Screening for eating disorders in primary care: EDE-Q versus SCOFF

Evaluation of the Affect School as supplementary treatment of Swedish women with eating disorders: a randomized clinical trial

BACKGROUND

Despite solid research there remains a large group of patients with eating disorders who do not recover. Emotion dysregulation has been shown to be a feature in the different eating disorders. A manualized group intervention developed in Sweden, the Affect School, aims to enhance emotional awareness and the ability to perceive and express emotions.

AIM

This study aimed to test the hypothesis that participation in the Affect School as a complement to ordinary eating disorder treatment would enhance awareness and regulation of emotions and reduce alexithymia and cognitive eating disorder symptoms in a sample of patients with eating disorders at a Swedish specialized outpatient clinic.

METHOD

Forty patients with various eating disorders were randomized to either participation in the Affect School as a supplement to treatment as usual (TAU), or to a TAU control group. Participants were assessed with the Eating Disorder Examination Questionnaire, the Deficits in Emotion Regulation Scale-36, and the Toronto Alexithymia Scale-20 at start, end of intervention, and at the 6- and 12-month follow-ups.

RESULTS

No significant differences were observed post-treatment but Affect School participants had improved significantly more than controls on eating disorder cognitions and behaviours and emotion dysregulation at the 6- and 12-month follow-ups and had significantly less alexithymia at the 6-month follow-up.

CONCLUSION

Difficulties with emotion recognition and/or regulation can complicate fulfilment of personal needs and obstruct communication and relationships with others. The present study indicates that adding Affect School group sessions to regular treatment enhances emotional awareness and emotion regulation and decreases eating disorder symptoms and alexithymia. Patients with eating disorder diagnoses have described problems with emotional management, for example: lower emotional awareness and difficulties in using adaptive emotional regulatory strategies compared to people without eating disorders. It has been suggested that interventions aiming at enhancing emotional awareness and acceptance would be beneficial in treatment. In the present study we explored whether adding the Affect School to regular treatment would enhance awareness and regulation of emotions and decrease eating disorder symptoms. Forty women with an eating disorder were randomly allocated to either an additional participation in a group treatment for 8 weeks or usual treatment only. The treatment contained education on different affects such as joy, fear, interest, shame, anger, disgust, and worry. The education was followed by discussions on own experiences. Participants filled in self-assessment forms that measured eating disorder symptoms, emotional recognition, and emotion regulation before the start and at the end of the group treatment, and after 6 and 12 months respectively. The results when comparing the two groups suggested that the Affect School could be an effective additional treatment. Participants in the Affect School improved their scorings but the change took time and did not show until at the 6- and 12 months follow-ups.

Variability in Eating Disorder Risk and Diagnosis in Transgender and Gender Diverse College Students

PURPOSE

To examine differences in elevated eating disorder risk and self-reported eating disorder diagnosis across subgroups of transgender and gender diverse (TGD) college students.

METHODS

Data from 5057 TGD college students participating in the national Healthy Minds Study between 2014-2019 were analyzed. Chi-square tests and logistic regression analyses examined heterogeneity in prevalence and odds of elevated eating disorder risk, as measured by the SCOFF, and self-reported eating disorder diagnosis by gender, as well as by intersecting gender and sexual orientation identities.

RESULTS

Genderqueer/non-conforming college students reported the highest prevalence of elevated eating disorder risk (38.8%) relative to gender expansive students. Genderqueer/non-conforming (11.1%), gender expansive (12.3%), and trans men/transmasculine students (10.5%) reported higher prevalence of a self-reported eating disorder diagnosis relative to trans women/transfeminine students (6.3%). Heterosexual or straight trans men had lower odds of eating disorder risk and self-reported diagnosis relative to trans men with a minoritized sexual orientation.

CONCLUSIONS

Genderqueer/non-conforming college students may be at heightened eating disorder risk. Moreover, a heterosexual/straight sexual orientation was associated with lower odds of elevated eating disorder risk and self-reported eating disorder diagnoses among trans men and genderqueer/non-conforming college students, but this finding did not hold for other groups. College campuses should aim to reduce eating disorder risk among TGD students.

Eye movements and eating disorders: protocol for an exploratory experimental study examining the relationship in young-adult women with subclinical symptomatology

BACKGROUND

Recent research indicates that patients with anorexia (AN) show specific eye movement abnormalities such as shorter prosaccade latencies, more saccade inhibition errors, and increased rate of saccadic intrusions compared to participants without AN. However, it remains unknown whether these abnormal eye movement patterns, which may serve as potential biomarkers and endophenotypes for an early diagnosis and preventive clinical treatments, start to manifest also in people with subclinical eating disorders (ED) symptomatology. Therefore, we propose a protocol for an exploratory experimental study to investigate whether participants with subclinical ED symptomatology and control participants differ in their performance on several eye movement tasks.

METHODS

The sample will be recruited through convenience sampling. The Eating Disorder Examination Questionnaire will be administered as a screening tool to split the sample into participants with subclinical ED symptomatology and control participants. A fixation task, prosaccade/antisaccade task, and memory-guided task will be administered to both groups. Additionally, we will measure anxiety and premorbid intelligence as confounding variables. Means comparison, exploratory Pearson's correlations and discriminant analysis will be performed.

DISCUSSION

This study will be the first to elucidate the presence of specific eye movement abnormalities in participants with subclinical ED symptomatology. The results may open opportunities for developing novel diagnostic tools/therapies being helpful to the EDs research community and allied fields.

The eating disorder examination questionnaire for adults from the Mexican general population: Reliability and validity

The Eating Disorder Examination Questionnaire is a widely used self-report questionnaire for eating disorders. An Eating Disorder Examination Questionnaire model that is not lacking in relevant content has been supported in three different samples, but existing studies on this model present shortcomings regarding generalizations to the general population. Therefore, the general purpose of the current research was to test the reliability and interpretation validity of the Eating Disorder Examination Questionnaire 6.0 scores in adults of both sexes from the Mexican general population. After translating, adapting, and assessing the Eating Disorder Examination Questionnaire 6.0 in the target population through three pilot studies, we conducted two independent studies. In Study 1, 684 women and 433 men aged 18–83 participated, whereas in Study 2, 591 women and 382 men aged 18–86 did it. They answered the Eating Disorder Examination Questionnaire 6.0 and a measure of either body dissatisfaction (Study 1) or self-esteem (Study 2). According to confirmatory factor analyses, the 14-item Eating Disorder Examination Questionnaire model that we tested fit acceptably for the four samples (two female, two male) and was invariant across sex. All 14-item Eating Disorder Examination Questionnaire 6.0 scores were reliable according to Cronbach’s alpha and McDonald’s omega, except for only one factor score in men. Pearson’s correlations of the 14-item Eating Disorder Examination Questionnaire 6.0 scores with body dissatisfaction and self-esteem were positive and negative, respectively. This new Latin American Spanish translation of the Eating Disorder Examination Questionnaire 6.0 works broadly as expected and provides evidence to extend the generalization of previous studies to the general population. Thus, the present translation of the Eating Disorder Examination Questionnaire 6.0 may be a valuable tool in the field of eating disorders for researchers and practitioners studying or serving Latin American Spanish speakers of either sex from the general population.

Establishing the optimal male cut-off point: confirmatory factor analysis of the eating disorder examination-questionnaire (EDE-Q) in a representative sample of Spanish university students

PURPOSE

Although the EDE-Q is derived from the "gold standard" for the assessment of eating disorders (ED), its factor structure is controversial, particularly in male samples. The aim of the study was to examine the psychometric properties and factor structure of the EDE-Q, as well as to establish a sensitive and specific cut-off point validated by EDE clinical interview.

METHODS

A series of Confirmatory Factor Analyses were performed among a representative sample of 796 male university students, of whom 139 were interviewed. Sensitivity and specificity were calculated by receiver-operating characteristic (ROC) analysis to determinate the most appropriate cut-off value.

RESULTS

The original factor structure was not confirmed, showing a better fit with a 2-factor solution. For the Spanish male sample, a cut-off ≥ 1.09 for at-risk of ED cases and ≥ 2.41 for clinical cases presents an optimal balance between sensitivity and specificity.

CONCLUSIONS

The establishment of specific cut-off points for males may help to reduce the under-diagnosis of ED in this population.

LEVEL OF EVIDENCE

III: evidence obtained from well-designed case-control study.

Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Eating disorders are associated with adverse health and social outcomes.

OBJECTIVE

To review the evidence on screening for eating disorders in adolescents and adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, Cochrane Library, PsycINFO, and trial registries through December 19, 2020; surveillance through January 1, 2022.

STUDY SELECTION

English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or interventions for eating disorders in populations with screen-detected or previously untreated eating disorders (trials limited to populations who are underweight were ineligible).

DATA EXTRACTION AND SYNTHESIS

Dual review of abstracts, full-text articles, and study quality. Meta-analysis of test accuracy studies and intervention trials.

MAIN OUTCOMES AND MEASURES

Test accuracy, eating disorder symptom severity, quality of life, depression, and harms.

RESULTS

Fifty-seven studies were included (N = 10 773); 3 (n = 1073) limited to adolescents (mean or median age, 14-15 years). No study directly evaluated the benefits and harms of screening. Seventeen studies (n = 6804) evaluated screening test accuracy. The SCOFF questionnaire (cut point ≥2) had a pooled sensitivity of 84% (95% CI, 74% to 90%) and pooled specificity of 80% (95% CI, 65% to 89%) in adults (10 studies, n = 3684). Forty RCTs (n = 3969) evaluated interventions for eating disorders; none enrolled a screen-detected population. Lisdexamfetamine for binge eating disorder (4 RCTs; n = 900) was associated with larger reductions in eating disorder symptom severity on the Yale-Brown Obsessive Compulsive Scale modified for binge eating (YBOCS-BE) than placebo (pooled mean difference, -5.75 [95% CI, -8.32 to -3.17]). Two RCTs (n = 465) of topiramate for binge eating disorder found larger reductions in YBOCS-BE scores associated with topiramate than placebo, from -6.40 (95% CI, -8.16 to -4.64) to -2.55 (95% CI, -4.22 to -0.88). Nine pharmacotherapy trials (n = 2006) reported on harms. Compared with placebo, lisdexamfetamine was associated with higher rates of dry mouth, headache, and insomnia, and topiramate was associated with higher rates of paresthesia, taste perversion, confusion, and concentration difficulty. Twenty-four trials (n = 1644) assessed psychological interventions. Guided self-help for binge eating disorder improved eating disorder symptom severity more than control (pooled standardized mean difference, -0.96 [95% CI, -1.26 to -0.67]) (5 studies, n = 391). Evidence on other interventions was limited.

CONCLUSIONS AND RELEVANCE

No studies directly assessed the benefits and harms of screening. The SCOFF questionnaire had adequate accuracy for detecting eating disorders among adults. No treatment trials enrolled screen-detected populations; guided self-help, lisdexamfetamine, and topiramate were effective for reducing eating disorder symptom severity among referred populations with binge eating disorder, but pharmacotherapies were also associated with harms.

Food insecurity is associated with eating disorders independent of depression and anxiety: Findings from the 2020-2021 Healthy Minds Study

OBJECTIVE

To examine the association between food insecurity and eating disorder (ED) risk independent of co-occurring anxiety/depression.

METHOD

Data were provided by 121,627 undergraduate/graduate students who participated in the 2020-2021 Healthy Minds Study (HMS). Participants responded to questionnaire measures of food insecurity and risk for EDs, depression, and anxiety. Established cut-offs were used to identify students with food insecurity and probable psychopathology. Separate modified Poisson regressions adjusted for age, gender, race/ethnicity, and socioeconomic background examined the association between food insecurity and each form of psychopathology. The association between food insecurity and probable ED was then examined in a regression further adjusted for probable depression and anxiety.

RESULTS

Food insecurity was significantly associated with all three forms of psychopathology when examined separately (prevalence ratios ranged from 1.41 to 1.54, all p's < .001). When accounting for probable depression/anxiety, food insecurity was significantly associated with 1.19 times greater prevalence of a probable ED (p < .001).

DISCUSSION

The association between food insecurity and EDs was replicated in a large, national sample of university students. To our knowledge, this is the first study to examine the independence of this relationship after adjusting for depression/anxiety. This finding supports the hypothesis that specific mechanisms, rather than general psychological distress, likely underlie the food insecurity-ED relationship.

What Is Healthy Eating? Exploring Profiles of Intuitive Eating and Nutritionally Healthy Eating in College Women

PURPOSE

Research suggests that food's nutritional content and the feelings and behaviors associated with eating contribute to overall health, yet these constructs are rarely considered simultaneously. The current cross-sectional study investigated healthy eating profiles in college women that included both nutritional quality and intuitive eating (IE), with IE being an eating style that prioritizes physiological hunger/satiety cues and minimizes dieting and emotional eating.

DESIGN/SETTING/SUBJECTS

Undergraduate women (n=352) completed an online assessment and daily diaries (80% retention).

MEASURES

Nutritionally healthy eating, IE, dieting, body dissatisfaction, disordered eating, and psychological health were examined.

ANALYSIS

Latent profile analysis explored patterns of nutritionally healthy eating and IE, and determined how these patterns related to psychological and eating disorder outcomes.

RESULTS

A four-profile solution emerged: 1) Dieting (high nutritionally healthy eating + intermediate IE), 2) Unhealthy Eating (low nutritionally healthy eating + low IE), 3) Intuitive Eating (moderately high nutritionally healthy eating + high IE), and 4) Non-Dieting (low nutritionally healthy eating + intermediate IE). These profiles significantly differed from one another, such that the Intuitive Eating and Non-Dieting profiles reported lower psychological distress, BMI, and eating disorder symptoms compared to other profiles, while the Dieting and Unhealthy Eating profiles showed the healthiest and poorest nutritional eating, respectively.

CONCLUSION

These findings suggest that IE and nutritionally healthy eating are distinct factors in conceptualizing the eating patterns of college women, and both should be considered when developing interventions. Future research should replicate these findings in larger/more diverse samples and examine eating profiles longitudinally.

The First Episode Rapid Early Intervention for Eating Disorders - Upscaled study: Clinical outcomes

BACKGROUND

First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway for emerging adults aged 16 to 25-years with a recent onset eating disorder (ED) of <3 years. A previous single-site study suggests that FREED significantly improves clinical outcomes compared to treatment-as-usual (TAU). The present study (FREED-Up) assessed the scalability of FREED. A multi-centre quasi-experimental pre-post design was used, comparing patient outcomes before and after implementation of FREED in participating services.

METHODS

FREED patients (n = 278) were consecutive, prospectively ascertained referrals to four specialist ED services in England, assessed at four time points over 12 months on ED symptoms, mood, service utilization and cost. FREED patients were compared to a TAU cohort (n = 224) of similar patients, identified retrospectively from electronic patient records in participating services. All were emerging adults aged 16-25 experiencing a first episode ED of <3 years duration.

RESULTS

Overall, FREED patients made significant and rapid clinical improvements over time. 53.2% of FREED patients with anorexia nervosa reached a healthy weight at the 12-month timepoint, compared to only 17.9% of TAU patients (X2 [1, N = 107] = 10.46, p < .001). Significantly fewer FREED patients required intensive (i.e., in-patient or day-patient) treatment (6.6%) compared to TAU patients (12.4%) across the follow-up period (X2 [1, N = 40] = 4.36, p = .037). This contributed to a trend in cost savings in FREED compared to TAU (-£4472, p = .06, CI -£9168, £233).

DISCUSSION

FREED is robust and scalable and is associated with substantial improvements in clinical outcomes, reduction in inpatient or day-patient admissions, and cost-savings.

Correlation between maternal eating disorder and early infant feeding regulation: a cross -sectional study

Background

The post-partum period is a vulnerable time for mothers in terms of eating disorder symptoms and is critical for the establishment of feeding patterns in infants. This study aimed to investigate the relationships between maternal eating disorder symptoms and objective indices of feeding regulation at 3 months, as well as perceived breastfeeding self-efficacy.

Methods

A sample of n = 73 full-term mother-child dyads (44% female) participated in the study. Mothers self-reported eating disorder symptoms and breastfeeding self-efficacy and objective indices of infant feeding regulation were obtained in the home.

Results

Findings revealed the existence of relationships between higher maternal eating disorder symptoms, and objective indices of infant feeding regulation with substantial gender differences in the patterns emerging. Among mother-daughter dyads, maternal weight and shape concerns were associated with higher infant transfer volume and rate during bottle feeding. In contrast, among mother-son dyads, higher maternal eating disorder symptoms, including weight, shape, and eating concern, were associated with lower infant transfer volume and rate as well as lower levels of proficiency while taking their bottle.

Conclusion

Relationships emerged between higher maternal eating disorder symptoms and feeding regulation with substantial gender differences in these patterns. Additional research clarifying the underlying mechanisms of these associations is warranted and further efforts should be directed towards supporting mothers during the postpartum period.

Prevalence and management of people with eating disorders presenting to primary care: A national study

OBJECTIVE

Primary care practitioners are well placed to support diagnosis and appropriate treatment of eating disorders as they are often the first point of contact with the health care system. However, little is known about management of eating disorders in primary care. We aimed to estimate the prevalence of management of eating disorders in primary care and identify how these disorders are managed.

METHODS

This study used data from the Bettering the Evaluation of Care of Health programme, which annually surveys 1000 randomly sampled general practitioners in Australia who each record details of 100 successive patient encounters. In total, data were utilised from 1,568,100 primary care encounters between 2000/2001 and 2015/2016.

RESULTS

Eating disorders were managed in less than 1% of primary care encounters between 2000/2001 and 2015/2016. When extrapolated to the Australian population, up to 0.32% of the population were managed in primary care for a primary or probable eating disorder. In the majority of encounters where an eating disorder was managed (58.5%), the encounter was initiated for reasons other than the eating disorder itself. Of a group of patients identified with a clinically significant low body mass index (N = 5917), a small number (n = 118) had either no other diagnosis or a related condition that may be indicative of an eating disorder. In encounters where an eating disorder was managed, referrals to a mental health specialist/service, medical specialist and nutritionist/dietician were provided in 20%, 8% and 6% of encounters, respectively. Mental health treatment plans, which provide subsidised access to mental health services, were ascribed in approximately 7.7% of encounters where an eating disorder was managed.

CONCLUSION

Primary care provides an opportunity to improve detection and management of eating disorders, particularly when patients present for 'other' issues or with unexplained low body mass index and one or more symptoms related to an eating disorder.

Measurement of Eating Pathology Using the Minnesota Multiphasic Personality Inventory-3 (MMPI-3)

Eating disorders are prevalent among college student populations. Although previous iterations of the instrument did not include specific measurement of eating pathology, the Minnesota multiphasic personality inventory-3 (MMPI-3) now includes a specific scale (i.e., Eating Concerns [EAT]) to assess problematic eating behaviors. The current study examined the MMPI-3 assessment of eating pathology among 249 undergraduate women. A pattern emerged where symptoms of internalizing psychopathology on the MMPI-3 were generally associated with symptoms of eating disorder. However, the newly included EAT scale demonstrated the strongest associations with most areas of eating dysfunction. Further, hierarchical regression analyses suggested that the EAT scale added substantial incremental predictive utility (up to 23%) over other MMPI-3 scales combined in assessing eating pathology. Classification accuracy statistics yielded high sensitivity and specificity coefficients when predicting eating disorder risk at an EAT scale score cutoff of 75 T or higher. These findings support the use of the MMPI-3 in assessing eating pathology in college women, although its performance with men and with women not of college age remains to be studied.

Early weight gain trajectories in first episode anorexia: predictors of outcome for emerging adults in outpatient treatment

BACKGROUND

Early response to treatment has been shown to be a predictor of later clinical outcomes in eating disorders (EDs). Specifically, early weight gain trajectories in anorexia nervosa (AN) have been shown to predict higher rates of later remission in inpatient treatment. However, no study has, as of yet, examined this phenomenon within outpatient treatment of first episode cases of AN or in emerging adults.

METHODS

One hundred seven patients with AN, all between the ages of 16 and 25 and with an illness duration of < 3 years, received treatment via the first episode rapid early intervention in eating disorders (FREED) service pathway. Weight was recorded routinely across early treatment sessions and recovery outcomes (BMI > 18.5 kg/m2 and eating psychopathology) were assessed up to 1 year later. Early weight gain across the first 12 treatment sessions was investigated using latent growth mixture modelling to determine distinct classes of change. Follow-up clinical outcomes and remission rates were compared between classes, and individual and clinical characteristics at baseline (treatment start) were tested as potential predictors.

RESULTS

Four classes of early treatment trajectory were identified. Three of these classes (n = 95), though differing in their early change trajectories, showed substantial improvement in clinical outcomes at final follow-up. One smaller class (n = 12), characterised by a 'higher' start BMI (> 17) and no early weight gain, showed negligible improvement 1 year later. Of the three treatment responding groups, levels of purging, depression, and patient reported carer expressed emotion (in the form of high expectations and low tolerance of the patient) determined class membership, although these findings were not significant after correcting for multiple testing. A higher BMI at treatment start was not sufficient to predict optimal clinical outcomes.

CONCLUSION

First episode cases of AN treated via FREED fit into four distinct early response trajectory classes. These may represent subtypes of first episode AN patients. Three of these four trajectories included patients with substantial improvements 1 year later. For those in the non-response trajectory class, treatment adjustments or augmentations could be considered earlier, i.e., at treatment session 12.

Identification of high risk and early stage eating disorders: first validation of a digital screening tool

BACKGROUND

Eating disorders are amongst the deadliest of all mental disorders, however detection and early intervention rates remain extremely low. Current standardised screening questionnaires can be arduous or confronting and are ill-validated for online use, despite a universal shift to digital healthcare. The present study describes the development and pilot validation of a novel digital screening tool (the InsideOut Institute-Screener) for high risk and early stage eating disorders to drive early intervention and reduced morbidity.

METHODS

We utilised a mixed cross-sectional and repeated measures longitudinal survey research design to assess symptom severity and recognised parameters of statistical validity. Participants were recruited through social media and traditional advertising, and through MTurk. An Eating Disorders Examination Questionnaire (EDE-Q) global score of 2.3 and assessment of eating disorder behaviours was used to determine probable ED. 1346 participants aged 14-74 (mean [SE] age 26.60 [11.14] years; 73.8% female, 22.6% male) completed the survey battery. 19% were randomised to two-week follow-up for reliability analysis.

RESULTS

Strong positive correlations between the IOI-S and both the EDE-Q global (r_s = .88) and SCOFF (r_s = .75) total score were found, providing support for the concurrent validity of the scale. Inter-item correlations were moderate to strong (r_s = .46-.73). Correlations between the IOI-S and two measures of social desirability diverged, providing support for the discriminant validity of the scale. The IOI-S demonstrated high internal consistency (α = .908, ω = .910) and excellent two-week test-retest reliability (.968, 95% CI 0.959-0.975; p ≤ 0.1). The IOI-S accurately distinguished probable eating disorders (sensitivity = 82.8%, specificity = 89.7% [AUC = .944], LR⁺  = 8.04, LR^- = 0.19) and two stepped levels of risk.

CONCLUSIONS AND RELEVANCE

The present study provides excellent initial support for the psychometric validity of the InsideOut Institute digital screening tool, which has the potential to streamline early intervention in the hopes of reducing current high morbidity and mortality. Further validation should be undertaken in known clinical populations. Eating disorders are amongst the deadliest of all mental disorders, however detection and early intervention rates remain extremely low. The present study describes the initial psychometric validation of a novel digital screening tool (the InsideOut Institute Screener) for high risk and early stage eating disorders, for self-referral and/or use in primary care. 1346 participants aged 14-74 of all genders completed a survey battery designed to assess common parameters of statistical validity. Strong support was found for the screener's ability to accurately measure eating disorder risk and symptomatology. The screener was highly positively correlated with a well known and extensively validated long form self-report questionnaire for eating disorder symptomatology. This study is a pilot validation and the genesis of a project that aims ultimately to drive early intervention leading to reduced morbidity and mortality rates in this illness group.

Hourglass Body Shape Ideal Scale and disordered eating

Disordered eating research has long considered the negative consequences of internalizing sociocultural appearance ideals (e.g., thin ideal, muscular ideal). However, the implications of internalizing a curvy or "hourglass" body shape remains unclear. The Hourglass Body Shape Ideal Scale (HBSIS) is a new self-report questionnaire that was developed and evaluated to appropriately measure the extent women subscribe to an hourglass body shape ideal. The measure was administered to a community and undergraduate sample of women via two separate online studies. Study 1 (N = 916) provided support for the factor structure as well as the convergent and discriminant validity of the HBSIS. The HBSIS was correlated with measures of appearance orientation, overweight preoccupation, and disordered eating. HBSIS was associated with disordered eating even after controlling for age, BMI, thin ideal and muscular ideal internalization. Further, higher HBSIS scores were associated with increased likelihood of having clinical levels of disordered eating symptoms. There were no racial and ethnic group differences on HBSIS. Study 2 (N = 195) replicated the factor structure of Study 1, in addition to its convergent and discriminant validity. The HBSIS allows for more precise examination of appearance-ideal internalization, capturing a unique construct understudied within eating pathology literature.

Reconsidering the use of cut-off scores for the Eating Disorder Examination-Questionnaire

The Eating Disorder Examination-Questionnaire (EDE-Q) is one of the most widely used self-report measures for the assessment of eating disorder psychopathology. Numerous studies have provided norm data for different populations and suggested possible cut-off values for the EDE-Q global score that may indicate the presence of an eating disorder. This commentary argues against the unquestioned use of such cut-off scores as their application may often be unnecessary, disadvantageous, or inappropriate.

Effects of diet and fitness apps on eating disorder behaviours: qualitative study

Background

Diet and fitness apps are often promoted in university and college settings and touted as a means to improve health with little attention given to unanticipated negative effects, especially among those at risk for or with eating disorders.

Aims

Few researchers have studied how these apps affect women with eating disorders in university and college settings. This research investigates the unintended negative consequences of engaging with these tools.

Method

Data collection sessions comprised three components conducted with 24 participants: survey (demographic and eating disorder symptoms), think-aloud exercise and semi-structured interview. Thematic analysis was used to analyse data.

Results

Participants reported that diet and fitness apps trigger and exacerbate symptoms by focusing heavily on quantification, promoting overuse and providing certain types of feedback. Eight themes of negative consequences emerged: fixation on numbers, rigid diet, obsession, app dependency, high sense of achievement, extreme negative emotions, motivation from ‘negative’ messages, and excess competition. Although these themes were common when users’ focus was to lose weight or eat less, they were also prevalent when users wanted to focus explicitly on eating disorder recovery.

Conclusions

Unintended negative consequences are linked to the quantified self movement, conception of appropriate usage, and visual cues and feedback. This paper critically examines diet and fitness app design and discusses implications for designers, educators and clinicians. Ultimately, this research emphasises the need for a fundamental shift in how diet and fitness apps promote health, with mental health at the forefront.

Eating disorder symptomatology in transgender patients: Differences across gender identity and gender affirmation

OBJECTIVE

Past studies have reported high rates of eating disorder (ED) symptomatology among transgender people, yet without consideration of gender affirmation. The primary objective of this study was to evaluate the relationship between gender identity, gender affirming interventions such as gender affirming hormones (GAH) and gender affirming surgeries (GAS), and ED symptomatology.

METHOD

Transgender patients at a primary care outpatient gender health program in the United States completed a survey consisting of demographics, medical history, and clinical variables, including the Eating Disorder Examination Questionnaire (EDE-Q). Multivariate analyses of covariance were conducted to compare EDE-Q scores across gender identity and gender affirmation.

RESULTS

Compared to transgender men (n = 79), transgender women (n = 87) reported higher EDE-Q scores and significantly higher Eating Concern. Compared to hormone/surgery-naïve and hormone-experienced/surgery-naïve patients, hormone/surgery-experienced patients had lower EDE-Q scores. Hormone/surgery-experienced patients reported significantly lower Shape Concern and marginally lower Global Score and Weight Concern than hormone-experienced/surgery-naïve patients. There were no differences in EDE-Q scores between hormone/surgery-naïve and hormone-experienced/surgery-naïve patients.

DISCUSSION

Transgender patients report high levels of ED symptomatology. There are subtle, yet important, differences in ED between gender identities and gender affirmations. High ED prevalence may result from the dual pathways of sociocultural pressures as well as gender dysphoria. Both GAH and GAS may be effective interventions to support gender affirmation and thereby alleviate ED symptomatology. While the potential positive benefits of GAS on ED are more apparent, the effects of GAH are less clear.

Disordered eating measures validated in pregnancy samples: a systematic review

Although disordered eating in pregnancy has been linked to numerous negative consequences, there is currently no published instrument specifically devised to identify or measure such symptoms in pregnancy. As such, this study systematically reviewed the literature to evaluate the performance of general measures of disordered eating in pregnancy samples. A systematic search of the following electronic databases was undertaken from inception to April 2019: Scopus, Medline, PsycINFO, Embase, ProQuest Dissertations and Theses, and the Cumulative Index to Nursing and Allied Health Literature. From 1724 citations, eight publications met the inclusion criteria and were included in the review. Most of the included studies (6/8) were of reasonable quality. Overall, three self-report inventories (EDE-Q, EDI-2, and DEBS) and one semi-structured clinical interview (EDE) had some form of psychometric information available. Most studies reported reliability, with only two reporting validity. No studies assessed screening accuracy. Other than the EDE-Q, which had preliminary evidence to suggest possible utility in pregnancy, the findings of this review revealed little to no evidence to support the use of general measures of disordered eating in pregnancy. A strong need for research exploring the validity of existing measures in pregnancy samples, including the EDE-Q, was also evident.

Exploring a core psychopathology in disordered eating: the feelings of fat scale

BACKGROUND

Feelings of fat are common for people with eating disorders, but ways of measuring its intensity are needed. Therefore, our goal was to develop a self-report feelings of fat scale that asked participants to indicate how intensely they currently felt statements such as "I feel fat". With such a scale we can determine how strongly feelings of fat relate to evidence of disordered eating.

METHODS

We conducted three studies of eating disorders with undergraduate women taking introductory psychology classes. The combined sample was 472 participants. A previous eating disorder diagnosis was self-reported by 33 participants and a current diagnosis by 11. All participants completed the EDE-Q and the seven (Study 1) or nine item (Studies 2 and 3) "State Feelings of Fat" (SFF) scales we developed. Each item asked them to rate the intensity with which they felt statements such "I feel fat" on a seven-point scale from "not at all" to "the most I have ever felt".

RESULTS

Both the seven and nine item SFF scales were highly coherent (Cronbach's α were .94, .95 and .94), but factor analysis supported the seven-item version. We found high correlations between SFF and EDE-Q scores (Study 1: .816; Study 2: .808; Study 3: .841). SFF scores distinguished participants self-reporting no eating disorder diagnosis from those with a former diagnosis, t (361) = 2.33, p = .021, who in turn were distinguished from those with a current diagnosis, t (42) = 2.09, p = .043. Due to the high coherence of the scale, the single item "I feel fat" captured most of the variance in EDE-Q scores (r [472] = .793).

CONCLUSIONS

We have constructed an eating disorders relevant feelings of fat scale. Given that the EDE-Q is considered a valid questionnaire for measuring severity of eating disorders, our findings suggests that feelings of fat are core to the psychopathology of eating disorders. To the extent that EDE-Q scores are stable it also suggests that feelings of fat are surprisingly stable. Furthermore, the single item "I feel fat" alone may capture most of what the EDE-Q measures.

Eating Disorder Examination Questionnaire (EDE-Q-13): expanding on the short form

OBJECTIVE

The Eating Disorders Examination-Questionnaire (EDE-Q) is widely used but time-consuming to complete. In recent years, the advantages and disadvantages of several brief versions have therefore been investigated. A seven-item scale (EDE-Q-7) has excellent psychometric properties but excludes items on bingeing and purging. This study aimed to evaluate a thirteen-item scale (EDE-Q-13) including items on bingeing and purging.

METHOD

Participants were 1160 (188 [11.4%] males) community volunteers of mean age 28.79 ± 9.92. They completed the full EDE-Q in Hebrew, as well as measures of positive body experience, social and emotional connection, life satisfaction, positive and negative affect and positive eating. The six EDE-Q items about bingeing and purging, recoded to correspond to the response categories of the other EDE-Q questions, were added to the EDE-Q-7, resulting in the EDE-Q-13.

RESULTS

Confirmatory factor analysis confirmed the hypothesized EDE-Q-13 structure, including the bingeing and purging subscales. Strong positive correlations were found between the EDE-Q-13 and the original EDE-Q scores. The EDE-Q-13 showed convergent validity with related measures.

CONCLUSIONS

The EDE-Q-13 in Hebrew is a brief version of the EDE-Q that includes bingeing and purging subscales and has satisfactory psychometric properties. Its use in clinical and research contexts is encouraged.

Eating disorder prevalence among multiracial US undergraduate and graduate students: Is multiracial risk different than the sum of each identity?

The number of individuals identifying as multiracial in the United States (US) has significantly increased in the past few decades, yet they are rarely the focus of study in eating disorders (ED) research. The current study is among the first to examine prevalence estimates of ED pathology across several distinct multiracial groups, to contrast prevalence estimates of ED pathology in each multiracial group with those among the corresponding monoracial identities, and to investigate these findings intersectionally with gender identity. Data from 145,379 US students, 11,433 of whom were multiracial, were collected from 199 US colleges and universities participating in the Healthy Minds Study between 2014 and 2019. Elevated ED pathology was defined as a score ≥ 2 on the SCOFF. Multiracial individuals identifying as American Indian/Alaskan Native and Hispanic/Latinx exhibited the highest prevalence estimates of elevated ED pathology (41.4% compared to 23.5% in the full sample). This group, as well as some other doubly marginalized groups (African American/Black and Hispanic/Latinx; African American/Black and Asian American/Asian), exhibited higher prevalence of elevated ED pathology than expected based on the observed prevalence estimates in their corresponding monoracial groups. Across gender identities, greater than expected prevalence estimates of elevated ED pathology were observed among multiracial individuals identifying as African American/Black and White and lower than expected prevalence estimates were observed among multiracial individuals identifying as Middle Eastern/Arab/Arab American and White. These results have important implications for understanding ED pathology in multiracial individuals and should inform intervention and treatment efforts to support individuals from these underserved groups.

Adaptation and validation of the Eating Disorder Examination-Questionnaire in English among urban Indian adolescents

OBJECTIVE

Eating pathology is a salient issue in India, with clinical features reported among adults and adolescents. However, there are currently no validated measures of disordered eating in the Indian context. The present study therefore aimed to validate a culturally appropriate English language version of the Eating Disorder Examination Questionnaire (EDE-Q), a widely used measure, among adolescents in India.

METHOD

We adapted and examined the factor structure, reliability, and construct validity of the EDE-Q among an urban sample of 1,413 Indian adolescents (mean age = 13 years; 45% girls).

RESULTS

In contrast to the original four-factor model, exploratory factor analysis identified a two-factor solution for girls and boys, which was verified by confirmatory factor analysis; a "Preoccupation and Control" subscale and a "Weight and Shape Concerns" subscale. The total scale comprised 15 items for girls and 18 items for boys. Test-retest reliability and internal consistency were satisfactory for the girls' and boys' scales (Cronbach's α = .91 for both) and their comprising subscales (αs ≥ .80). Concurrent validity was established through medium-high significant correlations with measures of body image and internalization of appearance ideals. Combining items common to both versions of the scale led to a psychometrically acceptable model which was largely invariant across both genders, thus facilitating gendered comparison.

DISCUSSION

Findings indicate the reliability and validity of the EDE-Q among English-speaking urban Indian adolescents. This will facilitate further research examining the prevalence and nature of eating pathology among adolescents in India.

Exploring the primary care experiences of adult patients with eating disorders: a qualitative analysis

Eating disorders (EDs) are severe psychological conditions, often requiring specialized treatment. Patients with EDs generally first present in primary care before being referred to tertiary centres. Evidence suggests that family physicians do not identify most patients with clinical EDs. The objective of this study was to explore the primary care experiences of adult patients with EDs. Ten individual, semi-structured interviews with adult women with an ED were conducted. A qualitative descriptive approach was adopted using thematic analysis. The researchers identified codes, which were categorized into five major themes: 1) disparate patient experiences in primary care, 2) delayed diagnosis, 3) key family physician qualities for ED care, 4) individual and systemic barriers to recovery, and 5) patient needs in primary care. Most participants reported that their diagnosis was not timely, suggesting a need for improved screening and diagnostic procedures. Inconsistent treatment practices imply that family physicians would benefit from the development of standardized guidelines for ED diagnosis and treatment in primary care as well as additional training in ED care. Family physicians being empathic and nonjudgmental and facilitating access to resources are of particular importance to this patient population.

Transitioning to digital first line intervention - validation of a brief online screener for early identification of a suspected eating disorder: study protocol

BACKGROUND

Only one in four people with eating disorders seeks treatment, and of those who do seek treatment, 20% go on to experience a chronic course. Early intervention has been associated with better prognosis, with those seeking specialised intervention in the early stages of their illness more than twice as likely to achieve remission. Current screening measures typically require expert administration and are rarely validated across a spectrum of DSM-5 eating disorder presentations or for online use. In light of COVID-19 and increasing reliance on telehealth technologies in the intervention and delivery of mental health services, online assessments suitable for self-referral are likely to be the first step to seeking care. InsideOut Institute has developed a 6-item online screening tool for the purposes of identifying eating disorder risk and symptomatology, aimed specifically at increasing help-seeking behaviour in subsyndromal and early presentations.

METHODS

This study investigates the reliability and validity of the InsideOut Institute Screener (IOI-S), using a cross-sectional survey research design. Participants aged 14 and over will complete an extensive baseline survey battery for evaluation. 50% of participants will be randomly selected for one follow-up re-test of the IOI-S only, 2 weeks post initial testing. The IOI-S will be analysed for statistical reliability on two parameters: internal consistency and test re-test reliability, and for statistical validity on four parameters: concurrent validity, sensitivity and specificity, convergent and discriminant validity.

DISCUSSION

The rapid and ongoing shift to digital intervention has highlighted gaps and opportunities in our pathways to care. Adequate screening for eating disorders is a major gap. This study aims to validate an online screening tool for use in telehealth early intervention, designed for users seeking information for a suspected eating disorder. The screener meets those at risk 'where they are' (i.e. online) and may improve timely referrals to relevant services. This is of particular salience as face-to-face healthcare and traditional frontline interventions are disrupted, and we are challenged to re-design our practices to deliver diagnostic and treatment services in highly adaptive digital contexts.

Cognitive Behavioral Therapy Versus Usual Care Before Bariatric Surgery: One-Year Follow-Up Results of a Randomized Controlled Trial

BACKGROUND

Although early results of bariatric surgery are beneficial for most patients, some patients regain weight later. Cognitive behavioral therapy (CBT) has been suggested as a way to improve patients' psychological health and maintaining weight loss in the longer term. The added value of preoperative CBT to bariatric surgery was examined. Pre- and posttreatment and 1-year follow-up data are presented.

METHODS

In a multi-center randomized controlled trial, CBT was compared to a treatment-as-usual (TAU) control group. Measurements were conducted pre- and posttreatment/pre-surgery (T0 and T1) and at 1-year post-surgery (T2). Patients in the intervention group received 10 individual, weekly sessions of preoperative CBT focused on modifying thoughts and behaviors regarding eating behavior, physical exercise, and postoperative life style. Outcome measures included weight change, eating behavior, eating disorders, depression, quality of life, and overall psychological health.

RESULTS

Though no significant differences between conditions were found per time point, in the CBT, condition scores on external eating, emotional eating, depressive symptoms, and psychological distress decreased significantly more over time between pre- (T0) and posttreatment (T1) pre-surgery compared to TAU. No significant time x condition differences were found at 1-year post-surgery (T2).

CONCLUSIONS

Compared to TAU, preoperative CBT showed beneficial effects on eating behavior and psychological symptoms only from pretreatment to posttreatment/pre-surgery, but not from pre-surgery to 1-year post-surgery. Preoperative CBT does not seem to contribute to better long-term outcomes post-surgery. Recent studies suggest that the optimal time to initiate psychological treatment may be early in the postoperative period, before significant weight regain has occurred.

TRIAL REGISTRATION

https://www.trialregister.nl Identifier: Trial NL3960.

Results of an Online Survey about Food Insecurity and Eating Disorder Behaviors Administered to a Volunteer Sample of Self-Described LGBTQ+ Young Adults Aged 18 to 35 Years

BACKGROUND

There are few published studies addressing food insecurity and eating disorders in lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) individuals.

OBJECTIVE

The primary objective of this study was to describe the proportion of food insecurity and eating disorder behaviors in a volunteer sample of LGBTQ+ individuals aged 18 to 35 years.

DESIGN

This study was a cross-sectional analysis of questionnaire data collected from 253 participants between March 2018 and March 2019.

PARTICIPANTS AND SETTING

To be included in the study, participants had to be aged 18 to 35 years and identify as being LGBTQ+.

MAIN OUTCOME MEASURES

Food security score, Eating Attitudes Test score, Eating Disorder Examination Self-Report Questionnaire score, anxiety score (Beck), and depressive symptoms score.

STATISTICAL ANALYSES PERFORMED

The χ² test was used to analyze the categorical outcomes. One-way analysis of variance was used to compare continuous variables across gender identity groups. All P values < 0.05 were taken as statistically significant.

RESULTS

The proportion of participants identifying as a woman, trans male, gender nonconforming, and a man were 39%, 24%, 24%, and 13%, respectively. Food insecurity was reported by 54.4% of respondents with trans males reporting the highest proportions (64.8%). High levels of depressive symptoms were reported by 68.2% of men, 89.8% of women, 91.4% of trans males, and 95.5% of gender-nonconforming respondents (P = 0.009). High anxiety was reported by 20.5%. Eating Disorder Examination Self-Report Questionnaire scores were significantly higher (P < 0.001) compared with a community-based sample. The eating disorder behavior most frequently reported by respondents was binge eating. Only 4.3% reported having sought treatment for an eating disorder.

CONCLUSIONS

Members of the LGBTQ+ community are at greater risk for food insecurity, eating disorders, and depression, particularly those who identify as trans males. These findings denote the need to focus future research efforts on effective prevention and treatment strategies that are specific to sexual and gender identity groups within the LGBTQ+ community.

Eating-Disordered Behavior in Adolescents: Associations with Body Image, Body Composition and Physical Activity

Eating disorders (EDs) represent a disparate group of mental health problems that significantly impair physical health or psychosocial functioning. The aim of this study was to present some evidence about the prevalence of eating-disordered behavior (EDB) in adolescents, and explore its associations with body image (BI), body composition (BC) and physical activity (PA) in this age group. Data from 780 adolescents participating in a health behavior in school-aged children (HBSC) study conducted in Slovakia in 2018 were used (mean age 13.5 ± 1.3; 56% boys). Differences in mean values of numerical indicators were evaluated using the independent samples t-test. Differences between nominal variables were assessed by the chi-square test. Pearson correlation was used to describe the associations between all the selected variables. EDB was positively screened in 26.7% (208/780) of adolescents, with a higher prevalence in girls (128/344, 37.2%) than in boys (80/436, 18.3%). Significantly higher means of BI, body weight (BW), body mass index (BMI), body fat mass (BFM), body fat percentage (BFP), body fat mass index (BFMI), fat free mass index (FFMI), and SCOFF questionnaire score (SCOFF QS) were found in those positively screened for EDB. Pearson correlation analysis revealed positive associations between EDB and BI, BW, BMI, BFM, BFP and BFMI. The prevalence of EDB is high in Slovak adolescents. Positive associations between EDB, BI, BMI and fat-related body composition parameters support the idea of a more integrated approach in EDs and obesity prevention and treatment. At the same time, gender differences suggest the need for considering gender-specific strategies aimed at girls and boys separately.

Disparities in eating disorder risk and diagnosis among sexual minority college students: Findings from the national Healthy Minds Study

OBJECTIVE

To examine differences in eating disorder (ED) risk and diagnosis by sexual orientation in a national sample of college students.

METHOD

Data from 178 U.S. colleges and universities participating in the Healthy Minds Study between 2016 and 2019 were analyzed (36,691 cisgender men, 81,730 cisgender women; 15.7% self-identifying as sexual minorities). Outcomes were ED risk (≥2 on the SCOFF) and self-reported lifetime ED diagnosis. Prevalence estimates adjusted for demographics and weight status were computed via logistic regression.

RESULTS

Higher proportions of questioning (29.1%), bisexual (26.3%), and gay men (30.9%) exhibited elevated risk than heterosexual men (14.3%), and a higher proportion of gay men exhibited elevated risk than bisexual men. Higher proportions of questioning (34.5%) and bisexual women (34.6%) exhibited elevated risk than heterosexual women (27.6%); proportions of lesbian (28.1%) and heterosexual women were similar. Among those with elevated risk, higher proportions of bisexual (5.0%) and gay men (7.1%) and of questioning (14.7%), bisexual (18.1%), and lesbian women (19.6%) had been diagnosed relative to heterosexual men (2.0%) and heterosexual women (10.3%), respectively.

DISCUSSION

Questioning and bisexual individuals appear to be particularly vulnerable; they may experience elevated ED risk relative to their heterosexual peers yet underdiagnosis relative to their gay or lesbian peers.

Further development of the 12-item EDE-QS: identifying a cut-off for screening purposes

BACKGROUND

The Eating Disorder Examination - Questionnaire Short (EDE-QS) was developed as a 12-item version of the Eating Disorder Examination Questionnaire (EDE-Q) with a 4-point response scale that assesses eating disorder (ED) symptoms over the preceding 7 days. It has demonstrated good psychometric properties at initial testing. The purpose of this brief report is to determine a threshold score that could be used in screening for probable ED cases in community settings.

METHODS

Data collected from Gideon et al. (2016) were re-analyzed. In their study, 559 participants (80.86% female; 9.66% self-reported ED diagnosis) completed the EDE-Q, EDE-QS, SCOFF, and Clinical Impairment Assessment (CIA). Discriminatory power was compared between ED instruments using receiver operating characteristic (ROC) curve analyses.

RESULTS

A score of 15 emerged as the threshold that ensured the best trade-off between sensitivity (.83) and specificity (.85), and good positive predictive value (.37) for the EDE-QS, with discriminatory power comparable to other ED instruments.

CONCLUSION

The EDE-QS appears to be an instrument with good discriminatory power that could be used for ED screening purposes.

Eating Disorder Screening: a Systematic Review and Meta-analysis of Diagnostic Test Characteristics of the SCOFF

BACKGROUND

Eating disorders affect upwards of 30 million people worldwide and often go undertreated and underdiagnosed. The purpose of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of the Sick, Control, One, Fat and Food (SCOFF) questionnaire for DSM-5 eating disorders in the general population.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed. A PubMed search was conducted among peer-reviewed articles. Information regarding validation of the SCOFF was required for inclusion. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

RESULTS

The final analysis included 25 studies. The validity of the SCOFF was high across samples with a pooled sensitivity of 0.86 (95% CI, 0.78-0.91) and specificity of 0.83 (95% CI, 0.77-0.88). Subgroup analyses were conducted to examine the impact of methodology, study quality, and clinical characteristics on diagnostic accuracy. Studies with the highest sensitivity tended to be case-control studies of young women with anorexia nervosa (AN) and bulimia nervosa (BN). Studies which included more men, included those diagnosed with binge eating disorder, and recruited from large community samples tended to have lower sensitivity. Few studies reported on BMI and race/ethnicity; thus, subgroups for these factors could not be examined. No studies used reference standards which assessed all DSM-5 eating disorders.

CONCLUSION

This meta-analysis of 25 validation studies demonstrates that the SCOFF is a simple and useful screening tool for young women at risk for AN and BN. However, there is not enough evidence to support utilizing the SCOFF for screening for the range of DSM-5 eating disorders in primary care and community-based settings. Further examination of the validity of the SCOFF or development of a new screening tool, or multiple tools, to screen for the range of DSM-5 eating disorders heterogenous populations is warranted.

TRIAL REGISTRATION

This study is registered online with PROSPERO (CRD42018089906).

Binge Eating Disorder in Patients with Type 2 Diabetes: Diagnostic and Management Challenges

Type 2 diabetes mellitus (T2DM) is associated with an increased risk of disordered eating behaviors including binge eating disorder (BED). Comorbid BED in patients with T2DM has been associated with adverse clinical outcomes such as higher body mass index (BMI) and depressive symptoms. Identifying and addressing this disorder in patients with T2DM is a significant challenge for health-care providers. The purpose of this narrative review is to discuss current perspectives on BED in the context of T2DM with implications for screening and management of these highly comorbid conditions. BED continues to be underrecognized and underdiagnosed. However, there are established tools that providers can use to screen for BED such as the SCOFF Questionnaire and Questionnaire on Eating and Weight Patterns-5. There are several effective treatments for BED including cognitive behavioral therapy, interpersonal therapy, and lisdexamfetamine dimesylate. However, few studies have examined the effects of these treatments in patients with co-morbid T2DM and BED.

Differential Item Functioning in Brief Instruments of Disordered Eating

Abstract. Most instruments for the assessment of disordered eating were developed and validated in young female samples. However, they are often used in heterogeneous general population samples. Therefore, brief instruments of disordered eating should assess the severity of disordered eating equally well between individuals with different gender, age, body mass index (BMI), and socioeconomic status (SES). Differential item functioning (DIF) of two brief instruments of disordered eating (SCOFF, Eating Attitudes Test [EAT-8]) was modeled in a representative sample of the German population ( N = 2,527) using a multigroup item response theory (IRT) and a multiple-indicator multiple-cause (MIMIC) structural equation model (SEM) approach. No DIF by age was found in both questionnaires. Three items of the EAT-8 showed DIF across gender, indicating that females are more likely to agree than males, given the same severity of disordered eating. One item of the EAT-8 revealed slight DIF by BMI. DIF with respect to the SCOFF seemed to be negligible. Both questionnaires are equally fair across people with different age and SES. The DIF by gender that we found with respect to the EAT-8 as screening instrument may be also reflected in the use of different cutoff values for men and women. In general, both brief instruments assessing disordered eating revealed their strengths and limitations concerning test fairness for different groups.

The prevalence and correlates of eating disorders in adult emergency department patients

OBJECTIVE

This study describes the prevalence of eating disorders among adult patients who present to the emergency department for medical care and examines the relationship between eating disorders, depression, and substance use disorders.

METHOD

Emergency department patients aged 21-65 years (n = 1,795) completed a computerized questionnaire that included validated screening tools for eating disorders, risky drinking behavior, other substance use, and depression. Analyses were conducted comparing individuals who screened positive for an eating disorder with those who did not based on demographics (gender, age, race, income, education), body mass index (BMI), risky drinking behavior, other substance use, and depression.

RESULTS

Nearly 16% (15.9%) of all patients screened positive for an eating disorder regardless of their reason for presenting to the emergency department. Patients who screened positive for an eating disorder were significantly more likely to have a BMI > 30 (odds ratio [OR] = 2.68, confidence interval [CI] = 1.98, 3.62, p < .001), to also screen positive for depression (OR = 3.19, CI = 2.28, 4.47, p < .001) and to be female (OR = 2.37, CI = 1.76, 3.19, p < .001). No differences in the prevalence of positive screens for eating disorders were seen across age or racial groups, level of education or income, or for any of the included substance use variables.

DISCUSSION

Eating disorders are common among adult emergency department patients and are associated with high rates of comorbid depression and higher BMI. Given the significant morbidity and mortality associated with eating disorders, targeted screening may be warranted in the emergency department setting.

How eating disordered and non-eating disordered women differ in their use (and effectiveness) of cognitive self-regulation strategies for managing negative experiences

PURPOSE

The present study compared the use (and effectiveness) of cognitive self-regulation strategies in eating disordered (ED) and non-eating disordered women (non-ED), and whether ED subgroups differ in their use of avoidant/suppressive strategies and cognitive reappraisal.

METHODS

The participants consisted of 90 adult patients recruited from a specialist eating disorder service and 97 adults without an ED. Cognitive self-regulation strategies were examined on a baseline self-report measure and while looking in a mirror.

RESULTS

The results of this study showed that, relative to the non-ED group, ED participants engage in more worry and self-punishment and less distraction and social control strategies in general but not specifically during a body exposure task. Reappraisal strategies were equally likely to be used by clinical and non-clinical groups but participants with anorexia nervosa (AN) found them less effective during the task. Non-ED participants found distraction strategies more effective than the ED group for managing the body exposure experience. ED subgroups used avoidant/suppressive strategies and cognitive reappraisal strategies to a similar extent.

CONCLUSION

The use of maladaptive self-regulation strategies, and the use and effectiveness of some of the more adaptive self-regulation strategies sets eating disorders apart from those without an eating disorder, supporting previous research in the area. Contrary to what was predicted, the results were similar across ED subgroups. The findings highlight the importance of cognitive self-regulation strategies as a focus of research and clinical intervention.

LEVEL OF EVIDENCE

Level III: Case-control study.

Investigating the Components of Body Image Disturbance Within Eating Disorders

Body image disturbance has been highlighted as a common characteristic within the development and maintenance of clinical eating disorders (EDs), represented by alterations in an individual's bodily experience. However, whilst the perceptual stability of the sense of body ownership has been investigated in ED patients, the stability of the sense of body agency in those with ED is yet to be examined. Therefore, body ownership and body agency were investigated using the moving rubber hand illusion, alongside measures of explicit and implicit body satisfaction. Furthermore, with evidence demonstrating a direct link between perceptual and cognitive-affective components of body image in the healthy population, the relationship between measures of body perception and body satisfaction was investigated. Results showed that both ED and healthy individuals displayed a similar subjective experience of illusory ownership and agency towards the fake hand, following voluntary movement. However, whilst both groups initially overestimated their own hand width prior to the illusion, the ED group displayed a significant reduction in hand size estimation following the illusion, which was not matched to the same degree in healthy individuals. In addition, ED individuals displayed a significantly lower body satisfaction compared with healthy females, on both an explicit and implicit level. Such implicit outcomes were shown to be driven specifically by a weaker association between the self and attractiveness. Finally, a significant relationship was observed between specific perceptual measures and implicit body satisfaction, which highlights the important link between perceptual and cognitive-affective components of one's body image. Together, such findings provide a useful foundation for further research to study the conditions in which these two components relate with regard to body image and its disturbance, particularly in relation to the prognosis and treatment of EDs.

A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women

Objective: As eating disorders (EDs) often emerge during college, managing EDs would ideally integrate prevention and treatment. To achieve this goal, an efficient tool is needed that detects clinical symptoms and level of risk. This study evaluated the performance of a screen designed to identify individuals at risk for or with an ED. Participants: Five hundred forty-nine college-age women. Methods: Participants completed a screen and diagnostic interview. Results: Using parsimonious thresholds for ED diagnoses, screen sensitivity ranged from 0.90 (anorexia nervosa) to 0.55 (purging disorder). Specificity ranged from 0.99 (anorexia nervosa) to 0.78 (subthreshold binge eating disorder) compared to diagnostic interview. Moderate to high area under the curve values were observed. The screen had high sensitivity for detecting high risk. Conclusions: The screen identifies students at risk and has acceptable sensitivity and specificity for identifying most ED diagnoses. This tool is critical for establishing stepped care models for ED intervention.

Psychological aspects of diet: Development and validation of three measures assessing dietary goal-desire incongruence, motivation, and satisfaction with dietary behavior

OBJECTIVE

The current research created and validated three new measures of psychological mechanisms associated with dietary behavior: (i) a Dietary Goal-Desire Incongruence scale assessed the degree of conflict between ideal dietary behavior and incongruent tempting desires; (ii) a Motivation for Dietary Self-control scale measured the extent and type of motivation, according to Self-Determination Theory, which may be experienced when trying to control dietary behavior; and (iii) a Satisfaction with Dietary Behavior scale measured successful dietary goal-behavior alignment.

METHOD

A representative sample of Australian adults (N = 448, M_age = 45.7 years, SD = 16.98, 50.2% women) rated items assessing the three target constructs and also completed established scales that measure related and unrelated constructs.

RESULTS

Exploratory factor analyses indicated a 1-factor Dietary Goal-Desire Incongruence scale (6 items), 3-factor Motivation for Dietary Self-control scale (11 items), and a 1-factor Satisfaction with Dietary Behavior scale (8 items). Confirmatory factor analyses also supported the model fit of each scale's factor solution. Internal consistency as assessed by Cronbach's alpha (α) was 0.94, 0.78, and 0.94 for the three scales, respectively. A follow-up mediation analysis revealed a stage model of psychological factors related to dietary behavior (as assessed by these three scales) that build on each other. Test-retest reliability was high for each scale (r = .71-.84) and showed sound predictive validity.

CONCLUSION

The Dietary Goal-Desire Incongruence scale, Motivation for Dietary Self-control scale, and Satisfaction with Dietary Behavior scale show good psychometric properties and are brief, easy to administer measures. The utility of the scales can be explored further with other populations and in intervention studies.

Embodied Precision: Intranasal Oxytocin Modulates Multisensory Integration

Multisensory integration processes are fundamental to our sense of self as embodied beings. Bodily illusions, such as the rubber hand illusion (RHI) and the size-weight illusion (SWI), allow us to investigate how the brain resolves conflicting multisensory evidence during perceptual inference in relation to different facets of body representation. In the RHI, synchronous tactile stimulation of a participant's hidden hand and a visible rubber hand creates illusory body ownership; in the SWI, the perceived size of the body can modulate the estimated weight of external objects. According to Bayesian models, such illusions arise as an attempt to explain the causes of multisensory perception and may reflect the attenuation of somatosensory precision, which is required to resolve perceptual hypotheses about conflicting multisensory input. Recent hypotheses propose that the precision of sensorimotor representations is determined by modulators of synaptic gain, like dopamine, acetylcholine, and oxytocin. However, these neuromodulatory hypotheses have not been tested in the context of embodied multisensory integration. The present, double-blind, placebo-controlled, crossover study ( n = 41 healthy volunteers) aimed to investigate the effect of intranasal oxytocin (IN-OT) on multisensory integration processes, tested by means of the RHI and the SWI. Results showed that IN-OT enhanced the subjective feeling of ownership in the RHI, only when synchronous tactile stimulation was involved. Furthermore, IN-OT increased an embodied version of the SWI (quantified as estimation error during a weight estimation task). These findings suggest that oxytocin might modulate processes of visuotactile multisensory integration by increasing the precision of top-down signals against bottom-up sensory input.

Identifying a male clinical cutoff on the Eating Disorder Examination-Questionnaire (EDE-Q)

OBJECTIVE

Evidence suggests that eating disorders (EDs) may be under-detected in males. Commonly used measures of EDs such as the Eating Disorder Examination-Questionnaire (EDE-Q) were initially developed within female samples, raising concern regarding the extent to which these instruments may be appropriate for detecting EDs in males. The current study used receiver operating characteristic curve analysis to (a) examine the accuracy of the EDE-Q global score in correctly classifying males with and without clinically significant ED pathology, and (b) establish the optimal EDE-Q global clinical cutoff for males.

METHOD

Participants were a clinical sample of 245 male ED patients and a control sample of 205 male undergraduates.

RESULTS

Eating Disorder Examination-Questionnaire global scores demonstrated moderate-high accuracy in predicting ED status (area under the curve = 0.85, 95% CI: 0.82-0.89). The optimal cutoff of 1.68 yielded a sensitivity of 0.77 and specificity of 0.77.

DISCUSSION

Overall, results provide preliminary support for the discriminant validity of EDE-Q scores among males. However, concerns remain regarding the measure's ability to comprehensively assess domains of disordered eating most relevant to males. Therefore, careful attention to the possibility for measurement bias and continued evaluation of the scale in males is encouraged.

Validation of the clinical perfectionism questionnaire in an eating disorder sample: A bifactor approach

OBJECTIVE

Clinical perfectionism is involved in the etiology and maintenance of eating disorders. Limited research has examined the factor structure of the Clinical Perfectionism Questionnaire (CPQ) in clinical eating disorder samples. The aim of this research was to examine the validity and reliability of the CPQ in a mixed eating disorder sample.

METHOD

Patients (N = 211) with an eating disorder completed the CPQ at pretreatment. A bifactor model was tested that included a general clinical perfectionism factor and two group factors; overevaluation of striving and concern over mistakes. The unique contributions that general and group factors make to the prediction of eating disorder symptoms were also investigated. Unidimensional, correlated two-factor, and bifactor models were tested using confirmatory factor analysis.

RESULTS

A bifactor structure for a revised 10-item version of the CPQ provided the best fit, with a strong and reliable general clinical perfectionism factor. The general clinical perfectionism factor and the overevaluation of striving group factor explained reliable variance in the CPQ, and but only the general factor predicted eating disorder symptoms.

DISCUSSION

The results suggested that a total score is generally appropriate for assessing clinical perfectionism in a clinical eating disorder sample.

Emotion dysregulation and eating disorders-Associations with diagnostic presentation and key symptoms

OBJECTIVE

Emotion dysregulation seems involved in the development, maintenance, and outcome of eating disorders (EDs). The present study aimed to differentiate patients with EDs from a comparison group on emotion dysregulation, and to examine emotion dysregulation in relation to ED diagnostic presentation and ED symptoms.

METHOD

Participants, patients with EDs (N = 999) and a student comparison group (N = 252), completed the Difficulties in Emotion Regulation Scale and the Eating Disorder Examination Questionnaire. Patients were compared to the comparison group and compared by diagnosis regarding emotion dysregulation, and unique associations between emotion dysregulation aspects and ED symptoms were examined.

RESULTS

Patients reported greater general emotion dysregulation than the comparison group, especially poorer emotional awareness and clarity. There were very few diagnostic differences. In both patients and the comparison group, limited access to emotion regulation strategies was associated with cognitive ED symptoms, and presence of binge eating in the comparison group. In patients, poor emotional awareness and emotional non-acceptance were additionally associated with cognitive symptoms, and difficulties in impulse control and emotional non-acceptance were associated with binge eating.

DISCUSSION

Emotion dysregulation is an important transdiagnostic characteristic of ED. Results suggest interventions that enhance emotional awareness and acceptance, as well as emotion regulation skills training, in both ED treatment and prevention.

Rates and correlates of disordered eating among women veterans in primary care

Rates of disordered eating may be higher among women veterans than civilians, and are associated with co-occurring mental health (MH) conditions, such as depression, post-traumatic stress disorder (PTSD), and alcohol misuse. Although evidence suggests that these conditions are common in primary care settings, limited research has examined symptoms of disordered eating among women veterans in primary care. This study used a cross-sectional design to examine rates and MH correlates of disordered eating among women veterans treated in a primary care setting. Participants (N = 176) completed self-report measures of disordered eating attitudes and behaviors, depression, anxiety, PTSD, alcohol misuse, and military sexual trauma. Results indicated that women veterans were likely to report objective (35.8%) and subjective binge episodes (29.5%), as well as shape and weight concerns (36.4% and 23.3%, respectively). While, anxiety and PTSD were strongly associated with disordered eating, restraint, eating concerns, weight concerns, and shape concerns, military sexual trauma was often unrelated to these outcomes. Further study is needed to improve the detection of disordered eating behaviors among women veterans, as well as to identify effective management strategies in primary care. Overall, these findings suggest that integrated primary care (IPC) may be a useful setting to improve the detection and treatment of eating disorders, particularly by targeting binge eating and body dissatisfaction among women veterans within these settings.