"If I could survive without eating, it would be a huge relief": Development and initial validation of the Fear of Food Questionnaire.

BACKGROUND: Fear of food and behavioral avoidance of specific foods, food groups, and food related social situations can substantially reduce health related quality of life in individuals with a wide range of conditions that affect appetite, eating behavior, and digestion, including irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), vomit and choking phobias, and food allergies/sensitivities. When this avoidance leads to weight/nutritional and/or psychosocial impairment, the diagnostic criteria for Avoidant/restrictive food intake disorder (ARFID) are met. Fear of food is an important target for interventions designed to improve psychosocial functioning and quality of life in such individuals. The purpose of this research was to develop and validate a novel measure of fear of food. METHODS: Participants (n = 1138) were recruited from ongoing clinical trials for both IBD and IBS, from Amazon's Mechanical Turk, from Reddit support forums for IBS, IBD, and vomit phobia, and from an undergraduate subject pool. Exploratory and confirmatory factor analysis, Pearson's correlations, one-way ANOVA, and intraclass correlation coefficients were used to assess the validity and reliability of the Fear of Food Questionnaire. RESULTS: The final 18 item questionnaire showed excellent internal consistency, test-retest reliability, convergent validity, discriminative (known groups) validity, as well as good factor structure. Fear of food was highly correlated with visceral hypersensitivity, catastrophizing, GI symptom severity and health related quality of life, as well as with self-reported Fear-ARFID symptoms. Individuals meeting study criteria for Fear-ARFID reported the highest scores relative to control and other analogue clinical groups. CONCLUSION: The Fear of Food Questionnaire appears to be reliable and valid across populations and may be a valuable tool in the assessment and treatment of Fear-ARFID.

No effect of very brief exposure to masked food pictures on fear of food in anorexia nervosa.

OBJECTIVE: Very brief exposure to masked images of spider stimuli can facilitate approach behaviour towards spiders in fearful subjects. We hypothesized that a similar effect might occur for fear of food in patients with anorexia nervosa (AN), possibly offering a new treatment approach, with advantages over other methods of food exposure. METHODS: Patients with AN (n = 60) were randomly assigned to one of three experimental conditions and received a single session of exposure to either masked and very briefly presented food images, clearly visible food images, or masked non-food images (i.e. household items). Effects of the three exposure conditions on fear of food and food avoidance were examined. RESULTS: Contrary to our expectations, very brief food cue exposure was not superior to the control conditions regarding fear of food and approach behaviour towards food immediately after the intervention and body mass index four weeks later. CONCLUSION: This finding suggests important differences between fear of food in AN and specific phobias such as fear of spiders. The absence of an effect reveals limitations of the very brief exposure method, which might be better suited for evolutionarily relevant threat stimuli.

Psychometric properties of the fear of food measure in Japanese women.

PURPOSE: The aim of the present study was to investigate the psychometric properties of the fear of food measure (FOFM) in Japanese women. METHODS: This study was a cross-sectional, observational, and multicenter study conducted at the University of Tokyo and Kyushu University. Participants were comprised of 169 healthy women and 149 patients with eating disorders. First, the present study explored the factor structure of FOFM in Japanese women using exploratory factor analyses. Then, the Cronbach's alpha and McDonald's omega were calculated to assess reliability. Concurrent validity was examined by calculating correlation coefficients with the Eating Attitudes Test, negative affect of Positive and Negative Affect Schedule, and Hospital Anxiety and Depression Scale. Additionally, the Wilcoxon rank-sum test was used to compare scores between the healthy control and patient group. RESULTS: The final model had four subscales. The subscales, thus, had high reliability and showed significant positive correlations with the questionnaires. The scores of subscales in the patient group were significantly higher than those in the healthy control group. CONCLUSIONS: The FOFM had a four-factor structure in Japanese women. Its reliability and validity were verified and it could be used as a tool to assess fear of food. LEVEL OF EVIDENCE: III, case-control analytic study.

Manipulating the theoretical framing of exposure therapy for eating disorders impacts clinicians' treatment preferences.

BACKGROUND: Exposure therapy is the most effective treatment for anxiety and related disorders and its efficacy in the eating disorders is rapidly gaining support. Despite the strong evidence behind exposure therapy, many anxiety disorder providers do not endorse the usage of exposure therapy. Limited research has explored the use of exposure therapy in eating disorder providers, as well as the impact of framing on likelihood to use exposure therapy. OBJECTIVE: The current study (N = 125 eating disorder providers) manipulated the framing of exposure to feared foods (pizza). METHODS: We framed the treatment as an exposure, behavioral experiment, or acceptance/mindfulness-based intervention. We also tested attitudes towards exposure therapy in eating disorder providers. RESULTS: Participants were more likely to endorse willingness to use a treatment framed as a behavioral experiment over exposure and acceptance-based framing. This effect did not vary by degree type, type of provider, years in practice, experience, or training. We also found that providers with more training, specifically in eating disorder exposure, were more likely to use exposure over acceptance-based framed intervention (and vice versa). Finally, we found that eating disorder providers had a somewhat positive view of exposure therapy. CONCLUSION: Framing of the intervention impacts likelihood that providers will endorse using specific interventions. Therefore, intervention development and dissemination efforts should consider the language around the description of evidence-based treatments. Furthermore, enhanced training and education specifically with eating disorder exposure therapy may enhance the likelihood of providers utilizing exposure therapy. Level I: experimental study.

Diagnostic, clinical, and personality correlates of food anxiety during a food exposure in patients diagnosed with an eating disorder.

BACKGROUND: Eating disorders are characterized by high levels of anxiety, especially while eating. However, little is known about anxiety experienced during meals and specifically what other variables may impact such anxiety. OBJECTIVE: We sought to further quantify and understand the relationship between food anxiety, eating disorders, and related correlates (e.g., comorbid diagnoses, personality). METHODS: In the current study [N = 42 participants diagnosed with an eating disorder (n = 36 participants with anorexia nervosa)], we quantified anxiety before, during, and after a meal using data from a food exposure session in a partial hospital eating disorder center. We examined diagnostic, personality, and clinical factors as correlates of food anxiety. RESULTS: Participants were more likely to experience higher food anxiety if they had a current diagnosis of major depression, obsessive-compulsive disorder, or post-traumatic stress disorder (PTSD). Concern over mistakes was the strongest and most consistent correlate of food anxiety regardless of time during the meal that anxiety was assessed. Other significant correlates were fear of positive evaluation, social appearance anxiety, BMI, and trust. CONCLUSIONS: These findings show how diagnoses, perfectionism (concern over mistakes), and other correlates relate to anxiety during meals. Food exposure interventions may benefit from personalizations that address these factors. LEVEL OF EVIDENCE: IV Evidence from a randomized control trial, but from the first session before effects of the design would be present.

Fear of food prospectively predicts drive for thinness in an eating disorder sample recently discharged from intensive treatment.

Fears of food are common in individuals with eating disorders and contribute to the high relapse rates. However, it is unknown how fears of food contribute to eating disorder symptoms across time, potentially contributing to an increased likelihood of relapse. Participants diagnosed with an eating disorder (N=168) who had recently completed intensive treatment were assessed after discharge and one month later regarding fear of food, eating disorder symptoms, anxiety sensitivity, and negative affect. Cross lagged path analysis was utilized to determine if fear of food predicted subsequent eating disorder symptoms one month later. Fear of food-specifically, anxiety about eating and feared concerns about eating-predicted drive for thinness, a core symptom domain of eating disorders. These relationships held while accounting for anxiety sensitivity and negative affect. There is a specific, direct relationship between anxiety about eating and feared concerns about eating and drive for thinness. Future research should test if interventions designed to target fear of food can decrease drive for thinness and thereby prevent relapse.