The relation of food insecurity to eating disorder characteristics and treatment-seeking among adult respondents to the National Eating Disorders Association online screen.

BACKGROUND: Food insecurity (FI), characterized by limited or uncertain access to adequate food, has been associated with eating disorders (EDs). This study explored whether FI was associated with ED behaviors, ED diagnosis, current treatment status, and treatment-seeking intentions among adults who completed an online ED screen. METHODS: Respondents to the National Eating Disorders Association online screening tool self-reported demographics, FI, height and weight, past 3-month ED behaviors, and current treatment status. Respondents were also asked an optional question about treatment-seeking intentions. Hierarchical regressions evaluated relations between FI and ED behaviors, treatment status, and treatment-seeking intentions. Logistic regressions explored differences in probable ED diagnosis by FI status. RESULTS: Of 8714 respondents, 25 % screened at risk for FI. FI was associated with greater binge eating (R2Change = 0.006), laxative use (R2Change = 0.001), and presence of dietary restriction (R2Change = 0.001, OR: 1.32) (ps < .05). Having FI was associated with greater odds of screening positive for a probable ED or as high risk for an ED (ps < .05). FI was not associated with current treatment status or treatment-seeking intentions (ps > .05). CONCLUSIONS: Findings add to existing literature supporting a relation between FI and EDs. Implications include a need to disseminate EDs screening and treatment resources to populations affected by FI and to tailor treatments to account for barriers caused by FI.

The role of stress in the association among food insecurity, eating disorder pathology, and binge eating-related appetitive traits.

PURPOSE: Growing literature demonstrates a positive association between food insecurity (FI) and eating disorder pathology. Additionally, FI has been associated with two appetitive traits strongly linked to binge eating, food responsiveness and emotional overeating. However, little research has investigated factors that might help to explain these associations. One hypothesis is that experiencing FI may increase stress, and that eating disorder pathology, particularly binge eating-related phenotypes, may serve as a coping strategy. This study explores stress as a potential mechanism in the association between FI and general eating disorder pathology, as well as two appetitive traits strongly associated with binge eating (food responsiveness and emotional overeating). METHODS: Cis-gender women (N = 634) completed online questionnaires assessing FI, stress, eating disorder pathology (measured via the total score on the Short Eating Disorder Examination Questionnaire), and binge eating-related appetitive traits (measured via the Adult Eating Behavior Questionnaire). Cross-sectional indirect effects analyses with a 1000-sample bootstrap were used to test pathways among FI, stress, and eating-related constructs. RESULTS: FI was significantly associated with eating disorder pathology and associated appetitive traits (ps < 0.001). Stress explained a significant proportion of the correlation between FI and each eating-related construct. CONCLUSIONS: Our findings extend prior research on the relationships between FI, eating disorder pathology, and binge eating-related appetitive traits to provide preliminary evidence that stress may act as an underlying mechanism. Future studies should use longitudinal designs to assess the prospective relationships among these constructs.

Predictors of treatment seeking and uptake among respondents to a widely disseminated online eating disorders screen in the United States.

OBJECTIVE: To explore predictors of treatment seeking and uptake among individuals following an online eating disorders (EDs) screen in the U.S. disseminated by the National Eating Disorders Association. METHOD: Respondents who screened at risk or positive for a probable ED from 04/2019 to 05/2021 (N = 263,530) were eligible to complete a 2-month follow-up survey that assessed treatment seeking and uptake after being offered referral options following screening. Analyses were conducted using chi-square tests or logistic regressions. RESULTS: Sixty thousand thirty-four respondents (22.8%) opted-in to the follow-up survey, of whom 2276 (3.8%) completed it. Of the final analytic sample (n = 1922), 35.7% of respondents reported seeking and 22.4% reported receiving treatment. Treatment seeking and uptake were more common among respondents who were female, White, or >24 years of age; uptake was more common among respondents who were non-Hispanic or higher income. Elevated shape/weight concerns were significantly, albeit modestly, associated with reduced likelihood to receive treatment. DISCUSSION: Demographic differences in treatment seeking and uptake highlight the need to optimize ED screening tools/feedback to meet the needs of underserved groups and to address stereotypes and structural barriers that may interfere. Research is also needed to identify barriers to uptake among those with elevated shape/weight concerns. PUBLIC SIGNIFICANCE: Relatively low rates of treatment seeking and uptake were observed, particularly among underserved groups, 2 months following a widely disseminated online eating disorders screen. Optimization of online eating disorder screening tools and delivery of feedback and referral information may be needed to increase health care utilization.

Psychometric properties of the Perceived Benefits of Thinness Scale in college-aged women.

Thin ideal internalization is a risk factor for disordered eating behaviors, poor body image, and eating disorders (EDs). This paper evaluated the psychometric properties of a novel measure, the Perceived Benefits of Thinness Scale (PBTS), which assesses how individuals feel being thinner would affect various aspects of their lives. Three separate studies with unique samples of college-aged women over 18 years were conducted to assess reliability and validity. In Study 1, exploratory and confirmatory factor analyses suggested all PBTS items loaded onto one factor that was distinct from a measure of weight and shape concerns. A large correlation between changes in PTBS scores and changes in ED psychopathology scores over 8 months (r = .57, p < .01) suggested sensitivity to change. Greater severity in ED pathology was also associated with higher scores on the PBTS. In Study 2, the PBTS showed good test-retest reliability (r = .84, p < .001) and, in Study 3, expected correlations with existing measures of thin ideal internalization (rs = .38-.60, ps < .001). Overall, the PBTS displayed good factor structure, reliability, concurrent validity, and sensitivity to change. By emphasizing social, emotional, and quality of life benefits, the PBTS may serve clinicians, researchers, and patients in understanding thin ideal internalization and associated ED risk.

Overweight and obesity are associated with increased eating disorder correlates and general psychopathology in university women with eating disorders.

OBJECTIVE: Examine how eating disorder (ED) correlates, ED-related clinical impairment, general psychopathology, and ED diagnoses differ across weight statuses in a sample of university women with EDs. METHOD: Participants were 690 women from 28 U.S. universities who screened positive for an ED (with the exception of anorexia nervosa [AN]) and participated in the Healthy Body Image Program study. ED correlates, ED-related clinical impairment, general psychopathology (i.e., depression and anxiety), and ED diagnoses were compared across weight statuses (i.e., healthy weight, overweight, obesity) using analyses of variance and chi-square tests. RESULTS: Women with EDs and overweight or obesity had higher levels of, perceived benefit of thinness, depressive symptoms, anxiety, and weight/shape concerns (obesity only) than those with healthy weight (ps ≤ .017). Compared to those with healthy weight, those with obesity had higher rates of clinical and sub-clinical binge eating disorder and lower rates of bulimia nervosa (p < .001). DISCUSSION: Overweight and obesity in individuals with EDs, excluding AN, are associated with greater severity of ED correlates, ED-related clinical impairment, and co-morbid general psychopathology. The current study highlights the need to consider weight status in ED treatment and for optimization of ED treatments to address shared risk factors between EDs and overweight and obesity.

Lessons learned from service design of a trial of a digital mental health service: Informing implementation in primary care clinics.

Implementing a digital mental health service in primary care requires integration into clinic workflow. However, without adequate attention to service design, including designing referral pathways to identify and engage patients, implementation will fail. This article reports results from our efforts designing referral pathways for a randomized clinical trial evaluating a digital service for depression and anxiety delivered through primary care clinics. We utilized three referral pathways: direct to consumer (e.g., digital and print media, registry emails), provider referral (i.e., electronic health record [EHR] order and provider recommendation), and other approaches (e.g., presentations, word of mouth). Over the 5-month enrollment, 313 individuals completed the screen and reported how they learned about the study. Penetration was 13%, and direct to consumer techniques, most commonly email, had the highest yield. Providers only referred 16 patients through the EHR, half of whom initiated the screen. There were no differences in referral pathway based on participants' age, depression severity, or anxiety severity at screening. Ongoing discussions with providers revealed that the technologic implementation and workflow design may not have been optimal to fully affect the EHR-based referral process, which potentially limited patient access. Results highlight the importance of designing and evaluating referral pathways within service implementation, which is important for guiding the implementation of digital services into practice. Doing so can ensure that sustained implementation is not left to post-evaluation bridge-building. Future efforts should assess these and other referral pathways implemented in clinical practice outside of a research trial.

Preliminary data on help-seeking intentions and behaviors of individuals completing a widely available online screen for eating disorders in the United States.

OBJECTIVE: Scaling an online screen that provides referrals may be key in closing the treatment gap for eating disorders (EDs), but we need to understand respondents' help-seeking intentions and behaviors after receiving screen results. This study reported on these constructs among respondents to the National Eating Disorders Association online screen who screened positive or at high risk for an ED. METHOD: Respondents completed the screen over 18 months (February 9, 2018-August 28, 2019). Those screening positive or at high risk for an ED (n = 343,072) had the option to provide data on help-seeking intentions (after screen completion) and behaviors (2-month follow-up). RESULTS: Of eligible respondents, 4.8% (n = 16,396) provided data on help-seeking intentions, with only 33.7% of those reporting they would seek help. Only 7.6% of eligible respondents opted in to the 2-month follow-up, with 10.6% of those completing it (n = 2,765). Overall, 8.9% of respondents to the follow-up reported being in treatment when they took the screen, 15.5% subsequently initiated treatment, and 75.5% did not initiate/were not already in treatment. DISCUSSION: Preliminary results suggest that among the small minority who provided data, only one-third expressed help-seeking intentions and 16% initiated treatment. Online screening should consider ways to increase respondents' motivation for and follow-through with care.

Optimizing eating disorder treatment outcomes for individuals identified via screening: An idea worth researching.

In recent years, online screens have been commonly used to identify individuals who may have eating disorders (EDs), many of whom may be interested in treatment. We describe a new empirical approach that takes advantage of current evidence on empirically supported, effective treatments, while at the same time, uses modern statistical frameworks and experimental designs, data-driven science, and user-centered design methods to study ways to expand the reach of programs, enhance our understanding of what works for whom, and improve outcomes, overall and in subpopulations. The research would focus on individuals with EDs identified through screening and would use continuously monitored data, and interactions of interventions/approaches to optimize reach, uptake, engagement, and outcome. Outcome would be assessed at the population, rather than individual level. The idea worth researching is to determine if an optimization outcome model produces significantly higher rates of clinical improvement at a population level than do current approaches, in which traditional interventions are only offered to the few people who are interested in and able to access them.

Screening and offering online programs for eating disorders: Reach, pathology, and differences across eating disorder status groups at 28 U.S. universities.

OBJECTIVE: The Internet-based Healthy Body Image (HBI) Program, which uses online screening to identify individuals at low risk of, high risk of, or with an eating disorder (ED) and then directs users to tailored, evidence-based online or in-person interventions to address individuals' risk or clinical status, was deployed at 28 U.S. universities as part of a randomized controlled trial. The purpose of this study is to report on: (a) reach of HBI, (b) screen results, and (c) differences across ED status groups. METHOD: All students on participating campuses ages 18 years or older were eligible, although recruitment primarily targeted undergraduate females. RESULTS: The screen was completed 4,894 times, with an average of 1.9% of the undergraduate female student body on each campus taking the screen. ED risk in participating students was high-nearly 60% of students screened were identified as being at high risk for ED onset or having an ED. Key differences emerged across ED status groups on demographics, recruitment method, ED pathology, psychiatric comorbidity, and ED risk factors, highlighting increasing pathology and impairment in the high-risk group. DISCUSSION: Findings suggest efforts are needed to increase reach of programs like HBI. Results also highlight the increasing pathology and impairment in the high-risk group and the importance of programs such as HBI, which provide access to timely screening and intervention to prevent onset of clinical EDs.

Results of disseminating an online screen for eating disorders across the U.S.: Reach, respondent characteristics, and unmet treatment need.

OBJECTIVE: The treatment gap between those who need and those who receive care for eating disorders is wide. Scaling a validated, online screener that makes individuals aware of the significance of their symptoms/behaviors is a crucial first step for increasing access to care. The objective of the current study was to determine the reach of disseminating an online eating disorder screener in partnership with the National Eating Disorders Association (NEDA), as well to examine the probable eating disorder diagnostic and risk breakdown of adult respondents. We also assessed receipt of any treatment. METHOD: Participants completed a validated eating disorder screen on the NEDA website over 6 months in 2017. RESULTS: Of 71,362 respondents, 91.0% were female, 57.7% 18-24 years, 89.6% non-Hispanic, and 84.7% White. Most (86.3%) screened positive for an eating disorder. In addition, 10.2% screened as high risk for the development of an eating disorder, and only 3.4% as not at risk. Of those screening positive for an eating disorder, 85.9% had never received treatment and only 3.0% were currently in treatment. DISCUSSION: The NEDA online screen may represent an important eating disorder detection tool, as it was completed by >71,000 adult respondents over just 6 months, the majority of whom screened positive for a clinical/subclinical eating disorder. The extremely high percentage of individuals screening positive for an eating disorder who reported not being in treatment suggests a wide treatment gap and the need to offer accessible, affordable, evidence-based intervention options, directly linked with screening.

Validation of the Computerized Adaptive Test for Mental Health in Primary Care.

PURPOSE: The US Preventive Services Task Force recommends screening for depression in the general adult population. Although screening questionnaires for depression and anxiety exist in primary care settings, electronic health tools such as computerized adaptive tests based on item response theory can advance screening practices. This study evaluated the validity of the Computerized Adaptive Test for Mental Health (CAT-MH) for screening for major depressive disorder (MDD) and assessing MDD and anxiety severity among adult primary care patients. METHODS: We approached 402 English-speaking adults for participation from a primary care clinic, of whom 271 adults (71% female, 65% black) participated. Participants completed modules from the CAT-MH (Computerized Adaptive Diagnostic Test for MDD, CAT-Depression Inventory, CAT-Anxiety Inventory); brief paper questionnaires (9-item Patient Health Questionnaire [PHQ-9], 2-item Patient Health Questionnaire [PHQ-2], Generalized Anxiety Disorder 7-item Scale [GAD-7]); and a reference-standard interview, the Structured Clinical Interview for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) Diagnoses. RESULTS: On the basis of the interview, 31 participants met criteria for MDD and 29 met criteria for GAD. The diagnostic accuracy of the Computerized Adaptive Diagnostic Test for MDD (area under curve [AUC] = 0.85) was similar to that of the PHQ-9 (AUC = 0.84) and higher than that of the PHQ-2 (AUC = 0.76) for MDD screening. Using the interview as the reference standard, the accuracy of the CAT-Anxiety Inventory (AUC = 0.93) was similar to that of the GAD-7 (AUC = 0.97) for assessing anxiety severity. The patient-preferred screening method was assessment via tablet/computer with audio. CONCLUSIONS: Computerized adaptive testing could be a valid and efficient patient-centered screening strategy for depression and anxiety screening in primary care settings.

A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women.

Objective: As eating disorders (EDs) often emerge during college, managing EDs would ideally integrate prevention and treatment. To achieve this goal, an efficient tool is needed that detects clinical symptoms and level of risk. This study evaluated the performance of a screen designed to identify individuals at risk for or with an ED. Participants: Five hundred forty-nine college-age women. Methods: Participants completed a screen and diagnostic interview. Results: Using parsimonious thresholds for ED diagnoses, screen sensitivity ranged from 0.90 (anorexia nervosa) to 0.55 (purging disorder). Specificity ranged from 0.99 (anorexia nervosa) to 0.78 (subthreshold binge eating disorder) compared to diagnostic interview. Moderate to high area under the curve values were observed. The screen had high sensitivity for detecting high risk. Conclusions: The screen identifies students at risk and has acceptable sensitivity and specificity for identifying most ED diagnoses. This tool is critical for establishing stepped care models for ED intervention.