Multiple marginalization, discrimination, and disordered eating among youth aged 10-11.

OBJECTIVE: Although rates of weight discrimination are on-par with racial, ethnic, and gender discrimination, comparatively less work has examined impacts of weight-based discrimination in youth, including on disordered eating. Knowing whether experiences of weight-based discrimination, including in youth with multiply-marginalized identities, are associated with disordered eating could identify vulnerable youth and inform intervention efforts. METHOD: Youth (N = 11,875) ages 10-11 were recruited through the Adolescent Brain Cognitive Development (ABCD) study. Logistic regressions using cross-sectional data examined discrimination experiences (weight, perceived sexual orientation, race/ethnicity, national origin) and disordered eating (binge-eating, vomiting, weight-gain fear, weight self-worth). Models included race/ethnicity, age, sex, parental income, and degree of elevated weight. Raked poststratification weights were used. RESULTS: Rates of weight-based discrimination (6.2%) were similar to rates of race/ethnicity (4.4%) and sexual orientation discrimination (4.5%). Weight-based discrimination was associated with more disordered eating. Youth reporting multiple experiences of discrimination had significantly increased disordered eating compared to youth who did not report discrimination. DISCUSSION: Weight-based discrimination is common in youth and associated with disordered eating. Youth with elevated weight are more likely to be multiply marginalized and experience disordered eating. These findings suggest discrimination, including weight-based discrimination, is a critical intervention target to prevent and treat eating disorders. PUBLIC SIGNIFICANCE: Experiences of discrimination contribute to poorer health; however, weight-based discrimination is relatively understudied. Data from a large sample of youth ages 10-11 showed that youth with elevated weight reported experiencing multiple types of discrimination, and multiply-marginalized youth had increased odds of disordered eating with each additional type of discrimination. Together, this suggests that weight-based discrimination is a critical target to prevent and treat eating disorders, especially in multiply-marginalized youth.

Skepticism of and critical thinking about media messages: Conflicting relationships with body dissatisfaction.

Despite the theoretical connection between media literacy and body dissatisfaction, empirical findings about their relationship are decidedly mixed. There is not a clear explanation for these discrepancies. The present study aimed to 1) compare the attitudes young adult women with those of a reference group of adolescents to examine whether similar values were observed despite differences in age group and racial/ethnic identity, 2) to examine the relationships between media literacy and body dissatisfaction using recommended measures of media literacy. Racially diverse female undergraduate students (N = 152, Mage = 21.62) completed the Media Attitudes Questionnaire, the Critical Thinking about Media Measure, and the Body Shape Questionnaire online. Young adult women endorsed greater critical thinking about media messages and greater skepticism towards the similarity of media messages than adolescents. Additionally, greater skepticism towards the desirability and realism of media messages was associated with lower body dissatisfaction while greater critical thinking about media messages was found to be positively related to greater body dissatisfaction. It is possible that greater critical thinking within the context of media literacy cannot occur without increased attention towards or time spent thinking about media messages. Findings suggest that enhancing critical thinking about the media may not be the main mechanism of change for effective media literacy interventions. These findings underscore the complexities that exist within the relationships between media literacy and body dissatisfaction and highlight the continued need for research in this area.

"Ordinary days would be extraordinary": The lived experiences of severe and enduring anorexia nervosa.

OBJECTIVE: Approximately 25% of individuals with anorexia nervosa (AN) experience a chronic form of the disorder, referred to as severe and enduring anorexia nervosa (SE-AN). Although the classification of SE-AN remains preliminary, there have been increasing calls for a harm reduction-based, collaborative treatment model for these patients. To provide such care for patients with SE-AN, it is critical to listen to and learn from their lived experiences. METHOD: Patients (N = 17) admitted to an inpatient eating disorders program who met initial criteria for SE-AN completed semi-structured interviews about the course of their illness and prior treatment episodes. Interviews were audio recorded and transcribed. Data were analyzed using an inductive, reflexive approach to thematic analysis that examined common themes within and across interviews. RESULTS: Three themes were identified focused on (1) the all-encompassing nature of SE-AN, (2) treatment experiences, and (3) living with chronic illness. Within these themes, there were subthemes. Overall, individuals noted clear insight about their condition, both negative and positive experiences with previous treatment, and hope for better quality of life despite their illness. DISCUSSION: Individuals with SE-AN describe their illness as a chronic condition and hope for a harm reduction-based treatment. Future work, including the lived experiences of individuals with SE-AN, is important to build our understanding of the classification and clinical characteristics of SE-AN and to develop treatment approaches that may best serve these individuals. PUBLIC SIGNIFICANCE: Many people with anorexia nervosa do not achieve a full recovery despite repeated treatment episodes throughout their lifespan. Understanding the lived experiences of individuals with SE-AN may help to inform future treatment development efforts that could improve eating disorder and quality of life outcomes for these patients.

Outcomes for binge eating disorder in a remote weight-inclusive treatment program: a case report.

BACKGROUND: There are no known published reports on outcomes for medically and psychiatrically compromised patients with binge eating disorder (BED) treated remotely in higher level of care settings. This case report presents outcomes of an intentionally remote weight-inclusive partial hospitalization and intensive outpatient program based on Health at Every Size® and intuitive eating principles. CASE PRESENTATION: The patient presented with an extensive trauma background and long history of disturbed eating and body image. She was diagnosed with BED along with several comorbidities, most notably major depressive disorder with suicidality and non-insulin dependent diabetes mellitus. She completed a total of 186 days in the comprehensive, multidisciplinary treatment program encompassing individual and group therapy, as well as other supportive services such as meal support and in vivo exposure sessions. Upon discharge, her BED was in remission, her major depressive disorder was in partial remission, and she no longer exhibited signs of suicidality. Overall, she showed decreases in eating disorder, depressive, and anxiety symptoms as well as increases in quality of life and intuitive eating throughout treatment, which were largely maintained after one year. CONCLUSIONS: This case highlights the potential of remote treatment as an option for individuals with BED, especially in cases where access to higher levels of care might be limited. These findings exemplify how a weight-inclusive approach can be effectively applied when working with this population.

Change in impulsivity is prospectively associated with treatment outcomes for binge-eating disorder.

BACKGROUND: Impulsivity may be a process underlying binge-eating disorder (BED) psychopathology and its treatment. This study examined change in impulsivity during cognitive-behavioral therapy (CBT) and/or pharmacological treatment for BED and associations with treatment outcomes. METHODS: In total, 108 patients with BED (NFEMALE = 84) in a randomized placebo-controlled clinical trial evaluating the efficacy of CBT and/or fluoxetine were assessed before treatment, monthly throughout treatment, at post-treatment (16 weeks), and at 12-month follow-up after completing treatment. Patients completed established measures of impulsivity, eating-disorder psychopathology, and depression, and were measured for height and weight [to calculate body mass index (BMI)] during repeated assessments by trained/monitored doctoral research-clinicians. Mixed-effects models using all available data examined changes in impulsivity and the association of rapid and overall changes in impulsivity on treatment outcomes. Exploratory analyses examined whether baseline impulsivity predicted/moderated outcomes. RESULTS: Impulsivity declined significantly throughout treatment and follow-up across treatment groups. Rapid change in impulsivity and overall change in impulsivity during treatment were significantly associated with reductions in eating-disorder psychopathology, depression scores, and BMI during treatment and at post-treatment. Overall change in impulsivity during treatment was associated with subsequent reductions in depression scores at 12-month follow-up. Baseline impulsivity did not moderate/predict eating-disorder outcomes or BMI but did predict change in depression scores. CONCLUSIONS: Rapid and overall reductions in impulsivity during treatment were associated with improvements in specific eating-disorder psychopathology and associated general outcomes. These effects were found for both CBT and pharmacological treatment for BED. Change in impulsivity may be an important process prospectively related to treatment outcome.

Double trouble? Associations of parental substance use and eating behaviors with pediatric disordered eating.

OBJECTIVE: Comorbidity between substance use disorders and eating disorders is common and related to severity of psychopathology. Parents' eating disorder or substance use disorder have been examined independently and appear to be related to psychopathology in their children. However, no prior work has examined whether co-occurring substance use and eating disorder behaviors in parents relate to eating-disorder psychopathology and weight in their children. METHOD: Participants (N = 435) were parents who completed an online cross-sectional survey. Parents reported their personal substance use and eating-disorder behaviors. Relationships between parental substance use (SUD), parental binge eating (ED), and co-occurring parental substance use and binge eating (SUDxED) with child eating-disorder psychopathology and weight were examined using linear regression. Parent age and sex, child age and sex, parent impulsivity and parent depression scores were included as covariates in analyses. RESULTS: Greater severity of co-occurring parental SUDxED behavior was associated with greater child eating-related psychopathology, including child binge eating and child purging. Additionally, greater parental binge eating (ED) alone was associated with greater child binge eating and overeating. Parental SUD and/or ED behavior were not related to child weight. Child age did not moderate relationships between parent SUDxED behaviors and child binge eating or overeating. DISCUSSION: Overall, parents with greater co-occurring substance use and eating disorder behaviors had children with more severe eating-disorder psychopathology. Clinicians working with families, and those seeking to prevent pediatric eating-related problems, should consider assessing and addressing parents' psychopathology to improve prevention and treatment efforts.

Psychological and eating disorder symptoms as predictors of starting eating disorder treatment.

OBJECTIVE: Little is known about the treatment uptake rate for adults diagnosed with an eating disorder through formal assessment. This study aimed to identify psychological and eating disorder symptoms that predict whether individuals with diagnosed eating disorders start treatment after receiving a diagnostic assessment and recommendation to begin treatment. Identifying barriers to starting treatment can inform interventions to improve the uptake of treatment. METHOD: After a diagnostic assessment at an eating disorder specialty clinic, 223 adults were recommended to begin treatment and completed self-report measures of psychological functioning, clinical impairment, and eating psychopathology. Patient attendance was assessed to determine rates and predictors of starting treatment within 3 months of the assessment. RESULTS: Of the 223 patients recommended to begin treatment, approximately two-third started treatment within 3 months of the assessment. Logistic regression identified greater avoidance of eating, greater laxative use frequency, more social eating concerns, and lower weight dissatisfaction as predicting lower likelihood of beginning treatment after assessment. A chi-square test for independence found no significant differences between diagnostic groups on starting treatment. DISCUSSION: Findings identify eating disorder symptoms that predict treatment enrollment after diagnostic assessment and recommendation to begin treatment. Assessing for these symptoms at the diagnostic assessment stage is recommended to address potential treatment barriers. Future research should identify strategies that increase treatment uptake at this stage of the process.

The Neurobiology of Binge-eating Disorder Compared with Obesity: Implications for Differential Therapeutics.

PURPOSE: Emerging work indicates divergence in the neurobiologies of binge-eating disorder (BED) and obesity despite their frequent co-occurrence. This review highlights specific distinguishing aspects of BED, including elevated impulsivity and compulsivity possibly involving the mesocorticolimbic dopamine system, and discusses implications for differential therapeutics for BED. METHODS: This narrative review describes epidemiologic, clinical, genetic, and preclinical differences between BED and obesity. Subsequently, this review discusses human neuroimaging work reporting differences in executive functioning, reward processing, and emotion reactivity in BED compared with obesity. Finally, on the basis of the neurobiology of BED, this review identifies existing and new therapeutic agents that may be most promising given their specific targets based on putative mechanisms of action relevant specifically to BED. FINDINGS: BED is characterized by elevated impulsivity and compulsivity compared with obesity, which is reflected in divergent neurobiological characteristics and effective pharmacotherapies. Therapeutic agents that influence both reward and executive function systems may be especially effective for BED. IMPLICATIONS: Greater attention to impulsivity/compulsivity-related, reward-related, and emotion reactivity-related processes may enhance conceptualization and treatment approaches for patients with BED. Consideration of these distinguishing characteristics and processes could have implications for more targeted pharmacologic treatment research and interventions.

General impulsivity in binge-eating disorder.

BACKGROUND: The nature and significance of impulse-control difficulties in binge-eating disorder (BED) are uncertain. Most emerging research has focused on food-specific rather than general impulsivity. The current study examines the clinical presentation of patients with BED categorized with and without clinical levels of general impulsivity. METHOD: A total of 343 consecutive treatment-seeking patients with BED were categorized as having BED with general impulsivity (GI+; N = 73) or BED without general impulsivity (GI-: N = 270) based on structured diagnostic and clinical interviews. The groups were compared on demographic, developmental, and psychological features, and on rates of psychiatric and personality comorbidity. RESULTS: Individuals with BED and general impulsivity (GI+) reported greater severity of eating-disorder psychopathology, greater depressive symptoms, and greater rates of comorbidity than those without general impulsivity (GI-). CONCLUSIONS: A subtype of individuals with BED and general impulsivity may signal a more severe presentation of BED characterized by heightened and broader psychopathology. Future work should investigate whether these impulse-control difficulties relate to treatment outcomes.

Training in cognitive strategies reduces eating and improves food choice.

Obesity rates continue to rise alarmingly, with dire health implications. One contributing factor is that individuals frequently forgo healthy foods in favor of inexpensive, high-calorie, unhealthy foods. One important mechanism underlying these choices is food craving: Craving increases with exposure to unhealthy foods (and food cues, such as advertisements) and prospectively predicts eating and weight. Prior work has shown that cognitive regulation strategies that emphasize the negative consequences of unhealthy foods reduce craving. In Studies 1 and 2, we show that cognitive strategies also increase craving for healthy foods by emphasizing their positive benefits, and change food valuation (willingness to pay) for both healthy and unhealthy foods. In Studies 3 and 4, we demonstrate that brief training in cognitive strategies ("Regulation of Craving Training"; ROC-T) increases subsequent healthy (vs. unhealthy) food choices. This was striking because this change in food choices generalized to nontrained items. Importantly, in Study 5, we show that brief training in cognitive strategies also reduces food consumption by 93-121 calories. Consumed calories correlated with changes in food choice. Finally, in Study 6, we show that the training component of ROC-T is necessary, above and beyond any effect of framing. Across all studies (NTOTAL = 1,528), we find that cognitive strategies substantially change craving and food valuation, and that training in cognitive strategies improves food choices by 5.4-11.2% and reduces unhealthy eating, including in obese individuals. Thus, these findings have important theoretical, public health, and clinical implications for obesity prevention and treatment.

Potential psychological & neural mechanisms in binge eating disorder: Implications for treatment.

Binge Eating Disorder (BED) is a newly-established eating disorder diagnosis in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Although systematic research on BED is in its infancy and many studies feature small samples, several observations emerge. First, we review diagnostic, developmental, and socio-demographic features of BED. Next, although BED and obesity are linked and frequently co-occur, we review data suggesting that BED is a distinct phenotype. Importantly, we take a mechanism-focused approach and propose four psychological processes with neurobiological bases that may uniquely differentiate BED from obesity: emotion reactivity, food-cue reactivity, food craving, and cognitive control. Further, we propose that interactions between impairments in cognitive control and increased emotional reactivity, food-cue reactivity, and craving may underlie emotion dysregulation and promote binge eating. Consistently, neuroimaging studies point towards neural alterations in the response to rewards and to food specifically, and suggest preliminary links between impaired cognitive-control-related neural activity and binge eating. However, additional systematic work is required in this area. We conclude with a detailed review of treatment approaches to BED; specifically, we suggest that psychological and pharmacological treatments that target core mechanisms - including cognitive control and emotion/craving dysregulation - may be particularly effective.

Gender-related Differences in Food Craving and Obesity.

Food craving is often defined as a strong desire to eat. Much work has shown that it consistently and prospectively predicts eating and weight-related outcomes, contributing to the growing obesity epidemic. Although there are clear gender differences in the prevalence and health consequences of obesity, relatively little recent work has investigated gender differences in craving, or any sex-hormone-based differences as they relate to phases of the menstrual cycle. Here, we propose that gender-related differences in food craving contribute to gender-related differences in obesity. Drawing on findings in the addiction literature, we highlight ways to incorporate gender-based differences in food craving into treatment approaches, potentially improving the efficacy of obesity and weight loss treatment. Overall, this review aims to emphasize the importance of investigating gender differences in food craving, with a view towards informing the development of more effective treatments for obesity and weight loss.

Food cue reactivity and craving predict eating and weight gain: a meta-analytic review.

According to learning-based models of behavior, food cue reactivity and craving are conditioned responses that lead to increased eating and subsequent weight gain. However, evidence supporting this relationship has been mixed. We conducted a quantitative meta-analysis to assess the predictive effects of food cue reactivity and craving on eating and weight-related outcomes. Across 69 reported statistics from 45 published reports representing 3,292 participants, we found an overall medium effect of food cue reactivity and craving on outcomes (r = 0.33, p < 0.001; approximately 11% of variance), suggesting that cue exposure and the experience of craving significantly influence and contribute to eating behavior and weight gain. Follow-up tests revealed a medium effect size for the effect of both tonic and cue-induced craving on eating behavior (r = 0.33). We did not find significant differences in effect sizes based on body mass index, age, or dietary restraint. However, we did find that visual food cues (e.g. pictures and videos) were associated with a similar effect size to real food exposure and a stronger effect size than olfactory cues. Overall, the present findings suggest that food cue reactivity, cue-induced craving and tonic craving systematically and prospectively predict food-related outcomes. These results have theoretical, methodological, public health and clinical implications.

The association of "food addiction" with disordered eating and body mass index.

INTRODUCTION: The contribution of an addictive process to elevated body mass index (BMI) and disordered eating is an area of growing interest. Yet, little is known about how "food addiction" may be related to disordered eating and obesity. The ability of addictive-like eating to account for eating pathology not captured by traditional eating disorders is unknown. No prior research has examined the association of "food addiction" with bulimia nervosa (BN). Finally, little is understood about the association of "food addiction" with patterns of dieting and weight gain. The current study was conducted to address these gaps in the literature. MATERIAL AND METHODS: Participants (N=815) were recruited from online advertisements nationwide and completed measures related to "food addiction", BMI, weight history, and disordered eating. RESULTS: Addictive-like eating was associated with elevated current and lifetime highest BMI, weight cycling, and eating pathology. The prevalence of "food addiction" was higher in participants with BN than in those with binge eating disorder (BED). "Food addiction" continued to be related to clinically relevant variables, especially elevated BMI, even when participants did not meet criteria for BED or BN. The co-occurrence of "food addiction" with eating disorders appears to be associated with a more severe variant of eating pathology. DISCUSSION: An addictive-type response to highly palatable food may be contributing to eating-related problems, including obesity and eating disorders. BN relative to BED appears to be more strongly associated with "food addiction." Additionally, the concept of "food addiction" appears to capture clinically relevant information in participants who do not meet criteria for either BN or BED. Further examination of "food addiction" may be important in understanding the mechanisms underlying certain types of problematic eating behavior.

Self-regulatory depletion enhances neural responses to rewards and impairs top-down control.

To be successful at self-regulation, individuals must be able to resist impulses and desires. The strength model of self-regulation suggests that when self-regulatory capacity is depleted, self-control deficits result from a failure to engage top-down control mechanisms. Using functional neuroimaging, we examined changes in brain activity in response to viewing desirable foods among 31 chronic dieters, half of whom completed a task known to result in self-regulatory depletion. Compared with nondepleted dieters, depleted dieters exhibited greater food-cue-related activity in the orbitofrontal cortex, a brain area associated with coding the reward value and liking aspects of desirable foods; they also showed decreased functional connectivity between this area and the inferior frontal gyrus, a region commonly implicated in self-control. These findings suggest that self-regulatory depletion provokes self-control failure by reducing connectivity between brain regions that are involved in cognitive control and those that represent rewards, thereby decreasing the capacity to resist temptations.

Inducing negative affect increases the reward value of appetizing foods in dieters.

Experiencing negative affect frequently precedes lapses in self-control for dieters, smokers, and drug addicts. Laboratory research has similarly shown that inducing negative emotional distress increases the consumption of food or drugs. One hypothesis for this finding is that emotional distress sensitizes the brain's reward system to appetitive stimuli. Using functional neuroimaging, we demonstrate that inducing negative affect in chronic dieters increases activity in brain regions representing the reward value of appetitive stimuli when viewing appetizing food cues. Thirty female chronic dieters were randomly assigned to receive either a negative (n = 15) or neutral mood induction (n = 15) immediately followed by exposure to images of appetizing foods and natural scenes during fMRI. Compared with chronic dieters in a neutral mood, those receiving a negative mood induction showed increased activity in the OFC to appetizing food images. In addition, activity to food images in the OFC and ventral striatum was correlated with individual differences in the degree to which the negative mood induction decreased participants' self-esteem. These findings suggest that distress sensitizes the brain's reward system to appetitive cues, thereby offering a mechanism for the oft-observed relationship between negative affect and disinhibited eating.