Eating Behavior and Satiety With Virtual Reality Meals Compared With Real Meals: Randomized Crossover Study.

BACKGROUND: Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment. OBJECTIVE: This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women. METHODS: The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires. RESULTS: There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=-5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals. CONCLUSIONS: Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals. TRIAL REGISTRATION: ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209.

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis.

Eating disorders (anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified eating or feeding disorders) have a combined prevalence of 13% and are associated with severe physical and psychosocial problems. Early diagnosis, which is important for effective treatment and prevention of undesirable long-term health consequences, imposes problems among non-specialist clinicians unfamiliar with these patients, such as those working in primary care. Early, accurate diagnosis, particularly in primary care, allows expert interventions early enough in the disorder to facilitate positive treatment outcomes. Computer-assisted diagnostic procedures offer a possible solution to this problem by providing expertise via an algorithm that has been developed from a large number of cases that have been diagnosed in person by expert diagnosticians and expert caregivers. A web-based system for determining an accurate diagnosis for patients suspected to suffer from an eating disorder was developed based on these data. The process is automated using an algorithm that estimates the respondent's probability of having an eating disorder and the type of eating disorder the individual has. The system provides a report that works as an aid for clinicians during the diagnostic process and serves as an educational tool for new clinicians.

Physical activity and sleep during the first week of anorexia nervosa inpatient care.

BACKGROUND: Individuals with Anorexia Nervosa are often described as restless, hyperactive and having disturbed sleep. The result reproducibility and generalisability of these results are low due to the use of unreliable methods, different measurement methods and outcome measures. A reliable method to measure both physical activity and sleep is through accelerometry. The main purpose of the study was to quantify the physical activity and sleeping behaviour of anorexia nervosa patients. Another purpose was to increase result reproducibility and generalisability of the study. MATERIAL AND METHODS: Accelerometer data were collected from the first week of treatment of anorexia nervosa at an inpatient ward. Raw data from the Axivity AX3© accelerometer was used with the open-source package GGIR for analysis, in the free statistical software R. Accelerometer measurements were transformed into euclidean norm minus one with negative values rounded to zero (ENMO). Physical activity measurements of interest were 24h average ENMO, daytime average ENMO, inactivity, light activity, moderate activity, and vigorous activity. Sleep parameters of interest were sleep duration, sleep efficiency, awakenings, and wake after sleep onset. The sleep duration of different age groups was compared to recommendations by the National Sleep Foundation using a Fisher's exact test. RESULTS: Of 67 patients, due to data quality 58 (93% female) were included in the analysis. Average age of participants was 17.8 (±6.9) years and body mass index was 15.5 (±1.9) kg/m2. Daytime average ENMO was 17.4 (±5.1) mg. Participants spent 862.6 (±66.2) min per day inactive, 88.4 (±22.6) min with light activities, 25.8 (±16.7) min with moderate activities and 0.5 (±1.8) min with vigorous activities. Participants slept for 461.0 (±68.4) min, waking up 1.45 (±1.25) times per night for 54.6 (±35.8) min, having an average sleep quality of 0.88 (±0.10). 31% of participants met sleep recommendations, with a significantly higher number of 6-13 year old patients failing to reach recommendations compared to 14-25 year old patients. CONCLUSION: The patient group spent most of their time inactive at the beginning of treatment. Most patients failed to reach sleep recommendations. The use of raw data and opensource software should ensure result reproducibility, enable comparison across points in treatment and comparison with healthy individuals.

Sexual incentive motivation and male and female copulatory behavior in female rats given androgen from postnatal day 20.

Masculinization and feminization of rat sexual behavior has been supposed to occur during a short postnatal period. However, much data have made it evident that these processes may continue until adolescence. In the present study, we evaluated whether androgen treatment of females from postnatal day 20 and onwards could alter sexual motivation and behavior in a male direction. Juveniles were ovariectomized on day 20 and concurrently implanted with Silastic capsules containing either testosterone or dihydrotestosterone. Controls were implanted with an empty capsule. Tests for sexual incentive motivation and male sexual behavior were performed every fifth day when the females were between 50 and 75 days of age. At day 80, a test for female sexual behavior was performed. Females treated with testosterone approached a female sexual incentive far more than a male incentive, showing that sexual motivation had been changed in a male-like direction. Dihydrotestosterone had a similar, albeit smaller, effect. Females implanted with an empty capsule approached both incentives equally. Testosterone produced a high level of mounting behavior, whereas intromission-like behavioral patterns were rare and ejaculation-like behavior was absent. In the test for female sexual behavior, the testosterone-treated animals displayed a relatively high lordosis quotient, far above that displayed in females implanted with dihydrotestosterone or an empty capsule. It is concluded that treatment with an aromatizable androgen during the peripubertal-adolescent period masculinizes sexual motivation and partly sexual behavior. A non-aromatizable androgen weakly masculinize sexual motivation without enhancing male sexual behavior. It appears that simultaneous actions on androgen and estrogen receptors are needed for significant masculinization during the period studied here. Since the testosterone-treated females displayed lordosis, sexual behavior was not defeminized. In sum, these results suggest that sexual differentiation continues well into the peripubertal and adolescent periods.

Correction: Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study.

[This corrects the article DOI: 10.2196/24998.].

Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study.

BACKGROUND: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. OBJECTIVE: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. METHODS: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. RESULTS: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall "good" rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the "accuracy" item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. CONCLUSIONS: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges.

"He Gave Us the Cornerstone of Sexual Medicine": A Nobel Plan but No Nobel Prize for Eugen Steinach.

This paper reviews the files in the archive of the Nobel Prize Committee for Physiology or Medicine on the Austrian physiologist and pioneering researcher in the emerging fields of urology and sexual medicine: Eugen Steinach (1861-1944). It reconstructs and analyzes why and by whom Steinach was nominated for the Nobel Prize between 1920 and 1938 and discusses the reasons why he never received the award, although the Nobel Committee judged him as prizeworthy. Steinach's Nobel nominee career is extraordinary - not only because of his strong support by renowned international nominators from different scientific and medical disciplines, but also because of the controversial discussions within the Nobel Committee on his achievements, colored by the debates in the international scientific community. The Nobel Prize story adds a new perspective on how contemporary international scholars evaluated Steinach's research on reproduction, "male-making" females, "female-making" males, homosexuality, and the concept of rejuvenation.

Verifying Feighner's Hypothesis; Anorexia Nervosa Is Not a Psychiatric Disorder.

Mental causation takes explanatory priority over evolutionary biology in most accounts of eating disorders. The evolutionary threat of starvation has produced a brain that assists us in the search for food and mental change emerges as a consequence. The major mental causation hypothesis: anxiety causes eating disorders, has been extensively tested and falsified. The subsidiary hypothesis: anxiety and eating disorders are caused by the same genotype, generates inconsistent results because the phenotypes are not traits, but vary along dimensions. Challenging the mental causation hypothesis in Feighner et al. (1972) noted that anorexic patients are physically hyperactive, hoarding for food, and they are rewarded for maintaining a low body weight. In 1996, Feighner's hypothesis was formalized, relating the patients' behavioral phenotype to the brain mechanisms of reward and attention (Bergh and Södersten, 1996), and in 2002, the hypothesis was clinically verified by training patients how to eat normally, thus improving outcomes (Bergh et al., 2002). Seventeen years later we provide evidence supporting Feighner's hypothesis by demonstrating that in 2012, 20 out of 37 patients who were referred by a psychiatrist, had a psychiatric diagnosis that differed from the diagnosis indicated by the SCID-I. Out of the 174 patients who were admitted in 2012, most through self-referral, there was significant disagreement between the outcomes of the SCID-I interview and the patient's subjective experience of a psychiatric problem in 110 of the cases. In addition, 358 anorexic patients treated to remission scored high on the Comprehensive Psychopathological Rating Scale, but an item response analysis indicated one (unknown) underlying dimension, rather than the three dimensions the scale can dissociate in patients with psychiatric disorders. These results indicate that psychiatric diagnoses, which are reliable and valid in patients with psychiatric disorders, are less well suited for patients with anorexia. The results are in accord with the hypothesis of the present Research Topic, that eating disorders are not always caused by disturbed psychological processes, and support the alternative, clinically relevant hypothesis that the behavioral phenotype of the patients should be addressed directly.

Treatment outcomes for eating disorders in Sweden: data from the national quality registry.

OBJECTIVE: To report the outcomes of eating disorders treatment in Sweden in 2012-2016. DESIGN: The number of patients treated and the number of patients not fulfilling an eating disorders diagnosis (remission) at 1 year of follow-up at the clinics listed in the National Quality Registry for Eating Disorders Treatment were analysed. The published outcomes at three clinics, which used survival analysis to estimate outcomes, were compared with their outcomes in the registry. Outcomes at the three biggest clinics were compared. SETTING: All eating disorders clinics. PARTICIPANTS: All patients treated at eating disorders clinics. INTERVENTION: Cognitive-behavioural therapy at most clinics and normalisation of eating behaviour at the three clinics with published outcomes. OUTCOME MEASURE: Proportion of patients in remission. RESULTS: About 2600 patients were treated annually, fewer than half were followed up and remission rates decreased from 21% in 2014 to 14% in 2016. Outcomes, which differed among clinics and within clinics over time, have been publicly overestimated by excluding patients lost to follow-up. The published estimated rate of remission at three clinics that treated 1200 patients in 1993-2011 was 27%, 28% and 40% at 1 year of follow-up. The average rate of remission over the three last years at the biggest of these clinics was 36% but decreased from 29% and 30% to 16 and 14% at the two other of the biggest clinics. CONCLUSIONS: With more than half the patients lost to follow-up and no data on relapse in the National Quality Registry, it is difficult to estimate the effects of eating disorders treatment in Sweden. Analysis of time to clinically significant events, including an extended period of follow-up, has improved the quality of the estimates at three clinics. Overestimation of remission rates has misled healthcare policies. The effect of eating disorders treatment has also been overestimated internationally.

Automatic Analysis of Food Intake and Meal Microstructure Based on Continuous Weight Measurements.

The structure of the cumulative food intake (CFI) curve has been associated with obesity and eating disorders. Scales that record the weight loss of a plate from which a subject eats food are used for capturing this curve; however, their measurements are contaminated by additive noise and are distorted by certain types of artifacts. This paper presents an algorithm for automatically processing continuous in-meal weight measurements in order to extract the clean CFI curve and in-meal eating indicators, such as total food intake and food intake rate. The algorithm relies on the representation of the weight-time series by a string of symbols that correspond to events such as bites or food additions. A context-free grammar is next used to model a meal as a sequence of such events. The selection of the most likely parse tree is finally used to determine the predicted eating sequence. The algorithm is evaluated on a dataset of 113 meals collected using the Mandometer, a scale that continuously samples plate weight during eating. We evaluate the effectiveness for seven indicators and for bite-instance detection. We compare our approach with three state-of-the-art algorithms, and achieve the lowest error rates for most indicators (24 g for total meal weight). The proposed algorithm extracts the parameters of the CFI curve automatically, eliminating the need for manual data processing, and thus facilitating large-scale studies of eating behavior.

Control of Eating Behavior Using a Novel Feedback System.

Subjects eat food from a plate that sits on a scale connected to a computer that records the weight loss of the plate during the meal and makes up a curve of food intake, meal duration and rate of eating modeled by a quadratic equation. The purpose of the method is to change eating behavior by providing visual feedback on the computer screen that the subject can adapt to because her/his own rate of eating appears on the screen during the meal. The data generated by the method is automatically analyzed and fitted to the quadratic equation using a custom made algorithm. The method has the advantage of recording eating behavior objectively and offers the possibility of changing eating behavior both in experiments and in clinical practice. A limitation may be that experimental subjects are affected by the method. The same limitation may be an advantage in clinical practice, as eating behavior is more easily stabilized by the method. A treatment that uses this method has normalized body weight and restored the health of several hundred patients with anorexia nervosa and other eating disorders and has reduced the weight and improved the health of severely overweight patients.

Control of Body Weight by Eating Behavior in Children.

Diet, exercise, and pharmacological interventions have limited effects in counteracting the worldwide increase in pediatric body weight. Moreover, the promise that individualized drug design will work to induce weight loss appears to be exaggerated. We suggest that the reason for this limited success is that the cause of obesity has been misunderstood. Body weight is mainly under external control; our brain permits us to eat under most circumstances, and unless the financial or physical cost of food is high, eating and body weight increase by default. When energy-rich, inexpensive foods are continually available, people need external support to maintain a healthy body weight. Weight loss can thereby be achieved by continuous feedback on how much and how fast to eat on a computer screen.

Steinach and Young, Discoverers of the Effects of Estrogen on Male Sexual Behavior and the "Male Brain".

In the 1930s, Eugen Steinach's group found that estradiol induces lordosis in castrated rats and reduces the threshold dose of testosterone that is necessary for the induction of ejaculation, and that estradiol-treated intact rats display lordosis as well as mounting and ejaculation. The bisexual, estrogen-sensitive male had been demonstrated. Another major, albeit contrasting, discovery was made in the 1950s, when William Young's group reported that male guinea pigs and prenatally testosterone-treated female guinea pigs are relatively insensitive to estrogen when tested for lordosis as adults. Reduced estrogen sensitivity was part of the new concept of organization of the neural tissues mediating the sexual behavior of females into tissues similar to those of males. The importance of neural organization by early androgen stimulation was realized immediately and led to the discovery of a variety of sex differences in the brains of adult animals. By contrast, the importance of the metabolism of testosterone into estrogen in the male was recognized only after a delay. While the finding that males are sensitive to estrogen was based on Bernhard Zondek's discovery in 1934 that testosterone is metabolized into estrogen in males, the finding that males are insensitive to estrogen was based on the hypothesis that testosterone-male sexual behavior is the typical relationship in the male. It is suggested that this difference in theoretical framework explains the discrepancies in some of the reported results.

Recovering from anorexia nervosa by machine.

Any healthy person can develop anorexia nervosa. Prolonged dieting causes reversible endocrine changes that emerge to combat starvation, the main threat to survival. Animals have evolved to develop strategies to cope with this challenge, assisted by hormonal systems that facilitate food hoarding but which can also inhibit eating, reinforcing the anorexic state. However, a simple machine that provides feedback on how to eat can allow patients to escape from anorexia and restore their health.

Homeostasis in anorexia nervosa.

Brainstem and hypothalamic "orexigenic/anorexigenic" networks are thought to maintain body weight homeostasis in response to hormonal and metabolic feedback from peripheral sites. This approach has not been successful in managing over- and underweight patients. It is suggested that concept of homeostasis has been misinterpreted; rather than exerting control, the brain permits eating in proportion to the amount of physical activity necessary to obtain food. In support, animal experiments have shown that while a hypothalamic "orexigen" excites eating when food is abundant, it inhibits eating and stimulates foraging when food is in short supply. As the physical price of food approaches zero, eating and body weight increase without constraints. Conversely, in anorexia nervosa body weight is homeostatically regulated, the high level of physical activity in anorexia is displaced hoarding for food that keeps body weight constantly low. A treatment based on this point of view, providing patients with computerized mealtime support to re-establish normal eating behavior, has brought 75% of patients with eating disorders into remission, reduced the rate of relapse to 10%, and eliminated mortality.

Eugen Steinach: the first neuroendocrinologist.

In 1936, Eugen Steinach and colleagues published a work that brought steroid biochemistry to the study of sexual behavior and, using synthetic androgens and estrogens, foreshadowed by an astonishing 4 decades the discovery of the central role of estrogen in the sexual behavior of male rats. We offer an English translation of that paper, accompanied by historical commentary that presents Steinach as a pioneer in reproductive neuroendocrinology. His work 1) established the interstitial cells as the main source of mammalian gonadal hormones; 2) launched the hypothesis that steroid hormones act on the brain to induce sexual behavior and that chronic gonadal transplants produce sexual reversals in physiology and behavior; 3) demonstrated the influence of sensory stimulation on testicular function; and finally 4) spearheaded the development of synthetic commercial hormones for clinical use in humans. Although its applications were controversial, Steinach's research was confirmed by many, and his concepts were applied to fields such as oncology and vascular disease. His contemporaries lauded his research, as indicated by his 7 Nobel Prize nominations. But Steinach's basic research was rarely acknowledged as the field flourished after 1950. The translation and our commentary attempt to reverse that neglect among behavioral neuroendocrinologists and clarify his central role as a founder of the neuroendocrinology of sexual behavior and reproduction.