Validation of the youth-nine item avoidant/restrictive food intake disorder screen.

OBJECTIVE: This study assessed the factorial, divergent, and criterion-related validity of the Youth-Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (Y-NIAS) in a paediatric clinical sample at initial evaluation for an eating disorder (ED). METHOD: Participants included 310 patients (82.9% female, 77.4% White, Age M = 14.65) from a tertiary ED clinic. Confirmatory factor analysis (CFA) evaluated the three-factor of the Y-NIAS. One-way analysis of variance compared Y-NIAS scores across diagnoses. A receiver operating curve analysis assessed the ability of each subscale to identify ARFID presentations from the full sample. Two logistic regressions assessed the criterion-related validity of the obtained Y-NIAS cut-scores. RESULTS: CFA supported the original three-factor structure of the Y-NIAS. Clinically-elevated scores were observed in all diagnostic groups except for binge-eating disorder. Subscales were unable to discriminate ARFID cases from other ED diagnoses. Cut scores were identified for picky eating subscale (10) and Fear subscale (9), but not for Appetite subscale. In combination with the ED Examination Questionnaire (EDE-Q), classification accuracy was moderate for ARFID (62.7%) and other EDs (89.4%). DISCUSSION: The Y-NIAS demonstrated excellent factorial validity and internal consistency. Findings were mixed regarding the utility of the Y-NIAS for identifying clinically-significant ARFID presentations from other ED diagnoses.

The Intersection of Disorders of Gut-Brain Interaction With Avoidant/Restrictive Food Intake Disorder.

High rates of overlap exist between disorders of gut-brain interaction (DGBI) and eating disorders, for which common interventions conceptually conflict. There is particularly increasing recognition of eating disorders not centered on shape/weight concerns, specifically avoidant/restrictive food intake disorder (ARFID) in gastroenterology treatment settings. The significant comorbidity between DGBI and ARFID highlights its importance, with 13% to 40% of DGBI patients meeting full criteria for or having clinically significant symptoms of ARFID. Notably, exclusion diets may put some patients at risk for developing ARFID and continued food avoidance may perpetuate preexisting ARFID symptoms. In this review, we introduce the provider and researcher to ARFID and describe the possible risk and maintenance pathways between ARFID and DGBI. As DGBI treatment recommendations may put some patients at risk for developing ARFID, we offer recommendations for practical treatment management including evidence-based diet treatments, treatment risk counseling, and routine diet monitoring. When implemented thoughtfully, DGBI and ARFID treatments can be complementary rather than conflicting.

Psychological Considerations in the Dietary Management of Patients With DGBI.

In this article, an expert team of 2 gastro-psychologists, a dietician, and an academic gastroenterologist provides insights into the psychological and social implications of evidence-based and "popular" dietary interventions in disorders of gut-brain interaction (DGBI). We focus on practical approaches for evaluating a patient's appropriateness for a dietary intervention, considering the nutritional, psychological, behavioral, and social context in which a patient may find themselves managing their DGBI with dietary intervention. We also discuss how to identify risk factors for and symptoms of avoidant/restrictive food intake disorder, a growing concern in the DGBI population.

Prevalence and Characteristics of Avoidant/Restrictive Food Intake Disorder in Pediatric Neurogastroenterology Patients.

ABSTRACT: Recent reports document avoidant/restrictive food intake disorder (ARFID) symptoms among 13-40% of adults presenting to neurogastroenterology clinics, but ARFID in pediatrics is understudied. We conducted a retrospective review of charts from 129 consecutive referrals (ages 6-18 years; 57% female) for pediatric neurogastroenterology examination, from January 2016 through December 2018. Eleven cases (8%) met the full criteria for ARFID by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition and 19 cases (15%) had clinically significant avoidant/ restrictive eating behaviors with insufficient information for a definitive ARFID diagnosis. Of patients with ARFID symptoms (n = 30), 20 (67%) cited fear of gastrointestinal symptoms as motivation for their avoidant/ restrictive eating. Compared to patients without ARFID symptoms, patients with ARFID symptoms were older (P  < .001), more likely to be female (51% vs 79%, P  = 0.014), and more frequently presented with eating/weight-related complaints (15% vs 33%, P  = 0.026). This pilot retrospective study showed ARFID symptoms present in 23% of pediatric neurogastroenterology patients; further research is needed to understand risk and maintenance factors of ARFID in the neurogastroenterology setting.

Comprehensive Cognitive-Behavioral Interventions Augment Diaphragmatic Breathing for Rumination Syndrome: A Proof-of-Concept Trial.

BACKGROUND: Rumination syndrome (RS) is often treated in medical settings with 1-2 sessions of diaphragmatic breathing to target reflexive abdominal wall contraction in response to conditioned cues (e.g., food). However, many patients remain symptomatic and require additional behavioral interventions. AIMS: In an attempt to augment diaphragmatic breathing with additional interventions, we tested the proof-of-concept of a comprehensive Cognitive-Behavioral Therapy (CBT) for RS. METHODS: In an uncontrolled trial, adults with RS completed a 5-8 session CBT protocol, delivered by one of two psychology behavioral health providers. CBT included two main phases: awareness training and diaphragmatic breathing (Phase 1) and modularized interventions chosen by the therapist and patient to target secondary maintenance mechanisms (Phase 2). At pre-treatment, post-treatment, and 3-month follow-up, participants completed a semi-structured interview on RS symptoms with an independent evaluator. RESULTS: Of 10 eligible individuals (ages 20-67 years, 50% female) offered treatment, all 10 initiated treatment and eight completed it. All participants endorsed high treatment credibility at Session 1. Permutation-based repeated measures ANOVA showed participants achieved large reductions in regurgitations across treatment [F(1,7) = 17.7, p = .007, η p2 = .69]. Although participants reduced regurgitations with diaphragmatic breathing during Phase 1, addition of other CBT strategies in Phase 2 produced further large reductions [F(1,7) = 6.3, p = .04, η p2 = .47]. Of eight treatment completers, treatment gains were maintained at 3-month follow-up for n = 6. CONCLUSIONS: Findings provide evidence of feasibility, acceptability, and proof-of-concept for a comprehensive CBT for RS that includes interventions in addition to diaphragmatic breathing to target secondary maintenance mechanisms. Randomized controlled trials are needed.

Mindfulness and acceptance-based behavioral treatment for bulimia-spectrum disorders: A pilot feasibility randomized trial.

OBJECTIVE: Although existing research supports the efficacy of mindfulness- and acceptance-based treatments (MABTs) for eating disorders (EDs), few studies have directly compared outcomes from MABTs to standard CBT. METHOD: Participants (N = 44), treatment-seeking adults with bulimia-spectrum EDs, were screened for eligibility, consented, and randomized to receive 20 sessions of outpatient, individual CBT or MABT treatment. Treatment outcomes (binge eating and compensatory behavior episodes, global ED severity, depressive symptoms, quality of life, emotional awareness/clarity, distress tolerance, values-based decision-making, and emotion modulation) were measured at pre-treatment, post-treatment, and 6-month follow up. Data on feasibility and acceptability are also presented. RESULTS: Treatment and assessment retention rates were comparable between MABT and CBT (p range = .51-.73) and between-group differences on acceptability measures were very small (d range = 0.03-0.19). Both conditions produced notable and generally comparable changes in most treatment outcomes at post-treatment (within group d range = 0.06-1.77). DISCUSSION: The MABT and CBT conditions demonstrated comparable degrees of feasibility, acceptability, and symptom improvement, suggesting that MABTs warrant further evaluation as ED treatments.

Validating the visceral sensitivity index in an eating disorder sample.

OBJECTIVE: Individuals with eating disorders (EDs) often have difficulty tolerating uncomfortable body sensations. As such, anxiety sensitivity specific to gastrointestinal (GI) sensations, has relevance for EDs. However, to date, no validated measures of this construct exist in EDs. Thus, the present study sought to validate the visceral sensitivity index (VSI), a 15-item measure originally validated in an irritable bowel syndrome sample, in an ED sample and explore associations with ED symptoms. METHOD: Two hundred and sixty-six adolescents (n = 116) and adults (n = 150) in an ED partial hospital program completed the VSI and related measures at admission. Confirmatory factor analysis examined the factor structure of the VSI and hierarchical regression analyses explored associations between the VSI and ED symptoms. RESULTS: The original version of the VSI had adequate model fit. An alternative 13-item model removing specific items with poor fit and less theoretical relevance to EDs also demonstrated good fit. The 15-item and 13-item VSI had strong internal consistency (α = .93-.94), and correlation results supported the convergent and divergent validity of both versions. Higher visceral sensitivity was associated with elevated body dissatisfaction, cognitive restraint, purging, restricting, and excessive exercise (p-values <.05), beyond length of illness, body mass index, and trait anxiety. DISCUSSION: Results support the relevance of GI-specific anxiety in EDs and suggest that the original 15-item VSI and modified 13-item VSI have strong psychometric properties in an ED sample. Given comparable model fit and psychometric properties, both versions of the VSI may be used for future ED research.

Disorders of gut-brain interaction common among outpatients with eating disorders including avoidant/restrictive food intake disorder.

OBJECTIVE: Little research exists on Rome IV disorders of gut-brain interaction (DGBI; formerly called functional gastrointestinal disorders) in outpatients with eating disorders (EDs). These data are particularly lacking for avoidant/restrictive food intake disorder (ARFID), which shares core features with DGBI. We aimed to identify the frequency and nature of DGBI symptoms among outpatients with EDs. METHOD: Consecutively referred pediatric and adult patients diagnosed with an ED (n = 168, 71% female, ages 8-76 years) in our tertiary care ED program between March 2017 and July 2019 completed a modified Rome IV Questionnaire for DGBI and psychopathology measure battery. RESULTS: The majority (n = 122, 72%) of participants reported at least one bothersome gastrointestinal symptom. Sixty-six (39%) met criteria for a DBGI, most frequently functional dyspepsia-post-prandial distress syndrome subtype (31%). DGBI were surprisingly less frequent among patients with ARFID (30%) versus EDs that are associated with shape or weight concerns (45%; X2 [1] = 3.61, p = .058, Cramer's V = .147). Among those with ARFID, DGBI presence was associated with the fear of aversive consequences prototype and multiple comorbid prototype presence. DISCUSSION: We demonstrated notable overlap between DGBI and EDs, particularly post-prandial distress symptoms. Further research is needed to examine if gastrointestinal symptoms predict or are a result of greater ED pathology, including ARFID prototypes.

Frequency of Eating Disorder Pathology Among Patients With Chronic Constipation and Contribution of Gastrointestinal-Specific Anxiety.

BACKGROUND & AIMS: Individuals with eating disorders (EDs) frequently have constipation-related symptoms, although the mechanisms of this relationship are not clear. We examined the frequency of and relation between EDs and constipation in patients with chronic constipation referred for anorectal manometry. METHODS: We analyzed data from 279 patients with chronic constipation (79.2% female) evaluated at a tertiary center from June 2017 through September 2018. Participants completed a standardized psychometric assessment (patient assessment of constipation symptoms questionnaire and hospital anxiety and depression scale and visceral sensitivity index analyses) and anorectal manometry. A subset of patients completed colonic transit testing. Participants with clinically significant ED pathology were identified based on scores of 20 or higher on the Eating Attitudes Test-26. We performed a logistic regression analysis to examine factors associated with the likelihood of having ED pathology. Odds ratios were calculated based on continuous variables. We examined the contribution of anxiety to the relationship between severity of ED pathology and symptoms of constipation (such as abdominal pain) using a regression-based bootstrapping approach. RESULTS: Of the study participants, 53 (19.0%) had clinically significant ED pathology. The presence of ED pathology was associated with greater general anxiety scores, based on the hospital anxiety and depression scale (odds ratio, 1.20; 95% CI, 1.05-1.38), and greater gastrointestinal-specific anxiety scores, based on the visceral sensitivity index (odds ratio, 1.06; 95% CI, 1.03-1.09). Gastrointestinal-specific anxiety fully mediated the relationship between the severity of ED pathology and constipation (standardized ß, 0.11-0.16; P = .026-.024). We found no differences in anorectal manometry or colonic transit between patients with vs without ED pathology. CONCLUSIONS: In an analysis of patients with chronic constipation, we found that 19% had clinically significant ED pathology. Our preliminary finding indicated that ED pathology might contribute to constipation via gastrointestinal-specific anxiety. Clinicians should consider screening patients with chronic constipation for EDs-especially patients who report symptoms such as bloating and abdominal pain.

Prevalence and Characteristics of Avoidant/Restrictive Food Intake Disorder in Adult Neurogastroenterology Patients.

BACKGROUND & AIMS: Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder that is characterized by avoidant or restrictive eating not primarily motivated by body shape or weight concerns. We aimed to determine the frequency of ARFID symptoms and study its characteristics and associated gastrointestinal symptoms. METHODS: We conducted a retrospective review of charts from 410 consecutive referrals (ages, 18-90 y; 73.0% female) to a tertiary care center for neurogastroenterology examination, from January through December 2016. Blinded coders (n = 4) applied Diagnostic and Statistical Manual of Mental Disorders, 5th edition, criteria for ARFID, with substantial diagnostic agreement (κ = 0.66). RESULTS: Twenty-six cases (6.3%) met the full criteria for ARFID and 71 cases (17.3%) had clinically significant avoidant or restrictive eating behaviors with insufficient information for a definitive diagnosis of ARFID. Of patients with ARFID symptoms (n = 97), 90 patients (92.8%) cited fear of gastrointestinal symptoms as motivation for their avoidant or restrictive eating. A series of binary logistic regressions showed that the likelihood of having ARFID symptoms increased significantly in patients with eating- or weight-related complaints (odds ratio [OR], 5.09; 95% CI, 2.54-10.21); with dyspepsia, nausea, or vomiting (OR, 3.59; 95% CI, 2.04-6.32); with abdominal pain (OR, 4.72; 95% CI, 1.87-11.81); or with lower GI diagnoses (OR, 2.40; 95% CI, 1.34-4.32). CONCLUSIONS: In a retrospective study of patients undergoing neurogastroenterology examinations, we found ARFID symptoms to be related most frequently to fear of gastrointestinal symptoms. Patients undergoing neurogastroenterology or motility examinations should be evaluated for symptoms of ARFID, particularly when providers consider dietary interventions.

Relationships among symptoms of gastroparesis to those of avoidant/restrictive food intake disorder in patients with gastroparesis.

BACKGROUND: Patients with symptoms of gastroparesis (Gp) often reduce food intake in attempt to manage their symptoms. Up to 40% of adults with Gp have been reported to have symptoms of a non-body image-based eating disorder, avoidant/restrictive food intake disorder (ARFID). However, whether ARFID symptoms precede or follow the diagnosis of Gp is unknown. METHODS: From January 2021 to January 2022, consecutive adult patients with Gp at an academic center completed self-report surveys for Gp symptom severity (patient assessment of upper gastrointestinal symptoms; PAGI-SYM) and for ARFID (nine-item ARFID screen; NIAS). KEY RESULTS: One hundred and seven patients (age 45.4 ± 17.2 yrs, 84.1% female, BMI 26.4 ± 7.3) with Gp (4-h gastric retention 33.5 ± 21.8%) were included. Eighty-two of the 107 Gp patients (77%) screened positive for ARFID. Positive ARFID screen was most often on the NIAS appetite subscale (84%) and fear subscale (76%), with a lower positive screen rate on the picky subscale (45%). Of the Gp who screened positive for ARFID, 38% reported that eating difficulties came after their Gp diagnosis, whereas 17% reported that eating difficulties preceded their Gp diagnosis, and 15% reported that both began at the same time. CONCLUSIONS: Many (77%) patients with Gp screened positive for ARFID. In Gp patients with ARFID, the Gp diagnosis was more likely to precede the development of eating difficulties. Thus, a subset of patients with Gp may be at risk for developing ARFID. Further longitudinal research is needed to confirm findings and identify risk factors.

Psychiatric comorbidities among adult patients with disorders of gut-brain interaction: Prevalence and relationships to treatment outcomes.

BACKGROUND: Little is known about the impact of psychiatric comorbidity on pharmacologic treatment outcomes, including neuromodulators (medications targeting the gut-brain axis), among adult patients with disorders of gut-brain interaction (DGBI). Accordingly, we aimed to examine associations between psychiatric comorbidity and DGBI pharmacologic treatment outcomes. METHODS: In a retrospective study of consecutively referred new patients (N = 410; ages 18-90; 73% female) to a tertiary neurogastroenterology clinic in 2016 with follow-up through 2018, relationships between psychiatric illness (any psychiatric illness, anxiety disorders, depressive disorders) and pharmacologic treatment selection (any medication, neuromodulating medication) and treatment outcomes, respectively, were examined using multivariable logistic regression, adjusting for demographics, gastrointestinal (GI) diagnoses, and pre-existing neuromodulator use. KEY RESULTS: Anxiety disorders (35%) were the most common psychiatric comorbidity, followed by depressive disorders (29%). Patients with anxiety disorders were more likely to be prescribed a neuromodulator by their gastroenterologist (OR = 1.72 [95% CI 1.10-2.75]) yet less likely to respond to neuromodulators (OR = 0.43 [0.21-0.90]) or any GI medication (OR = 0.24 [0.12-0.50]) in fully adjusted analyses. In contrast, depressive disorders were not associated with neuromodulator prescription or response. CONCLUSIONS AND INFERENCES: Anxiety disorders are common among patients with DGBI and significantly reduce the likelihood of GI pharmacologic treatment response to any medication prescribed, including neuromodulators.

Unrecognized Functional Dyspepsia Among Those With Refractory Chronic Constipation: Analysis of a Tertiary Cohort.

BACKGROUND AND AIMS: Patients with functional constipation (FC) are frequently dissatisfied with current treatment options which may be related to persistent, unaddressed symptoms. We hypothesized that refractory FC may actually represent functional dyspepsia (FD) overlap. Among adults presenting with refractory FC, we sought to (1) identify the prevalence of concurrent FD and (2) identify the symptoms and presentations most frequently associated with concurrent FD and FC. METHODS: We assembled a retrospective cohort of 308 patients sequentially presenting to a tertiary neurogastroenterology clinic for evaluation of refractory FC, defined as having failed first-line therapy. Using Rome IV criteria, trained raters identified the presence and characteristics of concurrent FD in addition to demographics, presenting complaints, and psychological comorbidities. RESULTS: Among 308 patients presenting with refractory FC (average of 3.0 ± 2.3 constipation treatments tried unsuccessfully), 119 (38.6%) had concurrent FD. Aside from meeting FD criteria, the presence of concurrent FD was associated with patient complaints of esophageal symptoms (Odds ratio = 3.1; 95% confidence interval, 1.80-5.42) and bloating and distension (Odds ratio = 2.67; 95% confidence interval, 1.50-4.89). Patients with concurrent FD were more likely to have a history of an eating disorder (21.0% vs 12.7%) and were also more likely to present with current avoidant/restrictive food intake disorder-related symptoms (31.9% vs 21.7%). CONCLUSION: Almost 40% of adult patients referred for refractory FC met criteria for concurrent FD in a tertiary-level cohort. The presence of both FC and FD was associated with greater esophageal symptoms and bloating/distention. Determining presence of concurrent FD may represent an additional therapeutic opportunity in refractory patients who may attribute symptoms to FC alone.

Oxytocin response to food intake in avoidant/restrictive food intake disorder.

OBJECTIVE: To investigate the response of anorexigenic oxytocin to food intake among adolescents and young adults with avoidant/restrictive food intake disorder (ARFID), a restrictive eating disorder characterized by lack of interest in food or eating, sensory sensitivity to food, and/or fear of aversive consequences of eating, compared with healthy controls (HC). DESIGN: Cross-sectional. METHODS: A total of 109 participants (54 with ARFID spectrum and 55 HC) were instructed to eat a ∼400-kcal standardized mixed meal. We sampled serum oxytocin at fasting and at 30-, 60-, and 120-min postmeal. We tested the hypothesis that ARFID would show higher mean oxytocin levels across time points compared with HC using a mixed model ANOVA. We then used multivariate regression analysis to identify the impact of clinical characteristics (sex, age, and body mass index [BMI] percentile) on oxytocin levels in individuals with ARFID. RESULTS: Participants with ARFID exhibited greater mean oxytocin levels at all time points compared with HC, and these differences remained significant even after controlling for sex and BMI percentile (P = .004). Clinical variables (sex, age, and BMI percentile) did not show any impact on fasting and postprandial oxytocin levels among individuals with ARFID. CONCLUSIONS: Consistently high oxytocin levels might be involved in low appetite and sensory aversions to food, contributing to food avoidance in individuals with ARFID.

Characteristics and outcomes of patients with gastroparesis using enteral and/or exclusive parenteral nutrition.

BACKGROUND: Patients with gastroparesis (Gp) may need enteral nutrition (EN) or exclusive parenteral nutrition (PN). Among patients with Gp, we aimed to (1) identify the frequency of EN and exclusive PN use and (2) explore characteristics of patients using EN and/or exclusive PN compared with those using oral nutrition (ON), including changes over 48 weeks. METHODS: Patients with Gp underwent history and physical examination, gastric emptying scintigraphy, water load satiety testing (WLST), and questionnaires assessing gastrointestinal symptoms and quality of life (QOL). Patients were observed 48 weeks. RESULTS: Of 971 patients with Gp (idiopathic, 579; diabetic, 336; post-Nissen fundoplication, 51), 939 (96.7%) were using ON only, 14 (1.4%) using exclusive PN, and 18 (1.9%) using EN. Compared with patients receiving ON, patients receiving exclusive PN and/or EN were younger, had lower body mass index, and had greater symptom severity. Patients receiving exclusive PN and/or EN had lower physical QOL but not mental QOL or Gp-related QOL scores. Patients receiving exclusive PN and/or EN ingested less water during WLST but did not have worse gastric emptying. Of those who had been receiving exclusive PN and/or EN, 50% and 25%, respectively, resumed ON at 48-week follow-up. CONCLUSIONS: This study describes patients with Gp requiring exclusive PN and/or EN for nutrition support, who represent a small (3.3%) but important subset of patients with Gp. Unique clinical and physiological parameters are associated with this subset and provide insight into the use of nutrition support in Gp.

Virtual Tai Chi program for patients with irritable bowel syndrome with constipation: Proof-of-concept feasibility trial.

BACKGROUND: Satisfaction with current treatment options for irritable bowel syndrome with constipation (IBS-C) is low, with many patients turning to complementary treatments. Tai Chi is a mind-body medicine practice with proven efficacy in other functional disorders. As a proof-of-concept, we tested the feasibility and preliminary clinical outcomes associated with a Tai Chi program designed for IBS-C. METHODS: A total of 27 IBS-C patients participated in a single-arm trial of 8 sessions of Tai Chi delivered weekly over 7 weeks via live videoconferencing in group format. Clinical improvement was assessed via change in IBS Symptom Severity Score (IBS-SSS) from baseline to 4 weeks posttreatment (week 11) with secondary outcomes exploring symptom ratings, IBS-related quality of life (IBS-QOL), GI-specific anxiety, abdominal distention, and psychological factors. KEY RESULTS: Despite substantial dropout (n = 7; 26%), the treatment protocol had moderate to excellent feasibility for other criteria. Treatment satisfaction was excellent. Exit interviews confirmed high satisfaction with the program among completers, but a high burden of data collection was noted. One participant experienced an adverse event (mild, exacerbation of sciatica). There was a significant improvement in intra-individual IBS-SSS between baseline and posttreatment (average change -66.5, 95% CI -118.6 to -14.3, p = 0.01). Secondary outcomes were notable for improvements in other IBS symptom scoring measures, IBS-QOL, measured abdominal diameter, and leg strength. CONCLUSIONS AND INFERENCES: Our data provide preliminary evidence of the feasibility of a Tai Chi intervention for IBS-C, show promise for improving outcomes, and identify more streamlined data collection as an area for further program improvement.

Review article: exclude or expose? The paradox of conceptually opposite treatments for irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) is a heterogeneous disorder of gut-brain interaction (DGBI) maintained by interacting biological, psychological, and social processes. Interestingly, there are two contrasting yet evidence-based treatment approaches for reducing IBS symptoms: exclusion diets such as those low in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) and exposure-based cognitive-behavioural therapy (CBT). Exclusion diets recommend patients avoid foods thought to be symptom-inducing, whereas exposure-based CBT encourages patients to expose themselves to foods. AIMS: To address the paradox of conceptually opposite exclusion diets and exposure-based CBT for IBS. METHODS: In this conceptual review, we describe the rationale, practical implementation, evidence base and strengths and weaknesses of each treatment. We conducted up-to-date literature search concerning the low FODMAP diet and CBT, and performed a secondary analysis of a previously conducted trial to illustrate a key point in our review. RESULTS: The low FODMAP diet has demonstrated efficacy, but problems with adherence, nutritional compromise, and heightened gastrointestinal-specific anxiety raise caution. Exposure-based CBT has demonstrated efficacy with substantial evidence for gastrointestinal-specific anxiety as a key mechanism of action. Mediation analysis also showed that increased FODMAP intake mediated decreased symptom severity in exposure-based CBT. However, there is minimal evidence supporting which treatment "works best for whom" and how these approaches could be best integrated. CONCLUSIONS: Even though exclusion diets and exposure-based CBT are conceptually opposite, they each have proven efficacy. Clinicians should familiarise themselves with both treatments. Further research is needed on predictors, mechanisms and moderators of treatment outcomes.

Patient perspectives of pandemic-related disruptions in gastrointestinal care: developing communication strategies.

Objective: Normal elective outpatient care has been impacted during the COVID-19 pandemic, due to limitations imposed by healthcare systems. Clear communication is necessary to address patient concerns as resumption of elective care gains pace. Methods: Thirty patients who had diagnostic gastrointestinal (GI) testing within our motility lab during the initial viral surge in our state spring 2020 underwent semi-structured interviews. Codes were derived from transcripts using the constant comparative method. Results: Framework analysis revealed several patient themes, including (1) patient specific factors such as age and comorbidity; (2) pandemic-related evolution including case surges; and (3) healthcare related function - or dysfunction - that directly influenced patient perceptions of disrupted gastrointestinal care. These themes provide areas in which to focus communication using the shared decision making model to achieve resumption of delayed care. Conclusions: When communicating with patients, it is difficult to predict patient preferences and as much flexibility as possible should be offered. Concrete steps of (1) identification of patient barriers; (2) intervening upon then, and (3) having concrete plans to influence care will need to guide such communication. Innovation: Our patients' perspectives during the first viral surge can guide new communication strategies should healthcare delivery be compromised in the future.

State emotion modulation and loss-of-control eating in individuals with obesity: A preliminary ecological momentary assessment study.

There is ample evidence linking broad trait emotion regulation deficits and negative affect with loss-of-control (LOC)-eating among individuals with obesity and binge eating, however, few studies have examined emotion regulation at the state-level. Within and across day fluctuations in the ability to modulate emotion (or regulate emotional and behavioral responses), one facet of state emotion regulation, may be a more robust momentary predictor of LOC-eating than momentary negative affect and trait emotion regulation ability. As such, the current study tested if daily emotion modulation, and daily variability in emotion modulation differed on days with and without LOC-eating episodes, and if momentary emotion modulation was associated with subsequent LOC-eating episodes. For two weeks individuals (N = 14) with obesity and binge eating completed surveys as part of an ecological momentary assessment study. Participants reported on current ability to modulate emotion, LOC-eating, and current negative affect. On LOC-eating days compared to non-LOC-eating days, ability to modulate emotion was poorer (ß =0.10, p < .001) and average variability in ability to modulation emotions was greater (ß = 0.56, p = .008), even when controlling for negative affect. Greater momentary difficulty modulating emotion was associated with a 40% increase in subsequent risk for LOC-eating (ß = 0.34, p = .071, OR = 1.40). Findings from this pilot study suggest that individuals with obesity report poorer ability to modulate emotion and greater variability in ability to modulate emotion on LOC-eating days, even when controlling for negative affect. Future research should replicate findings and further elucidate the relationships between state emotion regulation, negative affect, and LOC-eating.