Transition support for patients admitted to intensive treatment for anorexia nervosa: qualitative study of patient and carer experiences of a hybrid online guided self-help intervention (ECHOMANTRA).

BACKGROUND: Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides psychoeducation and support to augment usual care. AIMS: To explore patient and carer experiences of receiving the ECHOMANTRA intervention. METHOD: This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts. RESULTS: Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability. CONCLUSIONS: Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.

Every mistake is a treasure: Lessons learned from the TRIANGLE trial for anorexia nervosa.

BACKGROUND: Despite several decades of treatment research for anorexia nervosa (AN), many of the same questions remain: how to boost enrollment, engage participants, prevent attrition, and meet the needs of a diverse patient population within the rigorous framework of a randomized controlled trial (RCT). METHODS: In this research forum, we highlight some of the challenges and opportunities observed over the course of TRIANGLE, the largest RCT for severe AN treatment in the UK to date. We discuss strategies for addressing common challenges and avoiding common pitfalls and propose solutions to future researchers seeking to conduct treatment research in AN. RESULTS: Our experience underscores the value of involving people with lived experience at every stage of intervention research. We offer additional recommendations for treatment researchers, including, (1) early qualitative research to identify patient barriers and obstacles, (2) clear, systematic collaboration with clinical sites for patient recruitment and passive data collection, (3) careful consideration of assessment metrics, including repeated measurement of quality of life, (4) adopting a flexible, patient-centered approach to clinical trial research, and (5) considering the unique needs and obstacles that might impact carer participation in research and their ability to provide support to their loved ones. DISCUSSION: We hope that these lessons learned will prove fruitful for the next generation of researchers embarking on treatment research for AN. PUBLIC SIGNIFICANCE: Using the TRIANGLE trial as an illustrative case study, we highlight the value of lived experience and codesign for developing and testing interventions for AN. We offer several lessons learned over the course of the trial, pertaining to trial enrollment, retention and engagement, measurement of outcomes, and research adaptations for real-world settings, and hope that these recommendations facilitate future treatment research for AN.

Patient and mentor language style matching as a predictor of working alliance, engagement with treatment as usual, and eating disorders symptoms over the course of an online guided self-help intervention for anorexia nervosa.

OBJECTIVE: The aim of this study was to examine the processes involved in a guided self-help (GSH) pre-treatment intervention (RecoveryMANTRA) for patients with anorexia nervosa (AN), by measuring the levels of patient/mentor Language Style Matching (LSM). RecoveryMANTRA was supported by student mentors or peer mentors (recovered individuals) over six weekly chat-based sessions. We examined whether LSM during RecoveryMANTRA predicted patients'working alliance with the clinic therapist, motivation, eating disorder (ED) and general psychopathology. A further aim was to examine differences in LSM between student mentors and peer mentors. METHOD: 87 AN adults received RecoveryMANTRA plus treatment as usual. The LSM algorithm was used to calculate verbal attunement between patient and mentor. Participants were assessed at baseline and at the end of the intervention. RESULTS: Both early (1st session) and late (6th session) LSM predicted higher working alliance with the clinic therapist. Moreover, late LSM predicted lower EDs symptoms at the end of the RecoveryMANTRA intervention. Patient/peer mentor dyads showed higher late verbal attunement than patient/student mentor dyads. CONCLUSIONS: These findings suggests that in the early phase of treatment relational aspects can impact on engagement with treatment. Verbal attunement in a GSH for AN is associated with working alliance and better clinical outcome.

Transitions from intensive eating disorder treatment settings: qualitative investigation of the experiences and needs of adults with anorexia nervosa and their carers.

BACKGROUND: Relapse rates for individuals with anorexia nervosa after intensive hospital treatment (in-patient or full-time day care) are high. Better knowledge about the difficulties and opportunities that arise during this transition is needed to identify factors that support or hinder continued recovery upon discharge. AIMS: The aim of this study was to explore the experiences of adult patients and their chosen carers on the process of transitioning from intensive eating disorder treatment settings to the community. METHOD: Semi-structured interviews were conducted with patients with anorexia nervosa (n = 11) discharged from day or in-patient care from specialised eating disorder units across the UK, and their chosen carers (n = 20). Data were analysed with inductive thematic analysis. RESULTS: Four interrelated themes were identified for both groups. For patients, themes were continuity of care, ambivalence about continued recovery, the value of social support and a call for enhanced transition support. For carers, themes were the impact of the eating disorder on themselves and the family, perceptions of recovery and support post-discharge, the impact of previous treatment and care experiences, and desire to create a supportive transition process. CONCLUSIONS: The study provides an insight into the unique challenges that individuals with anorexia nervosa face upon leaving intensive treatment. A lack of post-discharge planning, support system and identity formation outside of anorexia nervosa were perceived as barriers to continued recovery. Patients and carers advocated for transition support that incorporates a phased, inclusive approach with accessible professional and social support in the community.

Digging up the dirt on "clean" dietary labels: Public health considerations and opportunities for increased Federal oversight.

BACKGROUND: "Clean" dietary labels are often viewed by consumers as referencing products that are minimally processed, without additives, preservatives, artificial colors, or ingredients, but may also be interpreted as vegan, gluten-free, dairy-free, "real," or "natural." Although the "clean" diet trend continues to grow in popularity, there is a lack of consensus regarding the definition and use of this terminology with a corresponding lack of regulation for such labels in the United States. METHOD: This multidisciplinary scoping review examines the public health implications of the "clean" label trend and the legal and policy landscape for regulation. We report on findings from case law and legal research generated through the Westlaw database and from the U.S. Food and Drug Administration (FDA) enforcement actions and website documents to discuss options for federal- and state-level intervention to mitigate harm. RESULTS: One feasible avenue for change is for the FDA to provide industry guidance, disseminate public statements to debunk myths, and enforce labeling statutes to police deceptive "clean" labeling claims. We also suggest consumer-protection litigation and state-level litigation via attorneys general as alternative actions to combat the abundant misinformation associated with "clean" diets and labels. DISCUSSION: Although the FDA has taken some enforcement actions, these efforts are insufficient given the proliferation of "clean" label products in the marketplace and the potential for adverse impacts on public health including increased risk for disordered eating. The current unregulated, undefined landscape for "clean" dietary labels thus requires urgent action by federal authorities and state attorneys general.

Do media portrayals and social consensus information impact anti-fat attitudes and support for anti-weight discrimination laws and policies?

Although weight stigma and discrimination are associated with increased body dissatisfaction and eating disorder risk, reduced opportunities, and poorer well-being, there are few legal protections for such discrimination in the U.S. We addressed one barrier to enacting protective legislation - public attitudes toward anti-weight discrimination laws - by assessing the impact of media representations of fatness and information about peer attitudes. Using a 2 × 2 experimental design, participants (N = 525) completed baseline assessments of political conservatism and weight bias and were randomly assigned to view fat-negative or fat-positive media content that was ostensibly supported or not supported by their peers, followed by questionnaires assessing fat phobia and legislative attitudes. Two-way ANCOVAs controlling for baseline weight bias and political conservatism indicated a significant effect for media framing, with greater fat phobia and less support for anti-discrimination laws and policies among those who viewed the fat-negative frame; however, effects for ostensible peer support and interaction effects were not significant. These preliminary findings suggest that efforts to shift media rhetoric may enhance support for anti-weight discrimination laws. Future research should investigate other barriers to anti-discrimination legislation and estimate their impact on body dissatisfaction, eating disorder risk, and other indicators of population health.

The relationship between working alliance with peer mentors and eating psychopathology in a digital 6-week guided self-help intervention for anorexia nervosa.

OBJECTIVE: The quality of working alliance (WA) is associated with treatment outcomes across several types of psychiatric disorders and psychological interventions. This study examined the role of WA with peer mentors (people with lived experience of illness) and student mentors (graduated psychology students) in a 6-week, digital, guided self-help (GSH) intervention for anorexia nervosa. METHOD: Ninety-nine patients rated weekly, for 6 weeks: (a) eating psychopathology using the short version of the Eating Disorder Examination Questionnaire (EDE-QS) and (b) WA with a student mentor (n = 14) or a peer mentor (n = 10). WA was assessed by asking patients the extent to which they felt comfortable working with their mentor and the extent to which they agreed with them on the goals for support. WA with mentors and the association with eating psychopathology change were measured on a session-by-session basis. The analysis involved a random intercepts cross-lagged panel model. RESULTS: WA with peer mentors was slightly higher than WA with students (ES = 0.3). Peer mentors' WA in the previous session was significantly associated with eating psychopathology ratings in the next session. No significant relationship was found between the previous session's EDE-QS scores and peer mentor alliance in the following session. In the student mentor group, there were no session-by-session associations between WA and eating psychopathology. However, greater WA with the student mentor across sessions was associated with less eating psychopathology. DISCUSSION: These findings suggest that clinical outcomes are in part associated with the characteristics of the mentor delivering guidance in an online GSH for eating disorders.

Outcomes for adults with anorexia nervosa who do not respond early to outpatient treatment.

OBJECTIVE: To better understand those patients with anorexia nervosa who do not show early response to treatment and are likely to have poorer outcome. METHOD: From an existing data set of 187 patients with anorexia nervosa across 22 eating disorder outpatient services in the United Kingdom, participants who had started treatment and had at least one body mass index (BMI) observation in the first 6 weeks of treatment were eligible for these secondary analyses (N = 65), a latent class analysis of BMI change over the first 6 weeks of treatment. Fifty-six patients showed no early change in BMI. We used logistic regression to examine predictors of good outcome in the 40 participants who had 12-month follow-up data. Predictors included global EDE-Q, negative affect (Depression, Anxiety, and Stress Scales) and functional impairment (Work and Social Adjustment Scale). RESULTS: Good outcome was achieved by 23% of patients and remission by 15%. Good outcome was predicted by less functional impairment at baseline. DISCUSSION: Further work that can identify sub-groups of patients with anorexia nervosa who do not achieve good outcome after treatment will inform the development of targeted engagement approaches.

Network intervention analysis to assess the trajectory of change and treatment effects associated with the use of online guided self-help for anorexia nervosa.

AIM: The aim of this study was to use the innovative technique of Network Intervention Analysis (NIA) to examine the trajectory of symptom change associated with the use of a digital guided self-help intervention (RecoveryMANTRA) to augment treatment as usual in adult anorexia nervosa. METHODS: Self-reported eating disorder symptoms and mood (stress, anxiety and depression), work and social adjustment, motivation and treatment (Treatment as usual + RecoveryMANTRAand Treatment as usual) were included as nodes in the network and examined using NIA. Networks were computed at baseline (n = 88, 99), at end of treatment (6 weeks, n = 71, 75) and at 6- (n = 58, 63) and 12-month (n = 52, 63) follow-up. RESULTS: RecoveryMANTRA was associated with a direct effect on anxiety, shape concern and restraint at the end of the intervention. This effect was not maintained at follow-up. There were no direct effects of RecoveryMANTRA on motivation, stress and depression. CONCLUSIONS: These findings indicate that RecoveryMANTRA exerts a direct effect on eating disorder symptoms and anxiety. NIA is a promising method to evaluate trajectories of clinical change and direct and indirect effects of a therapeutic intervention compared to a control condition.

Exploring the ways in which COVID-19 and lockdown has affected the lives of adult patients with anorexia nervosa and their carers.

OBJECTIVE: This qualitative study explores the ways in which the coronavirus disease 2019 (COVID-19) pandemic and associated lockdown measures have affected the lives of adult patients with anorexia nervosa (AN) and their carers. METHOD: Semi-structured interviews were conducted with patients with AN (n = 21) and carers (n = 28) from the start of UK Government imposed lockdown. Data related directly to the impact of lockdown and COVID-19 were analysed using thematic analysis. RESULTS: Four broad themes were identified for patients and carers separately. Patients experienced: 1. reduced access to eating disorder (ED) services; 2. disruption to routine and activities in the community; 3. heightened psychological distress and ED symptoms; 4. increased attempts at self-management in recovery. Carer themes included: 1. concern over provision of professional support for patients; 2. increased practical demands placed on carers in lockdown; 3. managing new challenges around patient wellbeing; 4. new opportunities. CONCLUSIONS: Reduced access to ED services, loss of routine and heightened anxieties and ED symptoms resulting from COVID-19 and lockdown measures presented challenges for patients and carers. Increased remote support by ED services enabled the continuation of treatment and self-management resources and strategies promoted self-efficacy in both groups.

"It's Healthy Because It's Natural." Perceptions of "Clean" Eating among U.S. Adolescents and Emerging Adults.

Definitions for the culturally trendy "clean" eating phenomenon vary: whereas some characterize it as natural and healthy, others adopt more restrictive, moralizing, and affectively-laden definitions that may reflect disordered eating. We examined levels of familiarity with "clean" eating, sources of information, and perceptions of this dietary trend among a large, diverse sample of U.S. adolescents and emerging adults recruited from the National MyVoice Text Message Cohort (n = 1266; ages 14-24 years). Participants answered five questions assessing knowledge of "clean" eating, definitions, perceived healthiness vs. harm, and willingness to adopt "clean" eating, and responses were coded by three trained researchers. Results indicate that 55% of respondents had previously heard of "clean" eating, most commonly through social media, other online sources, and peers. Definitions were heterogeneous, with 40% offering "non-processed" or "whole foods" and 13% noting "non-GMO" or "organic" components. Few respondents (0.6%) expressed outright skepticism about "clean" eating, but many (30%) identified dietary avoidance and restriction as part of the definition. Overall, 71% characterized "clean" eating as a healthy approach, whereas 6% flagged it as "unhealthy", and 18% noted elements of both healthfulness and harm. Notably, 41% reported they "probably would" try "clean" eating themselves, with greater willingness to try "clean" eating among cisgender women. Present findings highlight high levels of awareness and positive attitudes toward "clean" eating among young people in the U.S., with little recognition of the potential risks of dietary restriction. Further research should examine actual dietary behaviors to clarify potential risks of "clean" eating and related trends and thus inform strategies for eating disorder prevention.

The Feasibility of Using Guided Self-Help in Anorexia Nervosa: An Analysis of Drop-Out From the Study Protocol and Intervention Adherence.

The implementation of online technologies to promote wellbeing is increasingly becoming a worldwide priority. This study includes secondary analyses of data and examined drop-out rates in an online guided self-help intervention for patients with anorexia nervosa. Specifically, rates of drop-out at end of treatment (i.e., 6 weeks assessment), as well as intervention adherence (minimum of four of six online guided sessions) and differences between completers and drop-outs were examined. Motivation to change and associated patient variables were assessed as predictors of drop-out using structural equation modeling. Ninety-nine patients were randomized to the intervention arm of the trial. Data were available for 82 individuals, 67 of whom completed the 6 weeks assessment and attended a minimum of four online sessions. No significant differences were found between completers and drop-outs at baseline. At the end of the first week of participation, drop-outs from the 6 weeks assessment or the intervention reported less satisfaction with their work with the mentor delivering online guidance. Greater confidence in own ability to change and higher controlled motivation (willingness to change due to pressure from others) predicted lower drop-out rates from the 6 weeks assessment. Stronger alliance with the therapist at the treatment center and lower psychological distress were associated with greater autonomous motivation (self-directed motivation) and importance and ability to change. Data demonstrate that a novel online guided self-help intervention for patients with anorexia nervosa is feasible. Early satisfaction with the program and external pressure to change have a protective role against drop-out rates. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02336841.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness.

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

A multicenter audit of outpatient care for adult anorexia nervosa: Symptom trajectory, service use, and evidence in support of "early stage" versus "severe and enduring" classification.

BACKGROUND: We explored the utility of "staging" anorexia nervosa (AN) by duration of illness and psychological wellbeing. We also investigated 12-month symptom trajectories and service usage in a large cohort of patients with AN assessed for outpatient treatment. METHOD: We conducted secondary analyses on data from a multisite clinical trial of adults with AN (n = 187) recruited from 22 NHS England specialist eating disorder (ED) services into a digital treatment augmentation study. Clinical outcomes and service use were measured at postintervention (six weeks), 6 and 12 months. We grouped patients into two categories: "early stage" (illness duration <3 years; n = 60) and "severe and enduring" stage (SE-AN; n = 41) indicated by distress (Depression Anxiety and Stress Scales, DASS ≥60) and illness duration (≥7 years). RESULTS: At 12 months, patients reported large improvements in body mass index, small to moderate improvements in ED symptoms, mood, and work/social adjustment, and 23.6% met criteria for recovery. However, patients classified as SE-AN reported higher rates of accessing intensive services, higher ED symptomatology, and poorer work/social adjustment at baseline, and lower rates of improvement in work/social adjustment at 12 months compared to "early stage" respondents. DISCUSSION: Although present findings suggest overall symptomatic improvements, exploratory results highlight marked differences in course and service use between people at different stages of AN, suggesting a need to consider staging for clinical decision-making. Further research differentiating between clinical subtypes of AN and adoption of a more personalized approach may ensure that services and care pathways better fit patient needs.

Diet Pill and Laxative Use for Weight Control and Subsequent Incident Eating Disorder in US Young Women: 2001-2016.

Objectives. To investigate the prospective association of diet pill and laxative use for weight control with subsequent first eating disorder diagnosis in young women.Methods. We used longitudinal data from 10 058 US women spanning 2001 through 2016. We used multivariable logistic regression models, adjusting for age, race/ethnicity, and overweight status to estimate the association between weight-control behaviors and subsequent eating disorder diagnosis.Results. Among those who had not previously received an eating disorder diagnosis, women who reported diet pill (adjusted odds ratio [AOR] = 5.6; 95% confidence interval [CI] = 3.0, 10.5) or laxative (AOR = 6.0; 95% CI = 4.2, 8.7) use for weight control had higher odds of receiving a subsequent first eating disorder diagnosis within 1 to 3 years than those who did not report using these products.Conclusions. Use of diet pills or laxatives for weight loss can be dangerous and may be a warning sign that warrants counseling and evaluation for the presence of or risk of developing an eating disorder.Public Health Implications. Policymakers and public health professionals should develop and evaluate policy initiatives to reduce or prohibit access to diet pills and laxatives abused for weight control.

A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa.

BACKGROUND: Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa. METHODS: Participants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months. RESULTS: Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks. CONCLUSIONS: Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.

Digital Manipulation of Images of Models' Appearance in Advertising: Strategies for Action Through Law and Corporate Social Responsibility Incentives to Protect Public Health.

CONTEXT: Widespread digital retouching of advertising imagery in the fashion, beauty, and other consumer industries promotes unrealistic beauty standards that have harmful effects on public health. In particular, exposure to misleading beauty imagery is linked with greater body dissatisfaction, worse mood, poorer self-esteem, and increased risk for disordered eating behaviors. Moreover, given the social, psychological, medical, and economic burden of eating disorders, there is an urgent need to address environmental risk factors and to scale up prevention efforts by increasing the regulation of digitally altered advertising imagery. METHODS: This manuscript summarizes the health research literature linking digital retouching of advertising to increased risk of eating disorders, disordered weight and appearance control behaviors, and body dissatisfaction in consumers, followed by a review of global policy initiatives designed to regulate digital retouching to reduce health harms to consumers. Next, we turn to the US legal context, reporting on findings generated through legal research via Westlaw and LexisNexis, congressional records, federal agency websites, law review articles, and Supreme Court opinions, in addition to consulting legal experts on both tax law and the First Amendment, to evaluate the viability of various policy initiatives proposed to strengthen regulation on digital retouching in the United States. FINDINGS: Influencing advertising practices via tax incentives combined with corporate social responsibility initiatives may be the most constitutionally feasible options for the US legal context to reduce the use of digitally alternated images of models' bodies in advertising. CONCLUSIONS: Policy and corporate initiatives to curtail use of digitally altered images found to be harmful to mental and behavioral health of consumers could reduce the burden of eating disorders, disordered weight and appearance control behaviors, and body dissatisfaction and thereby improve population health in the United States.

Is #cleaneating a healthy or harmful dietary strategy? Perceptions of clean eating and associations with disordered eating among young adults.

BACKGROUND: Although "clean eating" is widely propagated through social media and anecdotal reports in the popular press, there is almost no scientific research on this potentially risky dietary strategy. The current investigation explored definitions and perceptions of "clean eating" and its associations with indicators of disordered eating among diverse U.S.-based undergraduates. METHOD: Undergraduates (N = 148, M age = 19.41 years, 70.3% women) were asked to define "clean eating" via an open-ended question and then read vignettes featuring five "clean" diets, all of which caused mild functional impairment across multiple domains. Participants rated the extent to which they believed the diet was 1) "healthy," 2) reflective of "clean eating," and 3) likely to be adopted by them. Finally, participants completed questionnaires to assess body appearance evaluation, obsessive-compulsive symptoms, eating disorder symptoms, and symptoms of orthorexia nervosa. RESULTS: Open-ended responses indicated that participants defined "clean eating" in varied but overwhelmingly positive terms. Repeated measures ANOVAs indicated that the "meal substitution" vignette was perceived as the least healthy, least "clean," and least likely to be adopted, whereas the "new" (balanced) diet vignette was rated the highest on these domains. Correlations among diet perceptions and indicators of disordered eating were positive and significant. CONCLUSIONS: "Clean eating" is likely a heterogeneous phenomenon that is viewed favorably by U.S.-based college students even when it is linked with functional impairment and emotional distress. Ongoing examination of "clean eating" could clarify the potential benefits and risks posed by this dietary strategy and thus inform eating disorder prevention efforts.