Weight-Related Information Avoidance Prospectively Predicts Poorer Self-Monitoring and Engagement in a Behavioral Weight Loss Intervention.

BACKGROUND: Self-monitoring is a key component of behavioral weight loss (BWL) interventions. Past research suggests that individuals may avoid self-monitoring in certain contexts (e.g., skipping self-weighing after higher-than-usual calorie intake). However, no studies have attempted to quantify individuals' inclination to avoid information about their weight control ("weight-related information avoidance"; WIA) or prospectively examined its implications for treatment engagement and outcomes in BWL programs. PURPOSE: Characterize WIA using a validated questionnaire among adults enrolled in BWL treatment and examine whether WIA prospectively predicts self-monitoring adherence, session attendance, treatment discontinuation, or weight loss. METHODS: Participants (N = 87; MBMI = 34.9 kg/m2, 83% female) completed a measure of WIA prior to starting a 12 week, group-based BWL intervention. Participants were given digital self-monitoring tools and instructed to self-monitor their food intake daily, physical activity daily, and body weight weekly (Weeks 1-10) and then daily (Weeks 11-12). Session attendance and treatment discontinuation were recorded. Weight was measured in-clinic pretreatment and posttreatment. RESULTS: While mean WIA was low (M = 2.23, standard deviation [SD] = 0.95; potential scale range: 1-7), greater WIA predicted poorer attendance (r = -.23; p = .03) and poorer self-monitoring of physical activity (r = -.28; p = .009) and body weight (r = -.32; p = .003). WIA did not predict food monitoring (p = .08), treatment discontinuation (p = .09), or 12 week weight loss (p = .91). CONCLUSIONS: Greater WIA, as assessed via a brief questionnaire, may place individuals at risk for poorer self-monitoring and treatment engagement during BWL. Further research on the implications of WIA in the context of weight management is warranted, including evaluation of correlates, moderators, and mechanisms of action of WIA. CLINICAL TRIAL REGISTRATION: NCT03337139.

Physical discomfort intolerance as a predictor of weight loss and physical activity in a lifestyle modification program.

This study examined physical discomfort intolerance (DI) as a baseline predictor of weight loss and physical activity outcomes, and assessed whether changes in DI during the initial phase of weight loss prospectively predicted long-term treatment outcomes among adults enrolled in a group-based lifestyle modification program for obesity. DI was measured at baseline and 6 months, and weight and accelerometer-measured physical activity were assessed at baseline, 6 months, and 12 months. Baseline DI was not related to weight loss or physical activity at either timepoint. Change in DI during the first 6 months of treatment was not related to concurrent (i.e., 6-month) weight loss and physical activity, but was significantly predictive of weight loss and physical activity at 12 months. Assessing early changes in DI may help to identify individuals at risk for suboptimal outcomes. Future research should evaluate behavioral weight loss interventions designed to target DI.

Executive Functioning as a Predictor of Weight Loss and Physical Activity Outcomes.

BACKGROUND: Executive functioning, which is fundamental for carrying out goal-directed behaviors, may be an underappreciated predictor of outcomes in lifestyle modification programs for adults with obesity. PURPOSE: This study tested the hypotheses that higher levels of baseline executive functioning would predict greater weight loss and physical activity after 6 months of behavioral treatment. METHODS: Participants (N = 320) were recruited from the community and provided with 16 treatment sessions. Executive functioning was measured with the tower task component of the Delis-Kaplan Executive Function System (D-KEFS). At months 0 and 6, weight was measured in the clinic and physical activity was measured with tri-axial accelerometers. RESULTS: Baseline D-KEFS achievement score, rule violations, and completion time significantly predicted weight loss at 6 months. For example, among participants without any rule violations (n = 162), weight loss averaged 11.0%, while those with rule violations (n = 158) averaged 8.7% weight loss. Rule violations also significantly predicted physical activity at 6 months. Among participants without any rule violations, physical activity at 6 months averaged 169.8 min/week, versus 127.2 min/week among those with rule violations. CONCLUSIONS: Particular aspects of executive functioning may predict the relative ease or difficulty of changing eating and exercise-related behaviors, albeit with small effect sizes. This study is the first to our knowledge to detect a predictive relationship between components of executive functioning and objectively measured physical activity in adult lifestyle modification, and one of the first to predict weight loss in adults using an objective measure of executive functioning. CLINICALTRIALS.GOV REGISTRATION NUMBER: NCT02363010.

Comparing hospitalized adult patients with chronic anorexia nervosa with versus without prior hospitalizations.

BACKGROUND: Anorexia nervosa (AN) is a severe psychiatric disorder, from which recovery is often protracted. The role of prior specialized inpatient treatment on subsequent treatment attempts for adults with chronic AN and predictors of treatment response for severe and enduring AN (SE-AN) are needed to improve outcomes. METHOD: Participants (N = 135) with chronic AN (ill ≥7 years) admitted to an integrated inpatient-partial hospitalization eating disorders (ED) unit with prior ED hospitalization(s) (+ PH; n = 100) were compared to those without prior ED hospitalizations (-PH; n = 35) on admission characteristics (BMI, length of illness, outpatient ED treatment history, symptomatology (ED, anxiety, and depressive), history of suicide attempts or non-suicidal self-injury (NSSI)), treatment motivation and recovery self-efficacy, and discharge outcomes (discharge BMI, rate of weight gain, length of stay, clinical improvement). RESULTS: Groups were similar with regard to age, years ill, and admission BMI. The + PH group had lower desired weight, lifetime nadir BMI and self-efficacy for normative eating, and higher state and trait anxiety than the -PH group. +PH were also more likely to endorse history of NSSI and suicide attempt. Regarding discharge outcomes, most patients achieved weight restoration at program discharge (mean discharge BMI = 19.8 kg/m2). Groups did not differ on rate of weight gain, likelihood of attending partial hospital, partial hospital length of stay, program discharge BMI, or likelihood of clinical improvement (p's > 0.05) although inpatient length of stay was longer for the + PH group. CONCLUSIONS: Participants with chronic AN + PH exhibited more severe psychiatric comorbidity and lower self-efficacy for normative eating than AN -PH, however short-term discharge outcomes were similar. Future research should determine whether weight restoration and targeting comorbidities impacts relapse risk or need for rehospitalization among chronic and severe + PH. Despite similar illness durations, those with chronic AN -PH may be able to transition to partial hospital earlier. Conversely there is risk of undertreatment of chronic AN + PH given the recent shift promoting briefer self-directed admissions for adults with SE-AN. Research comparing + PH and -PH adults with chronic AN may facilitate efforts to individualize care and characterize relapse risk following intensive treatment.

Some individuals with longstanding anorexia nervosa (AN) remain ill despite multiple attempts at intensive treatment. Others reach a high level of specialty care (e.g. inpatient or residential) for the first time only late in their illness. This study compared 100 hospitalized patients with chronic AN (ill ≥ 7 years) who previously received specialty inpatient eating disorder care to 35 hospitalized patients with chronic AN and no prior intensive treatment. Participants completed questionnaires at admission and weight change and hospital course were assessed at program discharge by chart review. At admission, individuals with prior hospitalizations reported greater difficulties with anxiety and suicidal behavior, lower confidence for changing their eating habits, and lower desired body weight compared to those with no prior inpatient treatment. Both groups had similar weight change and clinical improvement during treatment with mean discharge BMI consistent with weight restoration. These outcomes suggest equivalent short term improvement and weight restoration for individuals with chronic AN regardless of whether they previously received inpatient treatment and call into question whether the recent shift to brief admissions for those with chronic and severe AN may result for some in undertreatment, given that weight restoration remains the strongest predictor of long-term recovery.

Impulsivity and reward and punishment sensitivity among patients admitted to a specialized inpatient eating disorder treatment program.

Introduction: Eating disorders (EDs) are conceptualized as disorders of under- and over-control, with impulsivity reflecting under-control. Extant research indicates that impulsivity and related factors such as reward sensitivity and punishment sensitivity may serve as trait-level transdiagnostic risk and/or maintenance factors in EDs. Findings on impulsivity and reward and punishment sensitivity by diagnosis are mixed and research on the relationship between these factors and ED symptoms, hospital course, and treatment outcomes is limited. Methods: Participants (N = 228) were patients admitted to a specialized inpatient behavioral treatment program for EDs who agreed to participate in a longitudinal study and completed self-report measures of impulsivity, reward sensitivity, and punishment sensitivity at admission. Weight and ED symptomatology were measured at admission and discharge. Hospital course variables included length of stay and premature treatment dropout. Results: Impulsivity was lower in individuals with anorexia nervosa (AN) restricting type compared to those with AN binge/purge type or bulimia nervosa; no other group differences were observed. Higher impulsivity was associated with greater bulimic symptoms on the Eating Disorder Inventory 2 (EDI-2) at admission. Impulsivity was not related to ED symptoms, weight outcomes, length of hospital stay, or treatment dropout at program discharge. Conclusion: Impulsivity may help distinguish restrictive versus binge/purge EDs, but does not necessarily relate to discharge outcomes in an intensive inpatient ED program. Findings from this study provide novel contributions to the literature on personality traits in EDs and have important clinical implications. Results suggest that patients with higher levels of impulsivity or reward and punishment sensitivity can be expected to respond to inpatient treatment. Suggestions for future research are discussed.

Inpatient hospital course and self-reported symptomatology in underweight adults with ARFID compared to age- and sex-matched controls with anorexia nervosa.

OBJECTIVE: Avoidant restrictive food intake disorder (ARFID) has similar prevalence to anorexia nervosa (AN) in adults, but research in this population is lacking. Although inpatient or residential treatment involving nutritional rehabilitation is increasingly recommended for malnourished individuals with ARFID, best practices remain poorly defined. Existing studies on self-reported symptomatology and treatment course and outcome are primarily in child and adolescent cohorts and demonstrate inconsistent findings. This study aimed to compare hospital course and self-reported symptomatology of underweight adult inpatients with ARFID and sex- and age-matched patients with AN. METHOD: Underweight adult patients with ARFID or AN admitted to a specialized, hospital-based behavioral treatment program completed measures of body dissatisfaction, drive for thinness, bulimic symptoms, anxiety, depression, and personality traits. Demographic and treatment course data were abstracted from electronic medical records. Patients with ARFID (n = 69) were matched to those with AN (n = 69) based on sex and age. RESULTS: Adults with ARFID were closer to target weight at admission, but gained weight at a slower rate, were discharged at lower BMI, and were less likely to reach target weight by discharge than adults with AN. Patients with ARFID reported less weight and shape-related eating disorder, state anxiety, and depression symptoms and lower neuroticism. DISCUSSION: Adults with ARFID progress through treatment more slowly and achieve less favorable weight outcomes by hospital discharge than patients with AN, but long-term outcomes are unclear. Describing clinical presentations and course of illness of adult ARFID may help inform treatment protocols.

This study examined hospital course and symptomatology in underweight adults with avoidant/restrictive food intake disorder (ARFID) compared to adults with anorexia nervosa (AN). Both groups were admitted at similar BMI, however compared to patients with AN, those with ARFID gained weight slower and were half as likely to reach target weight by discharge. Adults with ARFID were equally likely, however, to be rated as clinically improved at discharge. Patients with ARFID also reported less symptoms of anxiety, depression or neuroticism than did those with AN, and less weight and shape-related eating disorder symptoms at admission. The reason for slower weight restoration in adults with ARFID may reflect the need for more individualized protocols adapted to meet the unique, often heterogeneous needs of these individuals. Longer-term post-discharge outcomes for adults with ARFID remain unclear and require investigation.

Subjective experiences of physical activity and forecasting bias during behavioral weight loss.

Introduction: Engagement in physical activity (PA) is a critical component of behavioral weight loss (BWL) treatment. Subjective experiences surrounding PA may shape exercise decisions and need to be further understood within a BWL sample. Methods: Participants in this study were adults with overweight/obesity enrolled in an 18-month BWL program. At baseline, six, and 18 months, participants (N = 320) predicted how they would feel during a lab-based walking task and rated their experiences mid-walk and post-walk. They also completed self-report questionnaires assessing depressive symptoms and discomfort intolerance. Results and Discussion: Results indicated that exercise experience and expectations were more positive at later treatment points than at baseline. At each assessment point, post-walk ratings were more positive than mid-walk ratings, but pre-walk ratings did not differ from mid-walk ratings, suggesting BWL participants were relatively accurate in predicting their PA experience. These results suggest treatment-seeking adults with overweight/obesity feel most positive upon completion of PA, may not experience a forecasting bias as hypothesized and seem to have increasingly positive PA expectations and experiences as they proceed through treatment and lose weight. Lower discomfort intolerance and depressive symptoms were associated with more positive PA expectations and experiences. Understanding these individual differences in PA experience can inform intervention strategies.

Binge eating predicts adherence to digital self-monitoring during behavioral weight loss.

OBJECTIVE: Consistent self-monitoring of dietary intake, weight, and physical activity predicts better outcomes during behavioral weight loss, but the factors that influence self-monitoring adherence are not well understood. This study attempted to fill gaps in the existing literature by examining whether pre-treatment eating behaviors predict adherence to digital self-monitoring during a behavioral weight loss program. METHOD: Participants (N = 77) reported on binge eating, uncontrolled eating, and emotional eating at baseline, and were instructed to self-monitor their food intake, weight, and physical activity using digital devices (food logging app, Fitbit, and wireless "smart" scale) throughout the 12-week treatment. Adherence to self-monitoring was assessed using data captured from these devices. RESULTS: Greater baseline binge eating severity predicted greater adherence to self-monitoring of weight (ρ = 0.25, p = .03) and eating (ρ = 0.25, p = .03), but not self-monitoring of physical activity. Uncontrolled eating and emotional eating did not significantly predict self-monitoring adherence. CONCLUSIONS: In contrast to previous research, this study found that participants with greater pre-treatment binge eating severity had better adherence to self-monitoring of eating, and for the first time established a relationship between binge eating severity and digital self-monitoring of weight in behavioral weight loss. Individuals with greater pre-treatment binge eating may exhibit characteristics, such as motivation or rigidity, that are beneficial during the initial period of weight loss. Future studies should determine if there are features of analogue versus digital self-monitoring that may explain this pattern of findings, and examine these associations longitudinally.

Counselor Surveillance of Digital Self-Monitoring Data: A Pilot Randomized Controlled Trial.

OBJECTIVE: This pilot study tested counselor access to participants' digital self-monitoring (SM) data as a means of improving long-term lifestyle modification (LM) outcomes. METHODS: After 12 weeks of weight-loss treatment, participants (N = 77) were randomized to LM or LM+SHARE for weeks 13 to 52. All participants received monthly phone calls and weekly text messages from weeks 13 to 52 and were instructed to engage in daily digital SM of weight, eating, and exercise. In LM+SHARE, but not LM, counselors had access to SM device data. Assessments were conducted as weeks 0, 13, 26, and 52. RESULTS: Retention, engagement, and treatment satisfaction were excellent. LM+SHARE participants, compared with LM, had more frequent SM of weight and eating. Weight loss continued at a similar rate in both conditions from weeks 13 to 26. From weeks 26 to 52, those in LM regained approximately 2 kg, whereas those in LM+SHARE maintained weight loss, a significant difference. Nonetheless, total weight loss did not significantly differ by condition. Engagement in dietary SM mediated the effect of condition on weight. CONCLUSIONS: Counselor access to SM data is feasible and acceptable. Additional research is warranted to determine whether it can meaningfully improve outcomes.

Digital self-monitoring: Does adherence or association with outcomes differ by self-monitoring target?

OBJECTIVE: Digital self-monitoring of eating, physical activity, and weight is increasingly prescribed in behavioural weight loss programmes. This study determined if adherence rates or associations with outcomes differed according to self-monitoring target (ie, self-monitoring of eating versus physical activity versus weight). METHODS: Participants in a 3-month, group-based weight loss programme were instructed to use an app to record food intake, wear a physical activity sensor, and use a wireless body weight scale. At post-treatment, weight loss was measured in clinic and moderate-to-vigorous physical activity (MVPA) was measured by research-grade accelerometer. RESULTS: Adherence to self-monitoring decreased significantly over time for eating and weight but not physical activity. Overall, adherence to self-monitoring of weight was lower than that of eating or physical activity. Greater adherence to self-monitoring of eating, physical activity, and weight each predicted greater weight loss. Only greater adherence to self-monitoring of eating was associated with greater bouted minutes of MVPA. CONCLUSIONS: Findings from this study suggest that self-monitoring should be considered a target-specific behaviour rather than a unitary construct when conceptualizing adherence and association with treatment outcomes.

Investigating the Impact of Cognitive Load and Motivation on Response Control in Relation to Delay Discounting in Children with ADHD.

Attention-deficit/hyperactivity disorder (ADHD) is characterized by deficits in impulse control across a range of behaviors, from simple actions to those involving complex decision-making (e.g., preference for smaller-sooner versus larger later rewards). This study investigated whether changes in motor response control with increased cognitive load and motivational contingencies are associated with decision-making in the form of delay discounting among 8-12 year old children with and without ADHD. Children with ADHD (n = 26; 8 girls) and typically developing controls (n = 40; 11 girls) completed a standard go/no-go (GNG) task, a GNG task with motivational contingencies, a GNG task with increased cognitive load, and two measures of delay discounting: a real-time task in which the delays and immediately consumable rewards are experienced in real-time, and a classic task involving choices about money at longer delays. Children with ADHD, particularly girls, exhibited greater delay discounting than controls during the real-time discounting task, whereas diagnostic groups did not significantly differ on the classic discounting task. The effect of cognitive load on response control was uniquely associated with greater discounting on the real-time task for children with ADHD, but not for control children. The effect of motivational contingencies on response control was not significantly associated with delay discounting for either diagnostic group. The findings from this study help to inform our understanding of the factors that influence deficient self-control in ADHD, suggesting that impairments in cognitive control may contribute to greater delay discounting in ADHD.

Validation of an interpretation bias assessment for body dissatisfaction.

Currently, research on interpretation bias and body dissatisfaction is limited. The few experimental paradigms that have been used to explore this phenomenon utilized a method that may not accurately capture the nature of interpretation bias as explained by cognitive theory. The present study investigated the reliability and validity of a novel computerized assessment of interpretation bias (WSAP) for body dissatisfaction, which may more accurately reflect the cognitive processing involved in such bias by implementing the Word Sentence Association Paradigm (WSAP), a previously established method of measuring interpretation bias in other clinical populations. Undergraduate females (n=214) completed the WSAP and other measures. Results indicate initial support for the WSAP as a valid, reliable measure of interpretation bias for body dissatisfaction. Although preliminary, this study contributes to the minimal research in this area and serves as the first psychometric investigation of the WSAP to measure such interpretation bias for body dissatisfaction.