Effects of a dialectical behavior therapy-based skills group intervention for obese individuals: a Brazilian pilot study

Mindful eating questionnaire: Validation and reliability in Brazilian adults with type 2 diabetes mellitus

OBJECTIVE

The objective was to evaluate the psychometric properties of the Mindful Eating Questionnaire (MEQ) in Brazilian subjects with type 2 diabetes mellitus (T2DM) and validate a Brazilian version of the MEQ for adults with T2DM (MEQ-DM).

METHODOLOGY

Baseline data from the multicentre Nutritional Strategy for Glycaemic Control in Patients with Type 2 Diabetes Mellitus (NUGLIC) trial were used. Construct validity was assessed using exploratory factor analysis (EFA). The root mean square error of approximation (RMSEA), comparative fit index (CFI) and Tucker‒Lewis index (TLI) fit indices indicated the adequacy of the model. The reliability of the questionnaire was evaluated considering the different factor loadings. Criterion validity was tested by correlating the MEQ-DM with sociodemographic variables, body mass index (BMI) and physical activity levels.

RESULTS

A total of 370 participants were included, who were mostly female (60.8 %) and had a median age of 61 (54-67) years. The EFA results supported the two-factor structure of the 25-item MEQ-DM: disinhibition and awareness. The results of the fit indices (RMSEA = 0.04; CFI = 0.95 and TLI = 0.94) and composite reliability (disinhibition = 0.84 and awareness = 0.81) were consistent. The criterion validity analysis indicated a significant association between MEQ-DM scores and age, sex, civil status, education level, BMI and physical activity (p < 0.05).

CONCLUSION

When explored with Brazilian adults with T2DM, the MEQ-DM presented a factorial model with two dimensions: disinhibition and awareness. This model must be confirmed in future studies with Brazilians with T2DM.

Feasibility and Efficacy of Intensive Dialectical Behavior Therapy Skills Training in An Outpatient Setting for A Group of Patients with Extensive Care Needs - A Transdiagnostic Approach

PURPOSE

Dialectical behavior therapy (DBT) is a treatment originally developed för chronically suicidal adults. It is common to adapt it by using one specific component, the DBT skills training (DBT-ST) and apply it in a group therapy setting for a variety of mental disorders. The primary aim of the study was to explore whether patients with extended care needs would report improved mental health after participating in an intensive form of DBT-ST. The secondary aim was to explore whether the use of psychiatric inpatient care for the group would decrease.

METHODS

Thirty-seven participants completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), and visual analogue scale (VAS) at three time points: pre-intervention, post-intervention and at 6-month follow-up after intensive DBT-ST.

RESULTS

One-way ANOVA showed a significant effect for time on the CORE-OM: F (2,35) = 7.93, p = .001, η2 = 0.312 (large effect size). Post hoc tests indicated a significant difference between pre-intervention and post-intervention (p = .001) and between pre-intervention and follow-up (p = .01). A Friedman test indicated a statistically significant difference in the VAS scale scores across the three time points, with p-values between 0.00 and 0.05. There was no difference in psychiatric healthcare consumption.

CONCLUSION

These study results confirm to some extent the feasibility and effectiveness of the intensive DBT-ST in a transdiagnostic clinical setting. The participants had a positive outcome from the skills training program, but psychiatric healthcare consumption did not decrease.

An Open Trial Examining Dialectical Behavior Therapy Skills and Behavioral Weight Loss for Adults With Emotional Eating and Overweight/Obesity

Third-wave cognitive behavioral interventions for weight loss have shown promise. However, sparse data exists on the use of dialectical behavior therapy for weight loss. Adapted dialectical behavior therapy skills programs may be especially well suited for adults who engage in emotional eating and are seeking weight loss. Dialectical behavior therapy is skills-based, shares theoretical links to emotional eating, and is effective in treating binge eating. The current study examined the feasibility, acceptability, and preliminary efficacy of Live FREE: FReedom from Emotional Eating, a 16-session group-based intervention. A total of 87 individuals expressed interest in the program, and 39 adults with overweight/obesity (BMI ≥25) and elevated self-reported emotional eating were enrolled. Live FREE targeted emotional eating in the initial sessions 1-9, and sessions 10-16 focused primarily on behavioral weight loss skills while continuing to reinforce emotion regulation training. Assessments were administered at baseline, posttreatment, and 6-month follow up. Enrolled participants were primarily female (97.4%) and Caucasian (91.7%). Treatment retention was strong with participants attending an average of 14.3 sessions and 89.7% of participants completing the intervention. On average, participants lost 3.00 kg at posttreatment, which was maintained at follow-up. Intent-to-treat analyses showed improvements in key outcome variables (self-reported emotional eating, BMI, emotion regulation) over the course of the intervention. Combining dialectical behavior therapy skills with conventional behavioral weight loss techniques may be an effective intervention for adults with overweight/obesity who report elevated emotional eating.

A Narrative Review on Dialectical Behavior Therapy for Patients with Depressive Difficulties

Background:

Dialectical behavior therapy (DBT) is a type of cognitive behavioral therapy (CBT) that was earlier intended to treat only patients with borderline personality disorder (BPD), but researchers have found DBT to treat several psychological disorders, including depression.

Aim:

The article aims to review the clinical shreds of evidence regarding the use of DBT to treat depression.

Methods:

PubMed literature search was done by applying the year filter range, 2010 to 2021. Another filter applied was "Randomized controlled trial", so that the strength of evidence could be enhanced. The keywords used were "Dialectical Behavior Therapy" AND "Depression

Results:

33 articles were found, out of which only 20 relevant articles were reviewed. DBT was found to alleviate depressive symptoms associated with different psychological disorders like bipolar disorder and BPD but the number of studies that validated the afore-mentioned were less than those studies which showed that DBT had no significant effect on the patients with depressive difficulties. The long-term effect of DBT for treating depression is under a suspect, as studies showed DBT got ineffective during the follow-ups

Conclusion:

DBT shows benefits in depression but further studies are still required to validate this concretely as DBT did not show a significant effect when compared to its control counterparts. There is much need for future studies which can evaluate the long-term efficacy of DBT in depression is another challenging area because follow-up data did not favor DBT.

Depression and obesity among females, are sex specificities considered?

This study aimed to systematically review the relationship of obesity-depression in the female sex. We carried out a systematic search (PubMed, MEDLINE, Embase) to quantify the articles (controlled trials and randomized controlled trials) regarding obesity and depression on a female population or a mixed sample. Successively, we established whether the sex specificities were studied by the authors and if they reported on collecting data regarding factors that may contribute to the evolution of obesity and depression and that could be responsible for the greater susceptibility of females to those conditions. After applying the inclusion and exclusion criteria, we found a total of 20 articles with a female sample and 54 articles with a mixed sample. More than half of all articles (51.35%, n = 38) evaluated the relationship between depression and obesity, but only 20 (27.03%) evaluated this relationship among females; still, 80% of those (n = 16) presented supporting results. However, few articles considered confounding factors related to female hormones (12.16%, n = 9) and none of the articles focused on factors responsible for the binomial obesity-depression in the female sex. The resulting articles also supported that depression (and related impairments) influencing obesity (and related impairments) is a two-way road. This systematic review supports the concurrency of obesity-depression in females but also shows how sex specificities are ultimately under-investigated. Female sex specificity is not being actively considered when studying the binomial obesity-depression, even within a female sample. Future studies should focus on trying to understand how the female sex and normal hormonal variations influence these conditions.

Converging vulnerability factors for compulsive food and drug use

Highly palatable foods and substance of abuse have intersecting neurobiological, metabolic and behavioral effects relevant for understanding vulnerability to conditions related to food (e.g., obesity, binge eating disorder) and drug (e.g., substance use disorder) misuse. Here, we review data from animal models, clinical populations and epidemiological evidence in behavioral, genetic, pathophysiologic and therapeutic domains. Results suggest that consumption of highly palatable food and drugs of abuse both impact and conversely are regulated by metabolic hormones and metabolic status. Palatable foods high in fat and/or sugar can elicit adaptation in brain reward and withdrawal circuitry akin to substances of abuse. Intake of or withdrawal from palatable food can impact behavioral sensitivity to drugs of abuse and vice versa. A robust literature suggests common substrates and roles for negative reinforcement, negative affect, negative urgency, and impulse control deficits, with both highly palatable foods and substances of abuse. Candidate genetic risk loci shared by obesity and alcohol use disorders have been identified in molecules classically associated with both metabolic and motivational functions. Finally, certain drugs may have overlapping therapeutic potential to treat obesity, diabetes, binge-related eating disorders and substance use disorders. Taken together, data are consistent with the hypotheses that compulsive food and substance use share overlapping, interacting substrates at neurobiological and metabolic levels and that motivated behavior associated with feeding or substance use might constitute vulnerability factors for one another. This article is part of the special issue on 'Vulnerabilities to Substance Abuse'.

The moderating effects of mindful eating on the relationship between emotional functioning and eating styles in overweight and obese women

PURPOSE

The aim of the current study was to examine the moderating effect of mindful eating on the relationship between emotional functioning and eating styles in overweight and obese women.

METHODS

One hundred and eighty four overweight and obese adult women (BMI 30.12 ± 3.77 kg/m²) were assessed with the Difficulties in Emotion Regulation Scale, the Positive and Negative Affect Schedule, the Three Factor Eating Questionnaire and the Mindful Eating Scale.

RESULTS

Mindful eating significantly moderated several of the relationships between emotional functioning and eating styles. At all levels of mindful eating, emotion dysregulation and negative affect are both associated with greater emotional eating, but with stronger associations for high levels of mindful eating. For people low in mindful eating, both emotion dysregulation and negative affect are associated with lower restrictive eating, and neither of them are associated with uncontrolled eating. For people high in mindful eating, neither emotion dysregulation nor negative affect are associated with restrictive eating, and only negative affect is associated with greater uncontrolled eating.

CONCLUSION

When mindful eating techniques are included as part of an intervention for overweight or obese individuals, it is even more important that those interventions should also include techniques to reduce emotion dysregulation and negative affect.

LEVEL OF EVIDENCE

Level V, descriptive study.

Emotion regulation and healthy behaviors of the body energy balance in adults: A review of evidence

There is no document that analyzes the state of the art of scientific research published between 2013 and 2018 in relation to possible interdependence links between emotional regulation [ER] and healthy behaviors associated with Body Energy Balance [BEB] (physical activity, balanced diet and sleep hygiene). To achieve this purpose, an exploratory systematic review was conducted, whose search criteria were “emotion regulation”, “emotion dysregulation” connected with the Boolean operator “AND” to the keywords “sleep hygiene”, “eating behavior” and “physical activity”. Terms like “alexithymia”, “depression”, “stress”, “negative emotions”, and “rumination” were omitted. The methodological quality of the evidence was assessed with a patented rubric. After applying the analysis criteria, 35 articles were obtained, reporting theexistence of reciprocal associations and interactions between ER and at least one of the three behaviors associated with BEB were analyzed. It is concluded that, despite the importance of these behaviors in the vital maintenance of people and the clear impact that emotional regulation has on them, their research has not been sufficient, and more empirical studies in this regard in Latin America are needed.

Emotion regulation mediates relationships between perceived childhood invalidation, emotional reactivity, and emotional eating

Dialectical Behavior Therapy (DBT) is informed by the biosocial model which suggests that emotional sensitivity and childhood invalidation interact to influence emotion dysregulation, leading to behavioral disorders. Although adapted DBT interventions have resulted in improved emotional eating, little research has been conducted to examine whether key aspects of the biosocial model apply to emotional eating. Adults ( N = 258) were enrolled via Amazon’s Mechanical Turk. Three separate mediation analyses were performed using Hayes’ SPSS macro. Results showed that emotion regulation difficulties mediated the relationships between biosocial variables (i.e. perceived maternal and paternal invalidation and emotional reactivity) and emotional eating.

A systematic review and meta-analysis of dropout rates from dialectical behaviour therapy in randomized controlled trials

Dropout is an important factor that may compromise the validity of findings from randomized controlled trials (RCTs) of dialectical behaviour therapy (DBT). We conducted a targeted meta-analytic review of dropout from RCTs of DBT, with the aims of (1) calculating average rates of dropout from DBT; (2) investigating factors that moderate dropout; (3) examining whether dropout rates from DBT differ to control interventions; (4) synthesising reasons for dropout. Forty RCTs of DBT met full inclusion criteria. The weighted mean dropout rate was 28.0% (95% CI = 23.6, 32.9). Dropout rates were not related to target disorder, dropout definition, delivery format, therapist experience, and therapist adherence. Unexpectedly, dropout rates were significantly higher in trials that offered telephone coaching and utilized a therapist consultation team. DBT dropout rates did not significantly differ to dropout rates from control interventions. Few trials reported reasons for dropout, and there was little consistency in the reported reasons. Findings suggest that over one in four patients drop out from DBT in RCTs. This review highlights the urgency for future trials to explicitly report detail pertaining to patient dropout, as this may assist in the development of strategies designed to prevent future dropouts in RCTs of DBT.

Impact on mindfulness, emotion regulation, and emotional overeating of a DBT skills training group: a pilot study

PURPOSE

The current study investigated the impact of a modified Dialectical Behavior Therapy skills (DBT) training group for patients at a hospital outpatient weight management clinic. Emotional eating is a problematic strategy for managing unpleasant feelings that can have a deleterious impact on weight management. DBT addresses emotional dysregulation via incorporation of skills aimed at coping with unpleasant affect.

METHODS

This study examines outcomes for 18 patients who participated in a 12-week DBT skills building group. A pre-post design with 3-month follow-up investigated the impact of the group on emotional eating, psychological distress, emotion regulation, and mindfulness.

RESULTS

Four repeated measures ANOVAs were run to assess for changes related to life difficulties and functioning, emotional overeating, emotion regulation, and mindfulness. Fisher's LSD tests assessed for linear and quadratic trends. Improvements in mindfulness, emotion regulation, and emotional overeating were found; these were maintained at follow-up.

CONCLUSIONS

This study demonstrated the utility of a group-based intervention aimed at improving emotion regulation and mindfulness skills among weight management patients. Further study is needed to determine whether improvements in the constructs studied in this research would translate to improved weight management outcomes and in determining the pathway for improvements.

LEVEL OF EVIDENCE

Level IV, multiple time series with intervention.

Implementing a condensed dialectical behavior therapy skills group for binge-eating behaviors in adolescents

PURPOSE

Subthreshold binge-eating disorder (BED) symptoms can lead to additive physical and psychological health challenges and may put youth at risk for developing BED during the early adulthood. We examined the implementation of a condensed dialectical behavior therapy (DBT) skills intervention for subthreshold binge-eating behaviors in adolescents.

METHODS

Fifteen 14-18 years old participated in a 10-week DBT skills group, which experientially introduced mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills in the context of emotionally driven overeating behaviors. Adolescents and caregivers completed measures of emotional eating and binge-eating behaviors at baseline and post-intervention, including the Eating Disorder Examination Questionnaire and Emotional Eating Scale for Children and Adolescents. Eleven participants were retained at 3-month follow-up.

RESULTS

Descriptive statistics were compared at all three time points. Results suggested a reduction in emotional eating and binge-eating behaviors based on youth self-report and caregiver report. Acceptability ratings of the treatment were high among participants completing the intervention.

CONCLUSIONS

Using DBT skills to target emotionally driven overeating behaviors in youth may be useful in the treatment of subthreshold BED behaviors and potentially deter future development of full-criteria BED.

LEVEL OF EVIDENCE

Level IV, uncontrolled pilot trial.

Problematic and adaptive eating in people with obesity after a DBT-based skills training intervention: 3- and 8-month follow-up and mediation analysis

Background

Dialectical behavior therapy conceptualizes problematic behaviors as attempts to regulate emotions that occur when the individual lacks effective skills with which to manage his or her emotions and cope with distress. Problematic eating behaviors, e.g., binge and emotional eating, may serve to alleviate aversive emotional states, being highly associated with overweight and obesity. Dialectical behavior therapy skills training has been proven effective in reducing binge eating in several clinical studies. However, few studies reveal the effects of DBT on adaptive eating behaviors or the stability of outcomes.

Objectives

This study aimed to test the effect of a brief DBT-based skills training intervention, and the stability of outcomes at 3- and 8-month follow-ups.

Methods

Self-report measures of binge eating, emotional eating, intuitive eating, and mindful eating were taken on 5 timepoints before and after a 10-session DBT skills training intervention (2 baseline measures, 1 post-test, and 2 follow-ups). Data were analyzed using a mixed-model intention-to-treat approach and mediation analysis was conducted with path analysis.

Results

After the intervention, intuitive eating and mindful eating scores were significantly higher than before the intervention, while emotional eating and binge eating scores were lower. The results remained stable during the follow-up period, with minor fluctuations and small trends towards returning to baseline values for binge eating and emotional eating. Mindful eating partially mediated the improvements in all outcomes.

Limitations

Given that results are entirely based on self-report measures and that some instruments showed poor reliability, in addition to the high attrition rates, the results should be interpreted as preliminary.

Conclusions

The results provide evidence that a brief DBT intervention is effective not only in reducing problematic eating but also in increasing adaptive eating, achieving reasonably stable results. Also, the mediation analysis results support the hypothesis that mindful eating partially explains the effects of the intervention on binge and emotional eating. Future research should address the limitations of this study by investigating a more diverse sample, triangulating different measurement strategies, and including other putative mediators.