particular considerations regarding the EDE that warrant attention, including in its use with adolescents. The aims of this paper are therefore to: 1) provide a brief overview of the interview itself, as well as a description of its origin and underlying conceptual framework; 2) describe relevant factors for administering the interview with adolescents; 3) review potential limitations regarding use of the EDE with adolescents; 4) address considerations for using the EDE with pertinent subpopulations of adolescents who may experience distinct eating disorder symptoms and/or risk factors; and 5) discuss the integration of self-report questionnaires with the EDE. Advantages of using the EDE include the ability for interviewers to clarify complex concepts and mitigate inattentive responding, enhanced orientation to the interview timeframe to improve recall, increased diagnostic accuracy compared to questionnaires, and accounting for potentially salient external factors (eg, food/eating rules imposed by a parent/guardian). Limitations include more extensive training requirements, greater assessment burden, variable psychometric performance across subgroups, lack of items evaluating muscularity-oriented symptoms and avoidant/restrictive food intake disorder diagnostic criteria, and lack of explicit consideration for salient risk factors other than weight and shape concerns (eg, food insecurity).