Ultra-Processed Foods and Mental Health: Where Do Eating Disorders Fit into the Puzzle?

Ultra-processed foods (UPFs) like pastries, packaged snacks, fast foods, and sweetened beverages have become dominant in the modern food supply and are strongly associated with numerous public health concerns. While the physical health consequences of UPF intake have been well documented (e.g., increased risks of cardiometabolic conditions), less empirical discussion has emphasized the mental health consequences of chronic UPF consumption. Notably, the unique characteristics of UPFs (e.g., artificially high levels of reinforcing ingredients) influence biological processes (e.g., dopamine signaling) in a manner that may contribute to poorer psychological functioning for some individuals. Importantly, gold-standard behavioral lifestyle interventions and treatments specifically for disordered eating do not acknowledge the direct role that UPFs may play in sensitizing reward-related neural functioning, disrupting metabolic responses, and motivating subsequent UPF cravings and intake. The lack of consideration for the influences of UPFs on mental health is particularly problematic given the growing scientific support for the addictive properties of these foods and the utility of ultra-processed food addiction (UPFA) as a novel clinical phenotype endorsed by 14-20% of individuals across international samples. The overarching aim of the present review is to summarize the science of how UPFs may affect mental health, emphasizing contributing biological mechanisms. Specifically, the authors will (1) describe how corporate-sponsored research and financial agendas have contributed to contention and debate about the role of UPFs in health; (2) define UPFs and their nutritional characteristics; (3) review observed associations between UPF intake and mental health conditions, especially with depression; (4) outline the evidence for UPFA; and (5) describe nuanced treatment considerations for comorbid UPFA and eating disorders.

A novel weight suppression score associates with distinct eating disorder and ultra-processed food symptoms compared to the traditional weight suppression measure among adults seeking outpatient nutrition counseling.

BACKGROUND: Weight suppression has been defined as diet-induced weight loss, traditionally operationalized as the difference between one's highest and current weight. This concept has been studied in the context of eating disorders, but its value in predicting treatment outcomes has been inconsistent, which may be partially attributed to its calculation. METHOD: The current study operationalizes a novel weight suppression score, reflecting the midpoint between the lowest and highest adult weights among adults (N = 287, ages 21-75, 73.9% women) seeking outpatient treatment for disordered eating. This report compared the traditional weight suppression calculation to the novel weight suppression score in a simulated dataset to model their differential distributions. Next, we analyzed shared and distinct clinical correlates of traditional weight suppression versus the novel weight suppression score using clinical intake data. RESULTS: The novel weight suppression score was significantly associated with meeting criteria for both eating disorders and ultra-processed food addiction and was more sensitive to detecting clinically relevant eating disorder symptomatology. However, the novel weight suppression score (vs. traditional weight suppression) was associated with fewer ultra-processed food addiction symptoms. CONCLUSION: The novel weight suppression score may be particularly relevant for those with eating disorders and ultra-processed food addiction, with more relevance to individual eating disorder compared to ultra-processed food addiction symptoms. Consideration of the novel weight suppression score in future research on eating behaviors should extend beyond just those with diagnosed eating disorders.

Ultra-Processed Food Addiction: A Research Update.

PURPOSE OF REVIEW: Detail recent advancements in the science on ultra-processed food (UPF) addiction, focusing on estimated prevalence rates and emerging health disparities; progress towards identifying biological underpinnings and behavioral mechanisms; and implications for weight management. RECENT FINDINGS: Notable developments in the field have included: (1) estimating the global prevalence of UPF addiction at 14% of adults and 15% of youths; (2) revealing health disparities for persons of color and those with food insecurity; (3) observing altered functioning across the brain-gut-microbiome axis; (4) providing early evidence for UPF withdrawal; and (5) elucidating poorer weight management outcomes among persons with UPF addiction. The breadth of recent work on UPF addiction illustrates continued scientific and public interest in the construct and its implications for understanding and treating overeating behaviors and obesity. One pressing gap is the lack of targeted interventions for UPF addiction, which may result in more optimal clinical outcomes for this underserved population.

Development of the modified Highly Processed Food Withdrawal Scale (mProWS).

The Highly Processed Food Withdrawal Scale (ProWS) is a 29-item measure that operationalizes physical and psychological indicators of withdrawal symptoms associated with cutting down on the consumption of ultra-processed foods. The current study developed a briefer 7-item version of the ProWS (modified ProWS; mProWS) using the participant sample from the ProWS validation paper (n = 231). Then, in an independent sample recruited from Amazon Mechanical Turk, 244 participants (55.3% females) completed the mProWS, the ProWS, and measures of eating-related constructs in order to evaluate the psychometric properties of the mProWS, relative to the ProWS. The mProWS and the ProWS performed similarly on indexes of reliability, convergent validity with addictive-like eating behavior (e.g., Yale Food Addiction Scale 2.0 symptom count), discriminant validity with distinct measures (e.g., cognitive desire to restrict food consumption), and incremental validity evidenced by associations with weight cycling above and beyond body mass index (BMI) and YFAS 2.0 symptoms. The mProWS may be an appropriate choice for studies with higher participant burden (e.g., ecological momentary assessment) to assess withdrawal symptoms in real-time when they occur in response to cutting down on ultra-processed foods.

Perceived importance of moderate-to-vigorous physical activity as a weight control strategy in behavioral weight loss.

Background: Previous research has established the importance of moderate-to-vigorous physical activity (MVPA) for weight control. One area of unexplored investigation is the relationship between individuals' perceptions of the importance of MVPA for weight control and MVPA engagement. This study examined the associations between the perceived importance of MVPA and MVPA engagement, weight loss, barriers to PA, and exercise enjoyment in adults enrolled in a long-term behavioral weight loss (BWL) intervention. Methods: Adults (N = 301) with overweight/obesity (BMI = 27-45 kg/m2) completed an 18-month BWL intervention, followed by a no-intervention 18-month follow-up. At baseline, 6 months, 18 months (i.e., post-treatment), and 36 months (i.e., follow-up), participants ranked the importance of six strategies for weight control: keeping a food record, MVPA, light PA, self-weighing, small portions, and low-calorie diet. Observed MVPA (measured by accelerometer), percent weight loss, perceived barriers to PA, and exercise enjoyment were also measured at each assessment. Results: Results showed that most participants perceived MVPA as a primary weight control strategy (first, second, or third most important) throughout the intervention, regardless of the weight control goal (weight loss vs. maintenance). Individuals who ranked MVPA as a primary strategy for weight control at concurrent time points, compared to those who did not, engaged in significantly more MVPA at post-treatment, had greater weight loss at follow-up, endorsed fewer barriers to PA at post-treatment and follow-up, and reported greater exercise enjoyment at baseline and post-treatment. Conclusion: Perceived importance of MVPA was related to subjective experiences of MVPA, MVPA adherence, and weight loss in a long-term BWL intervention.

Examining the proportions of food addiction among women with and without polycystic ovarian syndrome who do and do not take hormonal birth control.

Polycystic ovarian syndrome (PCOS) is a reproductive disorder driven by insulin resistance. Insulin resistance may increase weight gain and increase the rewarding intake of ultra-processed foods (UPFs). Individuals with PCOS may be more susceptible to the reinforcing properties of UPFs, increasing the risk to consume UPFs in addictive-like ways, operationalized by food addiction (FA). Additionally, hormonal birth control, commonly prescribed to women with PCOS, are found to increase food cravings and overeating. This study examined the relationships between PCOS status, FA, and hormonal birth control use. The study sample (N = 365, assigned female at birth) was drawn from Amazon Mechanical Turk, with half of the sample (n = 181) reporting having PCOS and the other half not (n = 184). Participants answered questions about women's reproductive health (i.e., PCOS, hormonal birth control use) and completed the modified Yale Food Addiction Scale 2.0 (mYFAS 2.0). A chi-square test found that 51.9 % of participants with PCOS (M = 6.23, SD = 3.82) met diagnostic criteria for FA (assessed by the mYFAS 2.0) compared to 16.8 % of participants without PCOS (M = 2.47, SD = 3.39). A hierarchical linear regression found independent main effects of PCOS status (ß = 0.40, t(352) = 8.61, p < .001) and hormonal birth control use (ß = 0.16, t(351) = 3.59, p < .001), to be associated with higher mYFAS symptom count scores. No differences were found between the types of hormonal birth control participants reported taking. The finding suggests that FA is an overlooked, understudied psychological condition impacting these individuals in weight loss treatments. Future studies are needed to understand the relationship between FA and PCOS in clinical samples.

Long-term effects of an internalized weight stigma intervention: A randomized controlled trial.

OBJECTIVE: To test the long-term effects of a group-based, psychological intervention designed to reduce internalized weight stigma (IWS, i.e., self-stigma), delivered in combination with behavioral weight loss (BWL) treatment, compared to BWL alone. METHOD: Adults with obesity who had experienced and IWS (N = 105, Mage = 49 years, 90.5% women, 70.5% White, 24.8% Black, MBMI = 38 kg/m²) were randomized to receive BWL with the Weight Bias Internalization and Stigma (BIAS) Program or BWL alone. Participants received weekly group treatment for 20 weeks, followed by 52 weeks of monthly and every-other-month sessions. Percent weight change at Week 72 was the primary outcome, with secondary outcomes of weight change at other time points; physical activity (measured by accelerometry, interview, and self-report); cardiometabolic risk factors; and psychological and behavioral outcomes. Intention-to-treat analyses used linear mixed models to test for between-group differences. Treatment acceptability was assessed. RESULTS: Participants in the BWL + BIAS versus BWL group lost 2 percentage points more of baseline weight at Week 72, which was not a significant difference (mean weight change = -7.2% vs. -5.2%, 95% CI [-4.6 to 0.6], p = 0.14, d = 0.18). The BWL + BIAS (vs. BWL) group produced significantly greater improvements in weight self-stigma, eating self-efficacy, and some aspects of quality of life at specific time points. Most outcomes improved significantly over time but did not differ between groups. The trial had high retention and treatment acceptability, with higher ratings in the BWL + BIAS versus BWL group. CONCLUSIONS: No significant differences in weight loss were observed between the BWL + BIAS versus BWL group. Possible benefits of addressing weight stigma in weight management warrant further investigation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sharing digital self-monitoring data with others to enhance long-term weight loss: A randomized controlled trial.

BACKGROUND: Participants in behavioral weight loss (BWL) programs increasingly use digital tools to self-monitor weight, physical activity, and dietary intake. Data collected with these tools can be systematically shared with other parties in ways that might support behavior change. METHODS: Adults age 18 to 70 with overweight/obesity (BMI 27-50 kg/m2) will enroll in a remotely delivered, 24-month BWL program designed to produce and maintain a 10% weight loss. Participants will be asked to use a wireless body weight scale, wearable activity sensor, and dietary intake app daily. All participants will receive individual and group counseling, engage in text messaging with members of their group, and appoint a friend or family member to serve in a support role. A 2x2x2 factorial design will test the effects of three types of data sharing partnerships: 1) Coach Share: The behavioral coach will regularly view digital self-monitoring data and address data observations. 2) Group Share: Participants will view each other's self-monitoring data in small-group text messages. 3) Friend/Family Share: A friend or family member will view the participant's data via automated message. The primary outcome is weight loss at 24 months. Mediators and moderators of intervention effects will be tested. CONCLUSION: This study will provide a clear indication of whether data sharing can improve long-term weight loss. This study will be the first to discern the mechanisms of action through which each type of data sharing may be beneficial, and elucidate conditions under which the benefits of data sharing may be maximized.

Psychometric validation of the full Yale food addiction scale for children 2.0 among adolescents from the general population and adolescents with a history of mental disorder.

OBJECTIVE: Food addiction is a phenotype characterised by an addiction-like attraction to highly processed foods. Adolescence is a sensitive period for developing addictive disorders. Therefore, a valid measure to assess food addiction in adolescents is needed. Accordingly, the aim of the study was to establish a categorical scoring option for the full version of the Yale Food Addiction Scale for Children 2.0 (YFAS-C 2.0), and to psychometrically validate the full YFAS-C 2.0. METHOD: The data stem from the Food Addiction Denmark (FADK) Project. Random samples of 3750 adolescents from the general population aged 13-17 years, and 3529 adolescents with a history mental disorder of the same age were invited to participate in a survey including the full version of the YFAS-C 2.0. A confirmatory factor analysis was carried out and the weighted prevalence of food addiction was estimated. RESULTS: The confirmatory factor analysis of the YFAS-C 2.0 supported a one-factor model in both samples. The weighted prevalence of food addiction was 5.0% in the general population, and 11.2% in the population with a history of mental disorder. CONCLUSIONS: The full version of the YFAS-C 2.0 is a psychometrically valid measure for assessing clinically significant food addiction in adolescents.

Overlapping and distinct relationships between hedonic hunger, uncontrolled eating, food craving, and the obesogenic home food environment during and after a 12-month behavioral weight loss program.

Hedonic hunger, reward-driven eating outside of biological need, is a newer construct in eating behavior research. During behavioral weight loss (BWL), greater improvements in hedonic hunger are associated with higher weight loss, but it remains unclear if hedonic hunger predicts weight loss independent of more well-established, similar constructs (uncontrolled eating and food craving). Research also is needed to understand how hedonic hunger interacts with contextual factors (e.g., obesogenic food environment) during weight loss. Adults (N = 283) in a 12-month randomized controlled trial of BWL were weighed at 0, 12, and 24 months, and completed questionnaires assessing hedonic hunger, food craving, uncontrolled eating, and the home food environment. All variables improved at 12 and 24 months. Decreases in hedonic hunger at 12 months were associated with higher concurrent weight loss, but not when accounting for improvements in craving and uncontrolled eating. At 24 months, reduction in craving was a stronger predictor of weight loss than hedonic hunger, but improvement in hedonic hunger was a stronger predictor of weight loss than change in uncontrolled eating. Changes to the obesogenic home food environment failed to predict weight loss, regardless of levels of hedonic hunger. This study adds novel information on the individual and contextual factors associated with short- and long-term weight control, which can help refine conceptual models and treatment strategies.

Testing reward processing models of obesity using in-the-moment assessments of subjective enjoyment of food and non-food activities.

OBJECTIVE: Although altered reward processing is proposed to play a key role in obesity maintenance, the role of food enjoyment and enjoyment of non-food naturally rewarding activities ("non-food enjoyment") in obesity maintenance remains unknown. This study examined how food and non-food enjoyment were associated with baseline body mass index (BMI) and weight loss (WL) following year-long behavioral WL treatment. METHODS: At baseline, participants (MAge = 51.81; 73.8 % White, N = 279) with overweight/obesity completed a 7-day ecological momentary assessment (EMA) protocol inquiring about pleasure/enjoyment derived from eating and non-food activities over the past few hours. Participants also completed retrospective self-report measures of food/non-food enjoyment. With linear regressions, associations between EMA food/non-food enjoyment and BMI and post-treatment WL were examined. Race was included as a covariate. RESULTS: EMA and retrospective food/non-food enjoyment measures had modest concordance, providing preliminary psychometric support for the EMA measures. Partially consistent with hypotheses, greater EMA food enjoyment was associated with lower BMI (B = -1.03, p = .01) and with greater WL, though the latter association was not statistically significant (B = 1.15, p = .07). Exploratory analyses suggested that race was associated with food enjoyment (non-White participants had greater food enjoyment than White participants, d = 0.81, p = .005), and that race may have affected associations between food enjoyment and weight outcomes. Associations between non-food enjoyment and weight outcomes were small and nonsignificant (ps > .93). CONCLUSIONS: Results suggest enjoyment from food, but not from non-food domains, is associated with weight outcomes.

Using artificial intelligence to optimize delivery of weight loss treatment: Protocol for an efficacy and cost-effectiveness trial.

Gold standard behavioral weight loss (BWL) is limited by the availability of expert clinicians and high cost of delivery. The artificial intelligence (AI) technique of reinforcement learning (RL) is an optimization solution that tracks outcomes associated with specific actions and, over time, learns which actions yield a desired outcome. RL is increasingly utilized to optimize medical treatments (e.g., chemotherapy dosages), and has very recently started to be utilized by behavioral treatments. For example, we previously demonstrated that RL successfully optimized BWL by dynamically choosing between treatments of varying cost/intensity each week for each participant based on automatic monitoring of digital data (e.g., weight change). In that preliminary work, participants randomized to the AI condition required one-third the amount of coaching contact as those randomized to the gold standard condition but had nearly identical weight losses. The current protocol extends our pilot work and will be the first full-scale randomized controlled trial of a RL system for weight control. The primary aim is to evaluate the hypothesis that a RL-based 12-month BWL program will produce non-inferior weight losses to standard BWL treatment, but at lower costs. Secondary aims include testing mechanistic targets (calorie intake, physical activity) and predictors (depression, binge eating). As such, adults with overweight/obesity (N = 336) will be randomized to either a gold standard condition (12 months of weekly BWL groups) or AI-optimized weekly interventions that represent a combination of expert-led group, expert-led call, paraprofessional-led call, and automated message). Participants will be assessed at 0, 1, 6 and 12 months.

Refining the conceptualization and assessment of internalized weight stigma: A mixed methods approach.

Internalized weight stigma has gained increasing attention in empirical studies, though questions remain about the adequacy of existing measures. The current study utilized a mixed methods approach, including a novel semi-structured interview, to revisit the conceptualization of internalized weight stigma and explore in more depth the stereotypes and impacts of weight reported by individuals with high scores on the widely-used Weight Bias Internalization Scale. All participants were interviewed as part of the screening procedures for two clinical trials (Study 1 n = 84, mean age=47.8 years, 83.3% women, 67.9% Black, mean BMI=39.2 kg/m2; Study 2 n = 129, mean age=50.0 years, 88.4% women, 65.1% white, mean BMI=37.8 kg/m2). The most common weight stereotypes identified were being lazy, lacking willpower or self-control, and having poor eating habits. Up to 66% of participants reported that they did not endorse negative weight stereotypes or apply them to themselves. The most highly identified impacts of weight were on self-image (>70%) and emotions (68-83%), followed by social (37-62%) and health concerns (20-25%). Approximately 60% of participants indicated that weight affected their self-directed thoughts and feelings "very much" to "extremely." Findings have implications for understanding and assessing internalized weight stigma in research and in clinical settings where interventions are needed.