Change in adaptive and maladaptive exercise and objective physical activity throughout CBT for individuals with eating disorders.

Maladaptive exercise (i.e., exercise that compensates for binge eating or is used to avoid negative consequences of not exercising-like weight gain) is a common eating disorder (ED) behavior, yet, some individuals with EDs only engage in adaptive exercise. CBT for EDs targets reducing maladaptive exercise but does not address adaptive exercise. Thus, research is limited on how adaptive and maladaptive exercise are impacted during CBT for EDs. The current study examined how assessor-rated adaptive and maladaptive exercise and objectively measured physical activity changed over a 12-week CBT treatment among adults with transdiagnostic binge eating and restrictive eating that did and did not engage in maladaptive exercise at the start of treatment (n = 13 non-maladaptive exercise group, n = 17 maladaptive exercise group). The overall amount of adaptive and maladaptive exercise was measured via the Eating Disorder Examination Interview and objectively measured physical activity (e.g., step count, minutes of moderate-to-vigorous physical activity [MVPA]) was measured via a wrist-worn fitness tracker. Throughout treatment, the overall amount of adaptive exercise did not significantly change for both groups, but the overall amount of maladaptive exercise significantly decreased in the maladaptive exercise group. Step count did not significantly change for both groups, but minutes of MVPA significantly increased over treatment for the non-maladaptive exercise group. Increases in step count and minutes of MVPA were not associated with ED symptom changes in either group. These results enhance an understanding of exercise changes during transdiagnostic CBT-based ED treatment for individuals with varying baseline exercise profiles.Level of evidence: Level 1, randomized controlled trial.

A closer look at homework compliance in behavior therapy for bulimia nervosa: does homework compliance in between-session period prospectively predict session-by-session change in bulimia symptoms?

INTRODUCTION: Homework assignments are considered key components of behavioral treatments for bulimia nervosa (BN), but little is known about whether homework compliance predicts BN symptom improvement. The present study is the first to examine whether session-by-session change in homework compliance predicts session-by-session changes in BN symptoms during behavioral treatment. METHOD: Patients with BN-spectrum eating disorders (n = 42) received 20 sessions of behavioral treatment. Each session, their clinicians completed surveys assessing compliance with self-monitoring, behavioral, and written homework assignments and BN symptom frequency during the previous week. RESULTS: Significant between-persons effects of self-monitoring and behavioral homework compliance were identified, such that patients with greater compliance in the past week experienced greater reductions in binge eating and purging the following week. There were significant within-persons effects of self-monitoring compliance on binge eating and behavioral homework compliance on restrictive eating, binge eating, and purging, such that greater than one's usual compliance predicted greater improvements in BN symptoms the following week. No significant effects of written homework compliance were identified. CONCLUSION: Compliance with self-monitoring and behavioral homework predict improvements in BN symptoms during behavioral treatment. These findings reinforce the importance of self-monitoring and behavioral homework compliance as drivers of change during treatment for BN.

Perceived influence of wearable fitness trackers on eating disorder symptoms in a clinical transdiagnostic binge eating and restrictive eating sample.

Wearable fitness trackers are an increasingly popular tool for measuring physical activity (PA) due their accuracy and momentary data collection abilities. Despite the benefits of using wearable fitness trackers, there is limited research in the eating disorder (ED) field using wearable fitness trackers to measure PA in the context of EDs. Wearable fitness trackers are often underused in ED research because there is limited knowledge about whether wearable fitness trackers negatively or positively impact PA engagement and ED symptoms in individuals with EDs. The current study aimed to assess the perceived impact wearable fitness trackers have on PA engagement and ED symptoms over a 12-week CBT treatment for 30 individuals with binge eating and restrictive eating that presented to treatment engaging or not engaging in maladaptive exercise. Participants in the maladaptive exercise group (n = 17) and non-maladaptive exercise group (n = 13) wore a fitness tracker for 12 weeks and completed questionnaires assessing participants' perceptions of the fitness trackers' influence on ED symptoms and PA engagement throughout treatment. Results demonstrated a small percentage of individuals perceived the fitness tracker influenced ED behaviors or PA engagement, and there were mixed results on whether participants positively or negatively perceived the fitness tracker influenced them to engage in ED behaviors or PA engagement. Although preliminary, these results demonstrate the need to continue using objective measurements of PA via wearable fitness trackers to further our understanding of the positive and negative effects of fitness trackers on clinical ED samples.Level of Evidence: Level 1, randomized controlled trial.

Understanding momentary associations between body dissatisfaction and exercise in binge-spectrum eating disorders.

PURPOSE: Maladaptive exercise is common among individuals with binge-spectrum eating disorders. One mechanism that may drive engagement in exercise in this population is state body dissatisfaction. However, no studies to date have examined prospective, momentary relationships between state body dissatisfaction and exercise. METHODS: Adults with binge-spectrum eating disorders (N = 58) completed a 7-14-day ecological momentary assessment protocol assessing exercise and state body dissatisfaction several times per day. Multilevel models were used to evaluate prospective reciprocal associations between state body dissatisfaction and exercise. Mixed models examined trajectories of change in state body dissatisfaction pre- and post-exercise. Additional models examined exercise type (maladaptive vs. adaptive) as a moderator. RESULTS: Momentary increases (i.e., greater than one's average levels) in state body dissatisfaction at any given timepoint did not prospectively predict engagement in exercise at the next nearest timepoint. Exercise at any given timepoint did not prospectively predict momentary increases in state body dissatisfaction. State body dissatisfaction was found to increase in the initial hours preceding an exercise episode (linear estimate, ß = - 0.012, p = 0.004). State body dissatisfaction did not significantly change in the hours following engagement in exercise. Exercise type did not moderate these associations. CONCLUSION: If replicated, our results may suggest that momentary increases in state body dissatisfaction may not be associated with exercise behaviors in individuals with binge-spectrum eating disorders. LEVEL OF EVIDENCE: Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, orreports of expert committees.

Associations between fear of weight gain and exercise in binge-spectrum eating disorders.

PURPOSE: Maladaptive exercise (i.e., exercise that is either driven or compensatory) is thought to momentarily down-regulate elevated fear of weight gain (FOWG). However, little research has examined associations between FOWG and exercise, and no research has measured FOWG at a momentary level or considered exercise type (i.e., maladaptive vs. adaptive). Thus, we examined both within- and between-subject associations between FOWG and exercise among individuals with trans-diagnostic binge eating. METHODS: We recruited treatment-seeking adults (N = 58, 82.9% female) to complete a 7-14-day ecological momentary assessment protocol which assessed levels of FOWG and exercise engagement and type. Mixed models and generalized estimating equations assessed within-subject associations, and linear regression assessed between-subject associations. RESULTS: There was no main effect of FOWG on exercise engagement at the next survey. However, unexpectedly, exercise type moderated this relationship such that the relationship between FOWG and exercise was strongest for episodes of adaptive exercise. Overall exercise frequency accounted for 10.4% of the variance in FOWG and exercise type explained an additional 1.7% of the variance in FOWG. CONCLUSION: The findings of the current study indicate that momentary levels of FOWG are associated with subsequent adaptive exercise episodes, while higher overall levels of maladaptive exercise were associated with higher levels of FOWG. Future treatments should place a greater emphasis on reducing the frequency of maladaptive exercise by providing strategies for reducing FOWG. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series analysis such as case studies.

Real-time predictors of body dissatisfaction in females with binge eating: an ecological momentary assessment study.

PURPOSE: Body dissatisfaction (BD) is supported as a maintenance factor for eating disorders (EDs) characterized by binge eating (BE). Although it is traditionally conceptualized as a trait construct, ecological momentary assessment (EMA) studies have shown that it fluctuates within-day and that momentary elevations in BD prospectively predict near-time ED behaviors. However, less is known about the contextual factors that precipitate these fluctuations in BD. METHODS: The current study thus sought to examine whether certain internal (i.e., negative affect, shape/weight-related cognitions) and environmental (i.e., attending social events, being exposed to thin-ideal media, spending time on social media) factors prospectively predict momentary elevations in BD in females with BE. Participants (n = 25) completed an EMA protocol over 14 days. RESULTS: Data on BD and internal and environmental factors were analyzed using generalized estimating equations. Results showed that (1) greater than one's usual negative affect and shape/weight-related cognitions, and (2) spending time on social media prospectively predicted momentary elevations in BD. Interestingly, attending social events prospectively predicted momentary reductions in BD. CONCLUSION: These findings may have important implications for conceptualizing and managing BD to prevent ED behaviors. LEVEL OF EVIDENCE: Level II, controlled trial without randomization.

Characterizing rates of physical activity in individuals with binge eating disorder using wearable sensor technologies and clinical interviews.

OBJECTIVE: Research suggests physical activity (PA) improves behavioural, psychological and behavioural symptoms in individuals with binge eating disorder (BED), yet self-reported PA is notably low. Little remains known about objective rates of PA and subclinical levels of maladaptive PA (i.e., compensatory or driven PA), and few studies have attempted to understand the role that dissatisfaction and overvaluation with shape and weight plays in promoting PA in individuals with BED. We sought to characterize PA and investigate whether elevated rates of shape and weight concerns contribute to rates of PA in individuals with BED. METHOD: Individuals meeting DSM-5 diagnosis of BED (N = 56) completed the Eating Disorder Examination and wore a Fitbit Flex 2 for 1 week. RESULTS: On average, participants recorded 7621.12 (SD = 3034.20) daily steps and 194.30 (SD = 161.45) weekly moderate-to-vigorous PA minutes. About 21% of participants reported subclinical levels of maladaptive PA. Greater shape and weight overvaluation predicted lower duration of compensatory PA. CONCLUSION: A small percentage of individuals with BED are engaging in subclinical levels of maladaptive PA, and there is a need to identify factors that influence rates of PA in individuals with BED.

Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Feasibility, acceptability, and proof-of-concept for children and adolescents.

OBJECTIVE: Little is known about the optimal treatment of avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate feasibility, acceptability, and proof-of-concept for cognitive-behavioral therapy for ARFID (CBT-AR) in children and adolescents. METHOD: Males and females (ages 10-17 years) were offered 20-30 sessions of CBT-AR delivered in a family-based or individual format. RESULTS: Of 25 eligible individuals, 20 initiated treatment, including 17 completers and 3 dropouts. Using intent-to-treat analyses, clinicians rated 17 patients (85%) as "much improved" or "very much improved." ARFID severity scores (on the Pica, ARFID, and Rumination Disorder Interview) significantly decreased per both patient and parent report. Patients incorporated a mean of 16.7 (SD = 12.1) new foods from pre- to post-treatment. The underweight subgroup showed a significant weight gain of 11.5 (SD = 6.0) pounds, moving from the 10th to the 20th percentile for body mass index. At post-treatment, 70% of patients no longer met criteria for ARFID. DISCUSSION: This is the first study of an outpatient manualized psychosocial treatment for ARFID in older adolescents. Findings provide evidence of feasibility, acceptability, and proof-of-concept for CBT-AR. Randomized controlled trials are needed.

Medical comorbidities and endocrine dysfunction in low-weight females with avoidant/restrictive food intake disorder compared to anorexia nervosa and healthy controls.

OBJECTIVE: To improve our understanding of medical complications and endocrine alterations in patients with low-weight avoidant/restrictive food intake disorder (ARFID) and how they may differ from those in anorexia nervosa (AN) and healthy controls (HC). METHOD: We performed an exploratory cross-sectional study comparing low-weight females with ARFID (n = 20) with females with AN (n = 42) and HC (n = 49) with no history of an eating disorder. RESULTS: We found substantial overlap in medical comorbidities and endocrine features in ARFID and AN, but with earlier onset of aberrant eating behaviors in ARFID. We also observed distinct medical and endocrine alterations in ARFID compared to AN, such as a greater prevalence of asthma, a lower number of menses missed in the preceding 9 months, higher total T3 levels, and lower total T4 : total T3 ratio; these differences persisted after adjusting for age and might reflect differences in pathophysiology, acuity of weight fluctuations, and/or nutritional composition of food consumed. CONCLUSION: These results highlight the need for prompt diagnosis and intensive therapeutic intervention from disease onset in ARFID.

Behavioral inhibition moderates the association between overvaluation of shape and weight and noncompensatory purging in eating disorders.

OBJECTIVE: The cognitive-behavioral therapy (CBT) model of eating disorders suggests that compensatory purging behaviors (e.g., self-induced vomiting, inappropriate laxative use) are primarily driven by binge eating. However, many individuals endorse purging in the absence of binge eating (i.e., noncompensatory purging [NCP]). Research is needed to understand why some individuals purge in the absence of objective or subjective binge-eating episodes. METHOD: Given the importance of overvaluation of shape/weight in the CBT model, and the existing evidence linking temperamental characteristics like behavioral inhibition (i.e., the tendency to withdraw in response to threat cues) with purging in general, we tested whether behavioral inhibition moderated the relationship between overvaluation of shape/weight and NCP in a sample of individuals in a residential eating disorder treatment center (N = 143). RESULTS: Overvaluation was more strongly related to NCP in individuals with high (relative to low) levels of behavioral inhibition. Among individuals low in behavioral inhibition, overvaluation predicted engagement in NCP to a much weaker extent. DISCUSSION: For those high (relative to low) in behavioral inhibition, both emotional avoidance and overvaluation may be important targets in the treatment of NCP, particularly in the absence of binge eating.

Prevalence and correlates of psychiatric comorbidities in children and adolescents with full and subthreshold avoidant/restrictive food intake disorder.

OBJECTIVE: We aimed to characterize the current and lifetime prevalence of comorbid psychiatric diagnoses and suicidality in treatment- and nontreatment-seeking individuals with full and subthreshold avoidant/restrictive food intake disorder (ARFID). We also sought to examine unique associations between the three DSM-5 ARFID profiles (i.e., sensory sensitivity, fear of aversive consequences, and lack of interest in food or eating) and specific categories of psychiatric diagnoses and suicidality. METHOD: We conducted structured clinical interviews with 74 children and adolescents with full or sub threshold ARFID to assess the presence of comorbid psychiatric diagnoses, suicidality, and the severity of each of the three ARFID profiles. RESULTS: Nearly half of the sample (45%) met criteria for a current comorbid psychiatric diagnosis, and over half (53%) met criteria for a lifetime comorbid diagnosis. A total of 8% endorsed current suicidality and 14% endorsed lifetime suicidality. Severity in the sensory sensitivity profile was uniquely associated with greater odds of comorbid disorders in the neurodevelopmental, disruptive, and conduct disorders category; the anxiety, obsessive-compulsive, and trauma-related disorders category; and the depressive and bipolar-related disorders category. Severity in the fear of aversive consequences profile was associated with greater odds of disorders in the anxiety, obsessive-compulsive, and trauma-related disorders category. DISCUSSION: Our findings underscore the severity of psychopathology among individuals with ARFID and related presentations, and also highlight the potential that shared psychopathology between specific ARFID profiles and other psychiatric disorders represent transdiagnostic constructs (e.g., avoidant behavior) that may be relevant treatment targets.

A Diet High in Processed Foods, Total Carbohydrates and Added Sugars, and Low in Vegetables and Protein Is Characteristic of Youth with Avoidant/Restrictive Food Intake Disorder.

Avoidant/restrictive food intake disorder (ARFID) is characterized in part by limited dietary variety, but dietary characteristics of this disorder have not yet been systematically studied. Our objective was to examine dietary intake defined by diet variety, macronutrient intake, and micronutrient intake in children and adolescents with full or subthreshold ARFID in comparison to healthy controls. We collected and analyzed four-day food record data for 52 participants with full or subthreshold ARFID, and 52 healthy controls, aged 9-22 years. We examined frequency of commonly reported foods by logistic regression and intake by food groups, macronutrients, and micronutrients between groups with repeated-measures ANOVA. Participants with full or subthreshold ARFID did not report any fruit or vegetable category in their top five most commonly reported food categories, whereas these food groups occupied three of the top five groups for healthy controls. Vegetable and protein intake were significantly lower in full or subthreshold ARFID compared to healthy controls. Intakes of added sugars and total carbohydrates were significantly higher in full or subthreshold ARFID compared to healthy controls. Individuals with full or subthreshold ARFID had lower intake of vitamins K and B12, consistent with limited vegetable and protein intake compared to healthy controls. Our results support the need for diet diversification as part of therapeutic interventions for ARFID to reduce risk for nutrient insufficiencies and related complications.

Cognitive-behavioral treatment of avoidant/restrictive food intake disorder.

PURPOSE OF REVIEW: Avoidant/restrictive food intake disorder (ARFID) was added to the psychiatric nomenclature in 2013, but little is known about its optimal treatment. The purpose of this article is to review the recent literature on ARFID treatment and highlight a novel cognitive-behavioral approach, currently under study. RECENT FINDINGS: The current evidence base for ARFID treatment relies primarily on case reports, case series, and retrospective chart reviews, with only a handful of randomized controlled trials in young children. Studies in adults are lacking. ARFID treatments recently described in the literature include family-based treatment and parent training; cognitive-behavioral approaches; hospital-based re-feeding including tube feeding; and adjunctive pharmacotherapy. A novel form of outpatient cognitive-behavioral therapy for ARFID (CBT-AR) is one treatment currently under study. CBT-AR is appropriate for children, adolescents, and adults ages 10 years and more; proceeds through four stages across 20-30 sessions; and is available in both individual and family-supported versions. SUMMARY: There is no evidence-based psychological treatment suitable for all forms of ARFID at this time. Several groups are currently evaluating the efficacy of new psychological treatments for ARFID - particularly, family-based and cognitive-behavioral approaches - but results have not yet been published.