A systematic review of sociodemographic reporting and representation in eating disorder psychotherapy treatment trials in the United States

Guidelines for research with transgender, gender diverse, and intersex individuals with eating disorders: recommendations from trans and intersex researchers

Further research is urgently needed to address the disproportionately high rates of eating disorders (EDs) among transgender, gender diverse, and intersex (TGDI) individuals in comparison to cisgender, endosex (non-intersex) populations. As TGDI advocates, academics, and clinicians with lived/living experience with EDs, we propose a set of recommendations to guide ethical research specifically about EDs and disordered eating behaviors in TGDI populations. The guidelines included here aim to educate non-TGDI researchers and support TGDI researchers seeking to carry out such research. Considerations for study design, planning, data collection, and dissemination are included.

Sociodemographic representation in randomized controlled trials for anxiety-related disorders in the U.S.: A systematic review (1993-2023)

Cognitive behavioral therapies have been identified as evidence-based treatments for anxiety-related disorders. However, data supporting the effectiveness of these treatments have been largely collected from participants with majoritized identities, potentially limiting the extent to which they can be considered "evidence-based" for clients from minoritized groups. The current review examined sociodemographic representation and quality of sociodemographic reporting in randomized controlled trials for anxiety-related disorders in the U.S. between 1993 and 2023. We conducted a systematic literature review of U.S.-based randomized controlled trials of cognitive behavioral therapies for anxiety-related disorders, extracted data on sociodemographic variables, and rated quality of reporting. Data from 55 eligible studies (N = 4492) indicated that white and female identities were overrepresented relative to the U.S. population, with variables like disability status, sexual orientation, and religious identification consistently ignored. In addition, quality of reporting was generally poor (mean = 3.6 out of 10), with many studies failing to account for demographic variables in their analyses or description of study limitations. Publication year, sample size, and NIH funding status did not significantly predict gender representation (% women), ethnoracial representation (% white), or quality of reporting. These findings underscore the importance of critically evaluating to whom "evidence-based" treatments apply and increasing diversity of clinical samples, to ensure that evidence-based treatments are inclusive. Recommendations for future research, clinical implications, and limitations are discussed.

Telehealth-Delivered Radically Open Dialectical Behavior Therapy for Adolescents (RO DBT-A): A Pilot Mixed-Methods Study

OBJECTIVE

Disorders related to overcontrol frequently first appear during adolescence, are highly comorbid, and show limited treatment response, necessitating the adaptation of radically open dialectical behavior therapy (RO DBT; a transdiagnostic treatment targeting overcontrol) for adolescents (RO DBT-A). This study tested the preliminary efficacy of telehealth-delivered RO DBT-A in a heterogeneous clinical sample of youths.

METHODS

The sample consisted of 20 female participants ages 13-21 with elevated overcontrol; most were White (75%) and non-Hispanic/Latino (80%). RO DBT-A was provided over 20 weeks via skills group and individual sessions (N=13 participants). Participants seeking other treatment or no treatment formed the control group (N=7). Outcomes included self-reported symptoms and overcontrol. Follow-up interviews were analyzed by using inductive, contextualist thematic analysis to examine participant perceptions and reasons for dropout.

RESULTS

The RO DBT-A group showed significant improvements in depression (t=-1.78, df=10, p=0.011) and quality of life (QOL; Wilcoxon W=75, p=0.021) compared with the control group. From baseline to posttreatment, youths receiving RO DBT-A demonstrated significant improvements in maladaptive overcontrol (t=2.76, df=12, p=0.043), anxiety (t=2.91, df=12, p=0.043), depression (Wilcoxon signed rank V=82.5, p=0.043), and QOL (t=-3.01, df=12, p=0.043). Qualitative analysis revealed themes related to treatment barriers, facilitators, and timing.

CONCLUSIONS

The findings provide preliminary evidence supporting telehealth-delivered RO DBT-A in targeting overcontrol, decreasing symptomatology, and improving QOL in a heterogeneous clinical sample of youths. Qualitative follow-ups highlighted that dropout was driven by barriers related to therapy (e.g., structure- and therapist-related issues) and the timing of RO DBT-A compared with other treatments.

Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality

Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.

Examining the role of artificial intelligence to advance knowledge and address barriers to research in eating disorders

OBJECTIVE

To provide a brief overview of artificial intelligence (AI) application within the field of eating disorders (EDs) and propose focused solutions for research.

METHOD

An overview and summary of AI application pertinent to EDs with focus on AI's ability to address issues relating to data sharing and pooling (and associated privacy concerns), data augmentation, as well as bias within datasets is provided.

RESULTS

In addition to clinical applications, AI can utilize useful tools to help combat commonly encountered challenges in ED research, including issues relating to low prevalence of specific subpopulations of patients, small overall sample sizes, and bias within datasets.

DISCUSSION

There is tremendous potential to embed and utilize various facets of artificial intelligence (AI) to help improve our understanding of EDs and further evaluate and investigate questions that ultimately seek to improve outcomes. Beyond the technology, issues relating to regulation of AI, establishing ethical guidelines for its application, and the trust of providers and patients are all needed for ultimate adoption and acceptance into ED practice.

PUBLIC SIGNIFICANCE

Artificial intelligence (AI) offers a promise of significant potential within the realm of eating disorders (EDs) and encompasses a broad set of techniques that offer utility in various facets of ED research and by extension delivery of clinical care. Beyond the technology, issues relating to regulation, establishing ethical guidelines for application, and the trust of providers and patients are needed for the ultimate adoption and acceptance of AI into ED practice.

Pragmatic clinical trials to advance research in children and adolescents with eating disorders

OBJECTIVE

To discuss the utility of pragmatic clinical trials (PCTs) to help advance research in eating disorders (EDs).

METHODS

We describe challenges associated with traditional explanatory research trials and examine PCTs as an alternative, including a review of the PRECIS-2 tool.

RESULTS

There are many challenges associated with the design and completion of traditional RCTs within the field of EDs. Pragmatic clinical trials are studies that closely align with conditions available in everyday practice and focus on outcomes that are relevant to patients and clinicians. Results of PCTS maximize applicability and generalizability to clinical settings.

DISCUSSION

Available therapies established for the treatment of EDs provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In addition to a general overview of PCTs, we draw upon published literature and our own experiences involving adjunctive olanzapine for the treatment of children and youth with anorexia nervosa to help highlight challenges associated with randomized controlled trial (RCT) design and implementation, and offer pragmatic suggestions that would allow patients greater choice in treatment trials, while at the same time capturing outcomes that are most likely to advance treatment efforts.

CONCLUSIONS

Pragmatic clinical trials provide alternatives to RCT design that can help bolster research in EDs that aims to explore real-world effects of interventions.

PUBLIC SIGNIFICANCE

Available therapies established for the treatment of eating disorders (EDs) in children and adolescents provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In this article, we discuss the utility of pragmatic trials to help promote research that can help advance knowledge that is relevant to clinical care settings.

A randomized, controlled pilot study of positive affect treatment adapted for anorexia nervosa

OBJECTIVE

Novel treatments for adults with anorexia nervosa (AN) are sorely needed. Although psychological interventions have been developed for AN, none have been identified as superior to one another or nonspecific treatments. Common comorbidities (e.g., mood and anxiety disorders) are rarely targeted in AN treatments, possibly impairing long-term clinical improvement. AN is associated with reward processing dysfunctions paralleling those identified in affective disorders; however, few treatments directly target these processes.

METHOD

We adapted Positive Affect Treatment, a neuroscience-informed behavioral treatment developed for affective disorders, to the treatment of AN (PAT-AN). Adults with AN (N = 20) were randomized to 20 weeks of PAT-AN or waitlist to investigate the feasibility, acceptability, preliminary efficacy, and target engagement (on reward mechanisms) of PAT-AN.

RESULTS

PAT-AN demonstrated strong retention (100%) and acceptability ratings (M = 5.67-5.95 on a 7-point scale). BMI (p = .006) and eating disorder symptoms (p < .001) improved over PAT-AN sessions. The PAT-AN group showed medium to large pre-to-post-treatment improvements in BMI, eating disorder symptoms and impairment, depressive and anxiety symptoms, and some reward indices (ds = .56-.87); changes were largely sustained at 3-month follow-up. Waitlist showed negligible changes (ds < .20) on nearly all measures.

DISCUSSION

PAT-AN holds promise as an innovative treatment with capability to simultaneously improve eating disorder symptoms, affective symptoms, and underlying reward mechanisms. Findings should be interpreted cautiously due to small sample size and permitted concurrent enrollment in other treatments. Future, larger-scale research is warranted to establish the efficacy of PAT-AN.

PUBLIC SIGNIFICANCE

This study provided a preliminary evaluation of Positive Affect Treatment for anorexia nervosa (PAT-AN), a novel, neuroscience-informed treatment aimed at increasing rewarding life experiences outside of one's eating disorder. Initial results suggest that PAT-AN is considered acceptable and may alleviate eating disorder, depressive, and anxiety symptoms. Therefore, this study presents promising data on a treatment that may hold potential for improving the lives of individuals with this disorder.

Multiple marginalization, discrimination, and disordered eating among youth aged 10-11

OBJECTIVE

Although rates of weight discrimination are on-par with racial, ethnic, and gender discrimination, comparatively less work has examined impacts of weight-based discrimination in youth, including on disordered eating. Knowing whether experiences of weight-based discrimination, including in youth with multiply-marginalized identities, are associated with disordered eating could identify vulnerable youth and inform intervention efforts.

METHOD

Youth (N = 11,875) ages 10-11 were recruited through the Adolescent Brain Cognitive Development (ABCD) study. Logistic regressions using cross-sectional data examined discrimination experiences (weight, perceived sexual orientation, race/ethnicity, national origin) and disordered eating (binge-eating, vomiting, weight-gain fear, weight self-worth). Models included race/ethnicity, age, sex, parental income, and degree of elevated weight. Raked poststratification weights were used.

RESULTS

Rates of weight-based discrimination (6.2%) were similar to rates of race/ethnicity (4.4%) and sexual orientation discrimination (4.5%). Weight-based discrimination was associated with more disordered eating. Youth reporting multiple experiences of discrimination had significantly increased disordered eating compared to youth who did not report discrimination.

DISCUSSION

Weight-based discrimination is common in youth and associated with disordered eating. Youth with elevated weight are more likely to be multiply marginalized and experience disordered eating. These findings suggest discrimination, including weight-based discrimination, is a critical intervention target to prevent and treat eating disorders.

PUBLIC SIGNIFICANCE

Experiences of discrimination contribute to poorer health; however, weight-based discrimination is relatively understudied. Data from a large sample of youth ages 10-11 showed that youth with elevated weight reported experiencing multiple types of discrimination, and multiply-marginalized youth had increased odds of disordered eating with each additional type of discrimination. Together, this suggests that weight-based discrimination is a critical target to prevent and treat eating disorders, especially in multiply-marginalized youth.

Accounting for diversity in the treatment of suicide and self-injury: A systematic review of the past 50 years of randomized controlled trials

PURPOSE

Patients receiving treatment for self-injurious thoughts and behaviors (SITBs) have diverse backgrounds, yet it remains unclear exactly who is represented in the current SITB treatment literature.

METHODS

We conducted a systematic review of the past 50 years of randomized controlled trials (RCTs) testing SITB treatments to evaluate sampling practices and reporting of sample characteristics, as well as inclusion of global populations across the included 525 papers. We also assessed changes over the past five decades in these three domains.

RESULTS

SITB RCTs frequently reported age and sex (98.6%-95.1%), less frequently reported race (83.4%-38.6%), socioeconomic status (48.1%-46.1%) and ethnicity (41.9%-8.1%), and rarely reported LGBTQ+ status (3.7%-1.6%). U.S.-based RCTs featured predominantly White, non-Hispanic, and non-LGBTQ+ samples. Most RCTs were conducted in high-income North American or European countries. Sample reporting practices, sample representativeness, and inclusion of global populations modestly and inconsistently improved over time.

CONCLUSIONS

There has not been substantial improvement in reporting practices, sample representativeness, or inclusion of global populations in SITB RCTs over the past 50 years. Acknowledging who is being studied and representing diverse populations in SITB treatment research is key to connecting research advances with those who may need it most.

Disordered eating and emotional eating in Arab, middle eastern, and north African American women

Arab, Middle Eastern, and North African (A-MENA) American women are often subject to intersectional discrimination, and they have also not been traditionally recognized as a distinct racial group in disordered eating literature. No study to date has provided descriptive information on disordered and emotional eating A-MENA American women, nor has examined perceptions of widely used measurements of eating pathology in this population. The current study generated descriptive information among A-MENA women on two widely used measures of eating pathology, the Eating Disorder Examination Questionnaire (EDE-Q) and the Emotional Eating Scale (EES). Participants (N = 244) were A-MENA adult women were recruited via social media and snowball sampling. Qualitative findings provide potential sociocultural predictors of disordered eating that should be further explored, such as bicultural identity and family pressures/comments toward appearance. Secondly, themes from the EES-R indicate adding emotion of shame and considering identity-related stress. The current study provides prevalence data and future directions of research on widely used eating pathology and appearance attitude measurements for A-MENA American women.

Common practices for sociodemographic data reporting in digital mental health intervention research: a scoping review

BACKGROUND

The ability of digital mental health interventions (DMHIs) to reduce mental health disparities relies on the recruitment of research participants with diverse sociodemographic and self-identity characteristics. Despite its importance, sociodemographic reporting in research is often limited, and the state of reporting practices in DMHI research in particular has not been comprehensively reviewed.

OBJECTIVES

To characterise the state of sociodemographic data reported in randomised controlled trials (RCTs) of app-based DMHIs published globally from 2007 to 2022.

METHODS

A scoping review of RCTs of app-based DMHIs examined reporting frequency for 16 sociodemographic domains (eg, gender) and common category options within each domain (eg, woman). The search queried five electronic databases. 5079 records were screened and 299 articles were included.

RESULTS

On average, studies reported 4.64 (SD=1.79; range 0-9) of 16 sociodemographic domains. The most common were age (97%) and education (67%). The least common were housing situation (6%), residency/location (5%), veteran status (4%), number of children (3%), sexual orientation (2%), disability status (2%) and food security (<1%). Gender or sex was reported in 98% of studies: gender only (51%), sex only (28%), both (<1%) and gender/sex reported but unspecified (18%). Race or ethnicity was reported in 48% of studies: race only (14%), ethnicity only (14%), both (10%) and race/ethnicity reported but unspecified (10%).

CONCLUSIONS

This review describes the widespread underreporting of sociodemographic information in RCTs of app-based DMHIs published from 2007 to 2022. Reporting was often incomplete (eg, % female only), unclear (eg, the conflation of gender/sex) and limited (eg, only options representing majority groups were reported). Trends suggest reporting has somewhat improved in recent years. Diverse participant populations must be welcomed and described in DMHI research to broaden learning and the generalisability of results, a prerequisite of DMHI's potential to reduce disparities in mental healthcare.

Early evaluation of a DBT-informed online intervention for people with eating disorders

OBJECTIVES

Eating disorders (EDs) have a worldwide prevalence of 7.8%, with towering mortality rates and high healthcare costs. The current recommended treatment for EDs principally works by directly targeting ED thoughts and behaviours, but recovery rates are low. A multifaceted link between difficulties with emotions and EDs is now widely established, and newer third-wave therapies that aim to address these underlying emotion difficulties are promising. The current study piloted an online emotion self-help intervention which was co-developed with clinicians and people with lived experienced of EDs. The intervention aimed to specifically address difficulties with emotion identification and regulation, as well as unhelpful beliefs about emotions, which are believed to give rise to and maintain ED thoughts and behaviours.

METHOD

We recruited 39 people with self-reported EDs to test this intervention over a one-week period. Our participants were asked to complete a series of questionnaires measuring emotion processes and psychopathology on Day 1 (T1) before being given access to the intervention. Participants were then asked to practice the newly acquired skills for seven days, before taking the same questionnaires on Day 9 (T2). We also asked participants to qualitatively report on their experience of the intervention.

RESULTS

We found significant improvements in ED psychopathology (ED-15), depression (PHQ-9), and anxiety (GAD-7) pre- to post-intervention, with medium to large effect sizes. All our emotion variables namely alexithymia (TAS-20), difficulties regulating emotions (DERS-SF), and unhelpful beliefs about emotions (EBQ) also showed significant changes post-intervention with medium to large effect sizes. Most importantly, changes in emotion regulation processes were linked to improved eating psychopathology. The qualitative analysis corroborated this finding, highlighting how the intervention helped them form new beliefs about emotions, which helped them reduce ED behaviours.

DISCUSSION

Significant improvements in emotion processing and regulations, as well as psychopathology, along with positive qualitative feedback, suggest that the intervention effectively met its aims of increasing awareness of the link between emotions and eating psychopathology, providing help to identify and regulate emotions, and normalising emotional experiences. While our results are promising, further research is required to assess its effectiveness longer term and in clinical settings.

Factors increasing the risk for food addiction in Ecuadorian students

Background

Food addiction (FA) is a construct that has gained interest in recent years, but its relevance in the Ecuadorian population has not yet been explored. The aims of this study were to explore the differences in the psychological profile (including FA) between university students from Ecuador and to identify the underlying structure of the relationships of the FA severity level through a mediational model.

Methods

The sample consisted of 972 university students, women and men (mean age: 20.1 years old, SD = 2.6), recruited from four Ecuadorian regions. The assessment tools included a unidimensional scale of FA, eating-related measures, emotion regulation state, impulsivity, and psychopathology state. Path analysis modeled the direct and indirect effects explaining the FA severity level.

Results

The results indicated that higher psychopathological levels were associated with FA. Similarly, no differences in FA were observed between the Ecuadorian regions. The path analysis suggested that older age, female sex, and higher difficulties in emotional regulation, impulsivity, negative mood, and anxiety trigger disordered eating; subsequently, more impaired eating behavior impacted the FA level.

Conclusion

FA is a complex clinical entity that includes multiple components related to eating disorders (EDs) and other mental health problems. The results of this study provide empirical knowledge for designing evidence-based prevention and treatment strategies.

Therapeutic alliance in two forms of guided self-help for binge eating

The role of therapeutic alliance within psychological treatments for eating disorders (EDs), including those delivered remotely, is well established. However, few studies have investigated alliance in guided self-help, a widely recommended first-line treatment for EDs characterised by regular binge eating. Using data from a randomised controlled trial, the current study examined both facilitator and patient assessments of alliance within e-mail-assisted and face-to-face guided self-help and looked at associations between alliance, ED symptoms and ED-related impairment. One hundred thirteen patients and 11 facilitators completed measures of alliance during and following a course of guided self-help. Whilst ratings were reliable across patients and facilitators, alliance scores were higher both in the patient sample and in the face-to-face condition. Ratings of alliance showed no correlations with ED symptoms at post-treatment, and early alliance was not significantly associated with outcome, which could inform how early symptom change is encouraged in guided self-help.

Eating disorders among queer and trans individuals: Implications for conceptualization, assessment, and treatment

Eating disorders (EDs) have been traditionally viewed as a disorder affecting cisgender, heterosexual women. Yet, the prevalence of EDs among queer and trans (QnT) individuals, coupled with the lack of interventions that attend to contextual factors related to sexual orientation and gender identity, underscore a critical health disparity issue requiring urgent attention. Here, we first review factors pertaining to QnT individuals' minoritized sexual and gender identities that are important to consider in ED conceptualization for this population (e.g., minority stressors, identity-based body image standards). Next, we describe problematic assumptions present in existing ED assessment and propose more inclusive approaches. Lastly, we provide suggestions for practices that providers can implement within their treatment of EDs among QnT individuals.

The Longitudinal Associations of Body Dissatisfaction with Health and Wellness Behaviors in Midlife and Older Women

Emerging research suggests that body dissatisfaction (BD) is prevalent among midlife and older women (i.e., upwards of 70%). Cross-sectionally, BD is associated with myriad poor health and wellness outcomes (e.g., depression, disordered eating, bad nutrition) in midlife/older women. However, relatively few studies have examined the longitudinal relations between BD and health outcomes in this population. This preliminary study investigated the longitudinal associations of BD with wellbeing and health-related quality of life (QOL) among midlife/older adult women over one year. Participants (n = 86, women aged 40-72 years, M = 51.49, SD = 7.34, 86% white) completed self-report measures of BD, psychosocial impairment, health behaviors, and QOL at baseline (T1) and 12-month follow-up (T2). A series of multiple linear regression models included T1 BD as the predictor variable of health outcomes at T2, covarying for T1 BMI and age in all models. BD was associated with greater negative emotions and psychosocial impairment, less physical activity enjoyment, and poorer physical, psychological, and social QOL one year later. Findings suggest that BD is associated with negative consequences for women across the lifespan (ƒ2 ranges = 0.06-0.60). Future research investigating BD as a unique, modifiable risk factor for health outcomes among diverse samples of midlife/older women is warranted. Targeting BD in interventions may improve health indices beyond eating disorders for this population.

Moving toward targeted eating disorder care for transgender, non-binary, and gender expansive patients in the United States

OBJECTIVE

Literature suggests that transgender, non-binary, and/or gender expansive (TNG) people are more likely than cisgender peers to experience eating disorders (EDs) and engage in dangerous weight control behaviors. TNG individuals with EDs are dramatically higher risk for self-harm behaviors, suicidal ideation, and suicidal behaviors than cisgender peers with EDs or TNG peers without EDs, and often engage in ED symptoms/behaviors to alleviate gender dysphoria. Yet, no treatment paradigms have yet been adapted for TNG-specific ED care. This qualitative study aims to identify stakeholder needs from such care to inform future clinical interventions.

METHODS

We elicited patient (n = 12) and mental health clinician (n = 9) stakeholder needs and preferences regarding TNG-specific ED care. Semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and a behavioral insights framework, EAST, were developed to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. Using a rapid analysis procedure, we produced a descriptive analysis for each group identifying challenges of and opportunities in providing ED care for TNG adults.

RESULTS

Stakeholders expressed needs and preferences for TNG-specific treatment including that it be: (1) TNG-affirming, weight-inclusive, trauma-informed, and anti-racist; (2) delivered by an interdisciplinary team, including gender-affirming care clinicians; (3) focused on parsing gender dysphoria from other body image concerns, building distress tolerance, and working toward gender euphoria (rather than body acceptance).

DISCUSSION

Future work is needed exploring ED care delivery models that integrate gender-affirming care services with mental health care. Such models may improve TNG access to ED treatment and recovery.

PUBLIC SIGNIFICANCE

Transgender, non-binary, and/or gender expansive (TNG) experience disproportionately high rates of eating disorders and have unique barriers to accessing care. In individual interviews, TNG adults with eating disorders and mental health clinicians who provide psychotherapy for eating disorders voiced desire for greater availability of TNG-affirming, weight-inclusive eating disorder care, integrated with other gender-affirming care services. This informs future research developing eating disorder care for TNG individuals.

Naltrexone plus bupropion combination medication maintenance treatment for binge-eating disorder following successful acute treatments: randomized double-blind placebo-controlled trial

BACKGROUND

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but there is a dearth of controlled research examining pharmacotherapies as maintenance treatments for responders to initial interventions. This gap in the literature is particularly critical for pharmacotherapy for BED which is associated with relapse following discontinuation. The current study tested the efficacy of naltrexone/bupropion maintenance treatment amongst responders to acute treatments for BED.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested naltrexone/bupropion as maintenance treatment for responders to acute treatments with naltrexone/bupropion and/or behavioral weight-loss therapy for BED with comorbid obesity. Sixty-six patients (84.8% women, mean age 46.9, mean BMI 34.9 kg/m2) who responded to acute treatments were re-randomized to placebo (N = 34) or naltrexone/bupropion (N = 32) for 16 weeks; 86.3% completed posttreatment assessments. Mixed models and generalized estimating equations comparing maintenance treatments (naltrexone/bupropion v. placebo) included main and interactive effects of acute treatments.

RESULTS

Intention-to-treat binge-eating remission rates following maintenance treatments were 50.0% (N = 17/34) for placebo and 68.8% (N = 22/32) for naltrexone/bupropion. Placebo following response to acute treatment with naltrexone/bupropion was associated with significantly decreased probability of binge-eating remission, increased binge-eating frequency, and no weight loss. Naltrexone/bupropion following response to acute treatment with naltrexone/bupropion was associated with good maintenance of binge-eating remission, low binge-eating frequency, and significant additional weight loss.

CONCLUSIONS

Adult patients with BED with co-occurring obesity who have good responses to acute treatment with naltrexone/bupropion should be offered maintenance treatment with naltrexone/bupropion.

A qualitative analysis of relationship advice from the perspective of people living with and recovering from eating disorders while in diverse romantic relationships

Eating disorders (EDs) have adverse consequences across life domains, ranging from physical health to interpersonal relationships. While research suggests that romantic partners have the potential to support ED recovery, partners to those with EDs often report feeling confused and helpless in the face of the condition. The extant literature on EDs in relationships centers on the experiences of cisgender, heterosexual women. The present study aimed to garner a more comprehensive understanding of the types of support people with EDs believe are most helpful from romantic partners by analyzing relationship advice from a diverse group of individuals with EDs who were in romantic relationships. As part of a larger study on romantic relationships in ED recovery, we analyzed responses to the question, "If you had to give one piece of advice to someone who learns that their partner has an ED, what would it be?" Through Consensual Qualitative Research-Modified, we identified 29 themes, which we grouped into 7 domains: Foster Open Communication, Create an Environment of Emotional Intimacy, Let Your Partner Guide You, Educate Yourself, Be Compassionate with Yourself, Use Caution when Discussing Food and Bodies, and a Miscellaneous domain. These findings highlight the importance of patience, flexibility, psychoeducation, and self-compassion for individuals working to support their partner's ED recovery, and can inform future couples-based treatments and interventions for EDs.

An investigation of the dual continua model of mental health in the context of eating disorder symptomatology using latent profile analysis

OBJECTIVE

The dual continua model of mental health suggests that mental well-being and mental illness are two distinct continua that are interrelated in their contributions to overall mental health. This study investigated the dual continua model in individuals with eating disorder symptoms.

METHOD

Female university students (N = 346) completed measures of mental well-being, eating disorder symptomatology, clinical impairment and psychological distress. Confirmatory factor and latent profile analyses were used to derive underlying mental health profiles.

RESULTS

Results revealed two oblique factors representing the mental well-being and eating disorder symptomatology constructs and four unique mental health profiles that were partially consistent with the dual continua model emerged: 'flourishing', 'vulnerable', 'partially symptomatic and content', and 'languishing'. The derived mental health profiles had unique characteristics described by psychological distress and clinical impairment.

CONCLUSIONS

The results did not provide conclusive evidence for the dual continua model as they could also be interpreted in a manner consistent with the unidimensional approach. While the dual continua model is a promising avenue to understand mental health in a way that looks beyond symptoms, these results caution against its rapid adoption and encourage future research to understand how eating disorder symptomatology and positive mental health assets contribute to overall mental health.

A Translational Approach to Increase Pulse Intake and Promote Public Health through Developing an Extension Bean Toolkit

Practical, affordable solutions need to be implemented to address global challenges confronting human and environmental health. Despite a myriad of benefits for people and the planet, beans and other pulses (e.g., chickpeas, cowpeas, dry peas, lentils) are under-consumed. To better understand consumer concerns and interests, a Food Habits Survey was conducted and the findings were incorporated into the Colorado State University Extension Bean Toolkit. Guided by the Information-Motivation-Behavioral Skills model, the toolkit included informational social media posts, cooking guidance, and an online class. A convenience sample of participants was recruited through Extension and university networks. After class participation, significant gains in knowledge of pulse nutrition, versatility, and cooking were observed, with an average increase of 1.5 points on a 5-point Likert scale (p < 0.001). Moreover, participants (n = 86) perceived a greater importance of motivators (e.g., nutrition, versatility, environmental benefits) and found barriers (e.g., flatulence, long cooking times, unfamiliarity) to be less discouraging. Most participants reported an intention to eat more pulses, and among those who completed the 1-month follow-up survey, pulse intake frequency increased (p = 0.004). Emphasizing motivating factors while simultaneously mitigating barriers to consumption can help reverse insufficient intake and promote healthy behavior change. Leveraging Extension or similar networks is one way to adopt a translational approach to better reach the public with this information.

Race/Ethnicity as a Moderator of the Association Between Weight-Related Abuse and Disordered Eating

OBJECTIVES

Extant research supports a positive relationship between weight-related abuse (WRA) and disordered eating constructs. Individuals who face marginalization and who are more likely to live in larger bodies, such as Black and Hispanic individuals in the United States (U.S.), may be at a heightened risk of WRA. This study is aimed at understanding whether the relationship between WRA and disordered eating constructs varies by race/ethnicity. We hypothesized that individuals from marginalized backgrounds would have differential levels of dietary restraint, body dissatisfaction, and shape/weight overvaluation with increased experiences of WRA compared to non-Hispanic White individuals.

METHODS

Two thousand one hundred sixteen undergraduates were recruited from two U.S. universities for a survey-based study assessing psychosocial functioning. Participants completed a demographics questionnaire assessing race/ethnicity, the Weight-Related Abuse Questionnaire assessing WRA experiences, and the Eating Disorders Examination-Questionnaire assessing disordered eating constructs.

RESULTS

Results showed positive relationships between verbal (vWRA) and physical (pWRA) WRA and disordered eating behaviors and cognitions. Moreover, at higher levels of vWRA, Asian and multiracial individuals showed greater dietary restraint compared to White individuals. No other tested models were moderated by race/ethnicity.

CONCLUSION

WRA is positively associated with disordered eating behaviors and cognitions across racial/ethnic identities, and vWRA may be differentially related to increased dietary restraint in Asian and multiracial individuals compared to White individuals. Further research utilizing intersectional analyses (e.g., examining how this relationship varies according to the intersection of race/ethnicity, gender, and weight status) would help clarify this relationship.

Binge eating age of onset, frequency, and associated emotional distress among women aged 60 years and over

Emerging research indicates that binge eating is prevalent among older adult women. This study explored the characteristics of older women (aged 60+ years) with objective binge episodes (OBE) in later-life, including age of onset, distress, and frequency of OBE. Data consist of telephone clinical interviews conducted with individuals presenting for participation in a biomedical study of older women with OBE to establish inclusion criteria. Of 71 participants interviewed, 77.5% met DSM-5 criteria for OBE (≥1/week for ≥3 months); 33.3% reported OBE onset before age 40, 17.9% reported midlife onset (ages 40-55), and 48.7% reported late-life onset (56+). Regarding distress, older women with OBE in later-life reported themes of age-related self-blame surrounding eating, loss of control, and cognitive fixation on satiation. Among older women with OBE in later-life, onset in mid- to later-life may be relatively common. Furthermore, distress regarding OBEs was significant, highlighting the need for intervention research among this population.

Racial/ethnic differences in anorexia and bulimia diagnoses among U.S. college students

This study examined the prevalence of anorexia nervosa (AN) and bulimia nervosa (BN) diagnoses among college students from different racial/ethnic backgrounds. Utilizing archival data from the American College Health Association - National College Health Assessment II-C (ACHA-NCHA II-C), information from 426,425 college students collected between 2015 and 2019 was examined. Binary logistic regression analyses were conducted to determine the prevalence of AN and BN diagnoses among various racial and ethnic groups. The highest odds of AN diagnosis were observed among American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) students, with odds ranging from 2.143 (compared to White students) to 3.744 (compared to Black students). White students had higher odds of AN than Black (OR = 1.748), Hispanic/Latino (OR = 1.706), and Asian (OR = 1.531) students. Biracial/Multiracial students had significantly higher odds of AN than Black (OR = 1.653), Hispanic/Latino (OR = 1.616), and Asian (OR = 1.449) students. In terms of BN diagnoses, AI/AN/NH students had the highest odds compared to all other groups, ranging from 2.149 (compared to White students) to 2.899 (compared to Hispanic/Latino students). White students had higher odds of BN than Black (OR = 1.271) and Hispanic/Latino (OR = 1.350) students. Biracial/Multiracial students also had significantly higher odds of BN than Black (OR = 1.388) and Hispanic/Latino (OR = 1.474) students. Asian students had higher odds of BN than Black (OR = 1.252) and Hispanic/Latino (OR = 1.329) students. These findings demonstrate complex patterns of AN and BN diagnoses among different racial/ethnic groups. These results highlight the need for culturally sensitive prevention and treatment plans on college campuses.

Recruitment strategies to increase racial and ethnic diversity in anorexia nervosa clinical research

OBJECTIVE

Inclusion of underrepresented racial and ethnic groups in eating disorder (ED) research is a critical unmet need, but evidence-based recruitment strategies are lacking. We sought to determine whether methods we had implemented to increase recruitment of underrepresented racial and ethnic groups were successful in improving racial and ethnic diversity in a clinical trial in women with anorexia nervosa.

METHOD

We implemented new strategies for recruitment of underrepresented racial and ethnic groups in a clinical trial on bone health in women with anorexia nervosa, including leveraging social media, liberalizing language on advertisements to be more inclusive of women who are as yet undiagnosed with the disorder or feel stigmatized by its name, translating advertisements to Spanish, and engaging community health centers. We compared participants' race and ethnicity in this clinical trial versus two similar prior clinical trials.

RESULTS

The percent of non-White and Hispanic participants who have signed a consent form in our ongoing clinical trial (2021-2023) is higher versus two previous clinical trials on bone health in women with anorexia nervosa (2011-2019) with similar inclusion/exclusion criteria and endpoints [non-White: 11/38 (28.9%) vs. 11/188 (5.9%), Hispanic: 6/38 (15.8%) vs. 5/188 (2.7%), p ≤ 0.006]. There was no change in the percent of Black participants [0/38 (0%) vs. 1/188 (0.5%), p = 1.0].

DISCUSSION

Viewing clinical research recruitment through a diversity, equity, and inclusion lens can improve racial and ethnic diversity in ED research. Further research recruitment strategies are needed to be more inclusive of Black populations.

Inaccessibility of care and inequitable conceptions of suffering: a collective response to the construction of "terminal" anorexia nervosa

Informed by our lived experiences with eating disorders, our work providing direct support to communities underserved by existing healthcare structures, and our commitment to social justice, we are deeply troubled by several aspects of the proposed characteristics for "terminal" anorexia nervosa outlined by Gaudiani et al. in Journal of Eating Disorders (10:23, 2022). We have identified two substantial areas of concern in the proposed characteristics provided by Gaudiani et al. and the subsequent publication by Yager et al. (10:123, 2022). First, the original article and the subsequent publication fail to adequately address the widespread inaccessibility of eating disorder treatment, the lack of parameters for what constitutes "high quality care", and the prevalence of trauma experienced in treatment settings for those who do access treatment. Second, the characteristics proposed for "terminal" anorexia nervosa are constructed largely based on subjective and inconsistent valuations of suffering which build on and contribute to harmful and inaccurate eating disorder stereotypes. Overall, we believe these proposed characteristics in their current form stand to detract from, rather than assist, the ability of patients and providers to make informed, compassionate, and patient-centered decisions about safety and autonomy both for individuals with enduring eating disorders and for individuals with more recently diagnosed eating disorders.

The Clinical Phenotype of Binge Eating Disorder among Postmenopausal Women: A Pilot Study

Binge eating disorder (BED), a form of overnutrition, may impact healthy aging for postmenopausal women. In community samples, 12-26% of older women (ages 60+) engage in binge eating. In younger adults, BED is comorbid with physical and psychological morbidities. However, little is known regarding the clinical phenotype, including medical and psychiatric comorbidities, of BED in postmenopausal women. This pilot study sought to identify psychosomatic, cardiometabolic, body composition, and physical function characteristics of postmenopausal, older adult (age ≥60 years) women with BED. Participants (N = 21, ages 60-75) completed a battery of physical assessments and surveys assessing psychosomatic health. Overall, 62% of women reported BE onset during peri- or post-menopause. Rates of comorbid depression, anxiety, sleep problems, and a history of severe menopausal symptoms were high. Cardiometabolic health was poor, and 42.9% met the criteria for metabolic syndrome. Additionally, 71.4% met the BMI criteria for obesity, and 40% of this sample met the criteria for sarcopenic obesity. Almost half of the sample presented with at least one mobility limitation; 85.7% had poor endurance. Evidence suggests that BED is highly comorbid with other chronic health conditions and may complicate treatment of these conditions, warranting further investigation and increased attention from healthcare providers serving postmenopausal women.

Untreatable or unable to treat? Creating more effective and accessible treatment for long-standing and severe eating disorders

The evidence base for the treatment of severe eating disorders is limited. In addition to improving access to early intervention, there is a need to develop more effective treatments for complex presentations of eating disorders. For patients with long-standing and severe illnesses, particular difficulties might exist with their engagement with treatment and achieving treatment outcomes. Alarmingly, there is an emerging international discourse about a concept labelled as terminal anorexia and about the withdrawal of treatment for people with severe eating disorders, resulting in the death of patients, as a legitimate option. This concept has arisen in the context of vastly overstretched specialist services and insufficient research and funding for new treatments. This Personal View combines multiple perspectives from carers, patients, and mental health professionals based in the UK, highlighting how the risks of current service provision are best alleviated by increasing resources, capacity, and training, and not by a narrowing of the criteria according to which patients with eating disorders are offered the care and support they need.

Disordered eating symptoms as a function of perceived weight status and race: An intersectional examination

Disordered eating (DE) exhibited by individuals with intersecting marginalized identities may be less likely to be perceived as pathological compared to DE exhibited by individuals with non-marginalized identities. The present experiment tested the intersectional impact of weight status and race stimuli on responses to DE in a college sample. Undergraduate students (N = 193, M_age = 18.57, SD = 1.88, 71 % female) read a fictional account from a female target with DE who was described as "underweight," "average weight," or "overweight," and "White" or "Black." Participants completed an in-lab survey assessing detection of and responses to DE. Three 2 (race: Black, White) x 3 (weight status: underweight, average weight, overweight) ANCOVAs revealed a main effect of weight status. DE was more likely to be detected in "underweight" than "average" and "overweight" targets (p < .001). Participants encouraged weight loss for "average" and "overweight" targets compared to "underweight" targets (p < .001) and encouraged weight restoration for "underweight" targets compared to "average weight" and "overweight" targets (p < .001). No significant effects for target race or interaction between weight status and race emerged. These findings underscore the salience of weight status in shaping perceptions of DE.

Epidemiology of eating disorders among US adults

PURPOSE OF REVIEW

Public policy efforts for prevention of and intervention upon eating disorders is severely limited in the United States due to the paucity of population-based data. This review article summarizes findings regarding eating disorders based on the National Epidemiological Studies on Alcohol and Related Conditions, Third Wave. The studies reviewed provide the most recent epidemiological indicators of anorexia nervosa, bulimia nervosa, and binge-eating disorder (BED) in the United States and demonstrate the utility of population-based data for validating the generalizability of findings from clinical samples.

RECENT FINDINGS

Anorexia nervosa, bulimia nervosa, and BED are widely distributed across sociodemographic characteristics, with substantially elevated risks for a variety of serious psychiatric, medical, and functional impairments, including heighted suicidality over the lifespan. Sexual minorities and individuals with adverse childhood experiences may be particularly vulnerable. Yet, many adults with eating disorders do not seek help, particularly professional help. National Epidemiological Studies on Alcohol and Related Conditions, Third Wave studies also validated some important clinical observations (e.g., overvaluation of shape/weight and physical inactivity in BED, more severe anorexia nervosa with onset prior to 14 years old).

SUMMARY

More rigorous population-based studies are needed to further advocate for appropriate resources and policies for eating disorders in the United States.

Structural validity of the Eating Disorder Examination-Questionnaire: A systematic review

OBJECTIVE

The main aim was to perform a systematic literature review of studies investigating the factor structure of the Eating Disorder Examination-Questionnaire (EDE-Q), a widely used measure of eating pathology. Secondary aims were to summarize the quality of reporting of latent variable (factor) analyses in these studies and review support for different factor solutions.

METHOD

Literature was identified through Scopus, Medline, PsycInfo, and ProQuest databases published up to February 23, 2022 and outreach via an international listserv. All studies published in English reporting factor analysis of the EDE-Q were included with few restrictions. Sixty studies including 63,389 participants met inclusion criteria.

RESULTS

The originally proposed four-factor solution received little empirical support, although few alternative models have been robustly evaluated. Items assessing shape and weight concerns frequently coalesce in factor solutions, suggesting that these constructs are closely related. Investigations of brief versions of the EDE-Q have produced more consistent findings, suggesting that these measures, particularly a seven-item version, might be useful alternatives to the full version. Quality of studies was reasonable, with important methodological elements of factor analysis often reported.

DISCUSSION

The findings are of relevance to practitioners and researchers, suggesting that the "original" factor structure of the EDE-Q should be reconsidered and that use of a seven-item version is to be encouraged.

PUBLIC SIGNIFICANCE

Self-report questionnaires are widely used in the assessment of disordered eating. The current study found that there is little consensus about the structure of a common measure of eating psychopathology. There is more consistent support for a brief, seven-item, version assessing dietary restraint, body dissatisfaction, and overvaluation of weight and shape.

Gender Differences in Treatment Outcomes for Eating Disorders: A Case-Matched, Retrospective Pre–Post Comparison

Eating disorders (EDs) are increasingly emerging as a health risk in men, yet men remain underrepresented in ED research, including interventional trials. This underrepresentation of men may have facilitated the development of women-centered ED treatments that result in suboptimal outcomes for men. The present study retrospectively compared pre- vs. post-treatment outcomes between age-, diagnosis-, and length-of-treatment-matched samples of n = 200 men and n = 200 women with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), or Eating Disorder Not Otherwise Specified (EDNOS), treated in the same setting during the same period, and using the same measurements. Compared to women, men with AN showed marked improvements in weight gains during treatment as well as in ED-specific cognitions and general psychopathology. Likewise, men with BED showed marked weight loss during treatment compared to women with BED; ED-specific cognitions and general psychopathology outcomes were comparable in this case. For BN and EDNOS, weight, ED-specific cognitions, and general psychopathology outcomes remained largely comparable between men and women. Implications for treatments are discussed.