Sleep and eating disorders: current research and future directions

The Integration of Sleep Research Into Eating Disorders Research: Recommendations and Best Practices

OBJECTIVE

Sleep disturbance is common among individuals with eating disorders (EDs), with approximately 50% of patients with EDs reporting sleep disturbance. Sleep problems may promote, exacerbate, or maintain ED symptoms through a variety of hypothesized mechanisms, such as impaired executive function, increased negative affect, and disruptions to appetitive rhythms. Although research investigating the role of sleep in EDs is growing, the current literature suffers from methodological limitations and inconsistencies, which reduce our ability to translate findings to improve clinical practice. The purpose of this forum is to propose a coordinated approach to more seamlessly integrate sleep research into ED research with particular emphasis on best practices in the definition and assessment of sleep characteristics.

METHODS

In this article, we will describe the current status of sleep-related research and relevant gaps within ED research practices, define key sleep characteristics, and review common assessment strategies for these sleep characteristics. Throughout the forum, we also discuss study design considerations and recommendations for future research aiming to integrate sleep research into ED research.

RESULTS/DISCUSSION

Given the potential role of sleep in ED maintenance and treatment, it is important to build upon preliminary findings using a rigorous and systematic approach. Moving forward as a field necessitates a common lens through which future research on sleep and EDs may be conducted, communicated, and evaluated.

Engagement in binge eating and fasting associated with poorer sleep quality in an online sample of adults

OBJECTIVES

Both disordered eating and disturbed sleep represent significant threats to mental health. Accumulating evidence suggests that disordered eating behaviors and sleep problems co-occur. A majority of current research, however, has focused on these behaviors as components of eating disorder diagnoses, rather than investigating the independent associations of transdiagnostic disordered eating behaviors and sleep. The present study sought to examine fasting, binge eating, self-induced vomiting, laxative or diuretic misuse, and driven exercise as predictors of sleep quality complaints.

METHOD

An online sample of 648 U.S. adults completed the Eating Disorder Examination - Questionnaire, the Pittsburgh Sleep Quality Index, and the Patient Health Care Questionnaire-2 as part of a larger parent study.

RESULTS

Results of a hierarchical linear regression revealed that, collectively, disordered eating behaviors predicted worse sleep quality [R2 = 0.30, F(7, 640) = 31.21, p < .001], and that both binge eating and fasting, but not other compensatory behaviors, accounted for unique variance in sleep quality after controlling for BMI and depression.

CONCLUSIONS

Overall, findings suggest that transdiagnostic disordered eating behaviors are associated with sleep quality complaints. Improved understanding of the specific relationships between individual eating behaviors and sleep characteristics can help refine the identification of individuals at high risk for sleep disturbance and address the potential reciprocal influence of sleep quality on disordered eating behaviors.

Eating Disorders and Sleep Disturbance as Determinants of Metabolic Control in Adolescents with Type 1 Diabetes

This cross-sectional study examined the effect of sleep disturbance and eating disorders on metabolic control in adolescents with Type 1 Diabetes. The study was conducted with adolescents with T1DM treated at a university hospital in Turkey between October 2023 and January 2024. The study sample consisted of 120 adolescents with T1DM between the ages of 10-18. Data were collected online using the Adolescent Information Form, Dutch Eating Behavior Questionnaire (DEBQ), and DSM-5 Sleep Disorder Scale (SDS). Mean, percentage, and regression analyses were used to analyze the data. Ethics committee, institutional permission and written permission from the adolescents with Type 1 Diabetes and their parents were obtained for the study. In the current study, sleep disturbance and eating disorders explained 38.5% and 40.2% of HbA1c, respectively, and were found to have a significant effect (respectively: F = 73.737, p ≤ .001; F = 19.353, p ≤ .001). This study provides evidence that eating disorders and sleep disturbance explain approximately half of HbA1c. The results of the study revealed that sleep disturbance and eating disorders were significant predictors of metabolic control in adolescents with type 1 diabetes.

Characterising illness stages and recovery trajectories of eating disorders in young people via remote measurement technology (STORY): a multi-centre prospective cohort study protocol

BACKGROUND

Eating disorders (EDs) are serious, often chronic, conditions associated with pronounced morbidity, mortality, and dysfunction increasingly affecting young people worldwide. Illness progression, stages and recovery trajectories of EDs are still poorly characterised. The STORY study dynamically and longitudinally assesses young people with different EDs (restricting; bingeing/bulimic presentations) and illness durations (earlier; later stages) compared to healthy controls. Remote measurement technology (RMT) with active and passive sensing is used to advance understanding of the heterogeneity of earlier and more progressed clinical presentations and predictors of recovery or relapse.

METHODS

STORY follows 720 young people aged 16-25 with EDs and 120 healthy controls for 12 months. Online self-report questionnaires regularly assess ED symptoms, psychiatric comorbidities, quality of life, and socioeconomic environment. Additional ongoing monitoring using multi-parametric RMT via smartphones and wearable smart rings ('Ōura ring') unobtrusively measures individuals' daily behaviour and physiology (e.g., Bluetooth connections, sleep, autonomic arousal). A subgroup of participants completes additional in-person cognitive and neuroimaging assessments at study-baseline and after 12 months.

DISCUSSION

By leveraging these large-scale longitudinal data from participants across ED diagnoses and illness durations, the STORY study seeks to elucidate potential biopsychosocial predictors of outcome, their interplay with developmental and socioemotional changes, and barriers and facilitators of recovery. STORY holds the promise of providing actionable findings that can be translated into clinical practice by informing the development of both early intervention and personalised treatment that is tailored to illness stage and individual circumstances, ultimately disrupting the long-term burden of EDs on individuals and their families.

How Dietary Choices and Nutritional Knowledge Relate to Eating Disorders and Body Esteem of Medical Students? A Single-Center Cross-Sectional Study

Eating disorders and body image concerns are increasingly prevalent issues among young individuals, with medical students being particularly vulnerable due to heightened stress levels. This study enrolled 879 medical students to investigate these concerns. The KomPAN questionnaire was utilized to assess dietary habits and knowledge, the Body Esteem Scale (BES) to evaluate body satisfaction, and The Eating Attitudes Test (EAT-26) to identify eating disorders. A higher level of nutritional knowledge was found to be statistically significantly associated with attempts at excessive calorie restriction among women (β = 0.0864) and negatively among men (β = -0.2039). Moreover, it was negatively associated with self-control of food intake only among men (β = -0.2060). Furthermore, a higher BMI was associated with attempts of excessive calorie restriction in both women and men (β = 0.1052 and β = 0.1656, respectively) and negatively with self-control of food intake (β = -0.0813 and β = -0.1453, respectively). A higher BMI was associated with poorer body esteem across all variables in both genders, except for upper body strength among men. Nutritional knowledge did not correspond with any of these variables, while dietary quality was positively associated with physical condition in women and with physical condition, physical attractiveness, and upper body strength in men. Our study findings suggest that dietary interventions could be improved by considering gender-based behavioral differences and focusing on portion control for individuals with a higher BMI. Caution is warranted in extrapolating the results to the general population due to the specific nature of the study population.

Dysphoric mood may explain the relation between sleep reactivity and binge eating but not purging

Objective: This study investigated whether sleep reactivity (i.e., a propensity to experience sleep disturbances when stressed) relates to eating disorder behavioral symptoms indirectly through dysphoric mood in a sample of college students. Participants: One hundred and ninety-eight college students (51.5% female). Methods: Participants completed self-report measures of dysphoric mood, eating disorder behavioral symptoms, and sleep reactivity. Results: Higher sleep reactivity was associated with greater binge-eating symptoms indirectly through higher dysphoric mood. Higher sleep reactivity was associated with greater purging symptoms; however, this association was not explained by dysphoric mood. Conclusions: Findings support the relevance of sleep reactivity to binge eating and purging and suggest that sleep reactivity relates to binge-eating symptoms indirectly through dysphoric mood. If replicated in prospective data, targeting stress-induced sleep and mood disturbances in college students may reduce risk for binge eating.

Sleep is the best medicine: assessing sleep, disordered eating, and weight-related functioning

Sleep quality is linked to disordered eating, obesity, depression, and weight-related functioning. Most research, however, has focused on clinical populations. The current study investigated relationships between sleep quality, disordered eating, and patterns of functioning in a community sample to better understand relationships among modifiable health behaviors. Participants (N = 648) recruited from Amazon Mechanical Turk completed assessments of eating, depression, weight-related functioning, and sleep. Self-reported height and weight were used to calculate body mass index (M = 27.3, SD = 6.9). Participants were on average 37.6 years (SD = 12.3), primarily female (65.4%), and White, not Hispanic (72.7%). Over half of participants endorsed poor sleep quality, and average sleep scores were above the clinical cutoff for poor sleep quality. Sleep scores were significantly positively correlated with disordered eating, depression, and weight-related functioning, even after adjusting for age, body mass index, and sex. Multivariate regression models predicting weight-related functioning and depression showed that both sleep quality and disordered eating independently predicted depression. Sleep quality did not independently predict weight-related functioning; however, disordered eating did. To the best of our knowledge, this is the first study to assess sleep behaviors, disordered eating, and weight-related functioning in a community sample of weight diverse participants. Results indicate that most participants endorsed poor sleep quality, which was associated with disordered eating patterns, including binge eating and poorer weight-related functioning, even after controlling for body mass index, highlighting that this relationship exists across the weight spectrum. These results speak to the importance of health behavior assessment and intervention within nonclinical samples.Level of evidence Level III: evidence obtained from well-designed cohort or case-control analytic studies.

Enhanced functional connectivity in the reward circuitry in healthy adults with weekend catch-up sleep

We aimed to identify structural and functional changes in healthy adults with catch-up sleep (CUS), we applied seed-based functional connectivity (FC) analysis using resting-state functional magnetic resonance imaging (MRI). We hypothesized that deficits in reward processing could be a fundamental mechanism underlying the motivation of taking CUS. Then, 55 healthy adults voluntarily (34 with CUS and 21 without CUS) participated in this study. Voxel-based morphometry was performed to explore region of gray matter volume (GMV) difference between CUS and non-CUS groups. Between-group comparison of FC was then carried out using resting-state functional MRI analysis seeding at the region of volume difference. Moreover, the region of volume difference and the strength of FC were correlated with scores of questionnaires for reward-seeking behavior and clinical variables. CUS group had a higher reward-seeking tendency, and increased GMV in the bilateral nucleus accumbens and right superior frontal gyrus relative to non-CUS group. FC analysis seeding at the bilateral accumbens revealed increases of FC in the bilateral medial prefrontal cortex in CUS group compared to non-CUS group. The questionnaire scores reflecting the reward-seeking tendency were correlated with the FC strength between bilateral accumbens and medial prefrontal cortex. Our results indicate that CUS is associated with reward-seeking tendency and increased GMV and FC in regions responsible for reward network. Our findings suggest that enhanced reward network could be the crucial mechanism underlying taking CUS and might be implicated in the detrimental effects of circadian misalignment.

Sleep Profiles in Eating Disorders: A Scientometric Study on 50 Years of Clinical Research

Sleep and diet are essential for maintaining physical and mental health. These two factors are closely intertwined and affect each other in both timing and quality. Eating disorders, including anorexia nervosa and bulimia nervosa, are often accompanied by different sleep problems. In modern society, an increasing number of studies are being conducted on the relationship between eating disorders and sleep. To gain a more comprehensive understanding of this field and highlight influential papers as well as the main research domains in this area, a scientometric approach was used to review 727 publications from 1971 to 2023. All documents were retrieved from Scopus through the following string "TITLE-ABS (("sleep" OR "insomnia") AND ("anorexia nervosa" OR "bulimia nervosa" OR "binge eating" OR "eating disorder*") AND NOT "obes*") AND (LIMIT-TO (LANGUAGE, "English"))". A document co-citation analysis was applied to map the relationship between relevant articles and their cited references as well as the gaps in the literature. Nine publications on sleep and eating disorders were frequently cited, with an article by Vetrugno and colleagues on nocturnal eating being the most impactful in the network. The results also indicated a total of seven major thematic research clusters. The qualitative inspection of clusters strongly highlights the reciprocal influence of disordered eating and sleeping patterns. Researchers have modelled this reciprocal influence by taking into account the role played by pharmacological (e.g., zolpidem, topiramate), hormonal (e.g., ghrelin), and psychological (e.g., anxiety, depression) factors, pharmacological triggers, and treatments for eating disorders and sleep problems. The use of scientometric perspectives provides valuable insights into the field related to sleep and eating disorders, which can guide future research directions and foster a more comprehensive understanding of this important area.

Association between eating disorders and sleep duration among college students: Findings from the National Healthy Minds study

OBJECTIVES

Explore associations between eating disorders (EDs) and sleep duration and the impact of depression symptoms (DSs) in American college students.

PARTICIPANTS

College students from 2018 to 2019 Healthy Minds Study.

METHODS

Multivariate logistic regression evaluated associations between EDs (bulimia, anorexia, binge eating [BED]) and sleep duration. Stratified analyses assessed effect modification by DSs and gender.

RESULTS

Students reporting any eating disorder had no greater risk of not recommended sleep duration during weekdays compared to those with no eating disorder history (Adjusted OR = 0.99, 95% CI: 0.89-1.13). However, subjects reporting BED were at greater risk of deficient sleep during weekends compared to those with no EDs (Adjusted OR = 1.26, 95% CI: 1.01-1.58). This association was not impacted by DSs. However, all EDs were associated with not-recommended sleep duration among those who identified as other gender identity in comparison to those with no EDs.

CONCLUSION

Health educators should monitor academic performance in students with EDs for adequate sleep duration.

Fear of COVID-19, insomnia, and eating disorder symptoms among Iranian college students

Objective

Eating disorders (EDs), fear of COVID-19, and insomnia have all increased during the COVID-19 pandemic in Western societies. Additionally, fear of COVID-19 and sleep disturbances relate to ED symptoms in Western societies. However, it is unknown whether fear of COVID-19 and insomnia relate to ED symptoms in non-Western countries, such as Iran. Thus, this study examined the relation between fear of COVID-19, insomnia, and ED symptoms among Iranian college students. Specifically, we hypothesized that insomnia and fear of COVID-19 would each uniquely relate to ED symptoms and the interaction between insomnia and fear of COVID-19 would also associate with increased ED symptoms.

Method

College students (N =1,043) filled out measures assessing fear of COVID-19, insomnia, and ED symptoms. We ran moderation analyses using linear regression for global ED symptoms and negative binomial regressions for binge eating and purging.

Results

Fear of COVID-19 and insomnia had unique effects on global ED symptoms and binge eating. Insomnia, but not fear of COVID-19, had a unique effect on purging. No significant interaction effect was found.

Discussion

This study was the first to examine the association between fear of COVID-19 and insomnia on ED symptoms in Iran. Fear of COVID-19 and insomnia should be incorporated into novel assessments and treatments for EDs.

Exploring the Relationship between Disordered Sleep and Mood in Male Anorexia Nervosa: An Actigraphy Study

Eating disorders (EDs), including anorexia nervosa (AN), are severe psychological disorders that affect individuals' eating behaviours and body perception. Previous research has shown that people with EDs often report poorer sleep. Some literature has suggested that it is mood dysregulation that mediates the link between EDs and sleep. However, the majority of previous studies only focused on females, while male ED patients have been overlooked. Therefore, the present study aimed to investigate the relationships between EDs, mood, and sleep among male ED patients. Using a mixture of actigraphy recordings and self-reported questionnaires, the current study analysed a total 33 adult male participants diagnosed with AN. The participants first wore an actigraphy device for seven continuous days, following which their ED severity and mood were assessed by the Eating Disorder Examination Questionnaire (EDE-Q) and Depression Anxiety Stress Scale (DASS), respectively. The descriptive actigraphy results suggested that, similar to females, males with AN also showed disturbed sleep, including insomnia, sleep fragmentation, low sleep efficiency, and increased napping sessions. However, when ED severity was correlated against actigraphy data and mood, no significant relationships were found between them. Thus, it was suggested that future studies may investigate discrete ED symptoms instead of global ED severity interacting with sleep and mood. Overall, this study represents an initial step in the investigation of EDs and sleep and mood dysregulation among an under-represented sample.

The Role of Leptin in Rodent and Human Sleep: A Transdiagnostic Approach with a Particular Focus on Anorexia Nervosa

This narrative review addressed to both clinicians and researchers aims to assess the role of hypoleptinemia in disordered sleep with a particular focus on patients with anorexia nervosa (AN). After introducing circadian rhythms and the regulation of circulating leptin, we summarize the literature on disordered sleep in patients with AN and in fasting subjects in general. We highlight novel single-case reports of substantially improved sleep within days after initiation of off-label metreleptin treatment. These beneficial effects are set in relationship to current knowledge of disordered sleep in animal models of an impaired leptin signaling. Specifically, both absolute and relative hypoleptinemia play a major role in animal models for insomnia, obstructive sleep apnea and obesity hypoventilation syndrome. We pinpoint future research required to complement our understanding of the role of leptin in sleep in patients with acute AN. Moreover, within the section clinical applications we speculate that human recombinant leptin may be useful for the treatment of treatment-resistant sleep-wake disorders, which are associated with (relative) hypoleptinemia. Overall, we stress the role of the hormone leptin in sleep.

Prevalence of Disordered Eating and Its Associated Factors From a Socioecological Approach Among a Sample of Spanish Adolescents: The EHDLA Study

Objectives: The aim of this study was twofold: a) to establish the prevalence of adolescents with disordered eating and b) to determine the factors associated with this prevalence in a sample of Spanish adolescents from the Valle de Ricote (Region of Murcia, Spain).

Methods: This cross-sectional study analyzed data from 730 adolescents (56.2% girls) from the EHDLA study. To determine the prevalence of disordered eating, the Sick, Control, One stone, Fat, Food (SCOFF) questionnaire was used. A socioecological approach was used to identify individual-, interpersonal-, or organizational-level factors associated with disordered eating.

Results: The prevalence of disordered eating was 30.1%. This condition was associated with female sex (odds ratio [OR] = 2.60; 95% confidence interval [CI], 1.81–3.73), immigrant status (OR = 2.22; 95% CI, 1.51–3.25), or excess weight (OR = 2.74; 95% CI, 1.93–3.89). Furthermore, for each additional hour slept, lower odds of having disordered eating were found (OR = 0.81; 95% CI, 0.67–0.98).

Discussion: Almost one-third of the sample of Spanish adolescents analyzed reported disordered eating. Female sex, immigrant status and excess weight are individual aspects that seem to be related to disordered eating among Spanish adolescents.

Unsound sleep, wound-up mind: a longitudinal examination of acute suicidal affective disturbance features among an eating disorder sample

BACKGROUND

Suicide is one of the most commonly reported causes of death in individuals with eating disorders. However, the mechanisms underlying the suicide and disordered eating link are largely unknown, and current assessments are still unable to accurately predict future suicidal thoughts and behaviors. The purpose of this study is to test the utility of two promising proximal risk factors, sleep quality and agitation, in predicting suicidal ideation in a sample of individuals with elevated suicidal thoughts and behaviors, namely those with eating disorders.

METHODS

Women (N = 97) receiving treatment at an eating disorder treatment center completed weekly questionnaires assessing suicidal ideation, agitation, and sleep. General linear mixed models examined whether agitation and/or sleep quality were concurrently or prospectively associated with suicidal ideation across 12 weeks of treatment.

RESULTS

There was a significant interaction between within-person agitation and sleep quality on suicidal ideation [B(s.e.) = -0.02(0.01), p < 0.05], such that on weeks when an individual experienced both higher than their average agitation and lower than their average sleep quality, they also experienced their highest levels of suicidal ideation. However, neither agitation nor sleep quality prospectively predicted suicidal ideation.

CONCLUSIONS

This study was the first to examine dynamic associations between interpersonal constructs and suicidal ideation in individuals with eating disorders. Results suggest that ongoing assessment for overarousal symptoms, such as agitation and poor sleep quality, in individuals with eating disorders may be warranted in order to manage suicidal ideation among this vulnerable population.

Sleep and emotionality in adolescents with anorexia nervosa during the Covid-19 pandemic

PURPOSE

The recent Covid-19 pandemic and its lockdown measures raised concerns about people's mental health, leading to an increased interest in identifying vulnerable groups especially at risk for mental distress. This cross-sectional study investigated the impact of this unprecedented situation on sleeping patterns and emotionality in adolescents with anorexia nervosa (AN).

METHODS

Variations in sleeping patterns and emotionality of two groups of adolescents with AN, assessed before (N = 50) and during (N = 51) the Covid-19 lockdown were analysed. We further investigated these variations over time, considering the two lockdown periods in France.

RESULTS

Adolescents self-reported significantly more sleep difficulties and lower rates of positive emotions during lockdown, compared to those evaluated before it. Furthermore, present findings overall suggest that as the lockdown progresses, adolescents with AN show an increased deterioration of sleep quality, as indicated by greater insomnia severity levels. They also show a significant decrease in the subjective experience of positive emotionality, in particular in feelings of tenderness.

CONCLUSIONS

These sleep and emotionality alterations may have amplified the severity and the incidence of AN in adolescents during the Covid-19 pandemic. These features may therefore represent therapeutic targets to optimise care of adolescents with AN. This is particularly urgent, considering kinetics of the deterioration. Tools such as those provided by cognitive behavioural therapy for insomnia and by the positive psychology framework seem appropriate to guide clinicians in this context.

LEVEL OF EVIDENCE

Level V, descriptive study (evaluation data retrospectively studied).

Exploring the Impact of COVID-19 on Individuals with Eating Disorders in Saudi Arabia: A Thematic Analysis

Food and sleep are critical for human survival. However, for individuals with eating disorders, they face two critical disruptions in terms of abnormal feeding patterns as well as poor sleep. These difficulties are exacerbated as a result of the recent coronavirus pandemic, which caused drastic changes in daily life schedules and living arrangements. The current study therefore aims to explore, through qualitative means, how individuals with eating disorders are affected during the subsequent lockdowns, with a particular emphasis on the pandemic's impact on their sleep in Saudi Arabia. Two groups of participants were recruited: participants with eating disorders and healthy controls. Based on thematic analysis of focus group discussion data, it was found that both types of participants experienced poorer sleep and poorer mental health. Participants with eating disorders too showed a deterioration of their symptoms. However, healthy participants tended to show greater levels of recovery and coping. Based on the study findings, recommendations for future studies are made.

Dual Role of Fibroblast Growth Factor Pathways in Sleep Regulation

Sleep plays an important function in neuro-immuno-endocrine homeostasis. Sleep disorders have been associated with an increased risk of metabolic and cognitive impairments. Among different factors that have an effect on sleep metabolism, a growing body of literature has investigated growth factors in the course of sleep quality and disorders. A good example of growth factors is fibroblast growth factors (FGFs), which are a large family of polypeptide growth factors. Evidence has shown that FGFs are involved in the modulation of sleep-wake behavior by their receptor subtypes and ligands, e.g., FFG1 plays an important role in the quality of sleep through somnogenic effects, while the high level of FGF23 is associated with secondary disorders in shift workers. Therefore, a controversial effect of FGFs can be seen in the course of sleep in physiologic and pathologic conditions. Further investigation on this topic would help us to understand the role of FGFs in sleep disorders as a therapeutic option and biomarker.

An examination of daily sleep characteristics and subsequent eating disorder behavior among individuals with binge-spectrum eating disorders

INTRODUCTION

Specific characteristics of sleep (e.g., duration, quality, and fatigue) are positively associated with (ED) behaviors, specifically binge eating (BE) potentially through decreased self-regulation and increased appetite. However, prior work has been largely cross-sectional and has not examined temporal relationships between sleep characteristics and next-day ED behaviors. Thus, the present study examined daily relationships between sleep and ED behaviors among individuals with binge-spectrum EDs.

METHOD

Participants (N = 96) completed 7 daily ecological momentary assessment (EMA) surveys over 7-14 days; morning surveys assessed sleep characteristics and 6 randomly timed surveys each day captured ED behaviors. Analyses examined within-subject and between-subject effects of sleep quality, duration, and fatigue on BE, compensatory purging behaviors, and maladaptive exercise.

RESULTS

Within-subject sleep quality was significantly negatively associated with engagement in maladaptive exercise later that day. Additionally, between-subject sleep duration was significantly negatively associated with engagement in compensatory purging behaviors.

DISCUSSION

Within- and between-subjects associations between sleep quality and duration and compensatory behavior engagement indicate that sleep plays an important role in ED behaviors. Future research should incorporate sensor-based measurement of sleep and examine how specific facets of sleep impact BE and treatment response.

LEVEL OF EVIDENCE

Level II: Evidence obtained from controlled trial without randomization.

Benefits of Exercise in Multidisciplinary Treatment of Binge Eating Disorder in Adolescents with Obesity

Obesity in childhood and adolescence represents a serious health problem worldwide. Similarly, eating disorders (EDs) are complex diseases that affect adolescents with an increasing prevalence and are an alarming health concern to both physical and mental health. Traditionally, obesity and EDs, particularly binge eating disorder (BED), have been considered separate conditions, but there is emerging evidence such as etiology, comorbidities, risk factors, psychosocial impairment, and prevention approaches, highlighting important overlaps among these conditions. In youth, the two conditions share risk factors and consequences at both the physical and psychological levels, requiring special care. Exercise, useful as strategy to prevent and treat overweight conditions, may have beneficial effects on BED symptoms, suggesting that it may be considered as one of the key factors in the treatment of individuals affected by obesity with BED. The purpose of this narrative review is to examine the bidirectional impact of obesity and BED in adolescents, in terms of risk factors, etiology and comorbid conditions. Specifically, we focused on the benefits of physical activity (PA) in the multidisciplinary treatment of subjects affected by obesity with BED. Even though additional research is needed to reach conclusions about the role of exercise in the treatment of obesity and comorbid BED, especially in adolescents, promising results have already suggested that closely monitored exercise is safe and, paired with cognitive behavioral therapy, may provide multiple benefits on both the physical and psychological levels. Tailored and integrated treatments for weight management and eating disorders are important to promptly and effectively treat obese subjects that have BED.

Sleep and Avoidant Restrictive Food Intake Disorder (ARFID): Correlation With Psychopathology, Gender, and Academic Performance

Objective

No studies have investigated sleep disturbance in avoidant/restrictive food intake disorder (ARFID). We examined sleep disturbance in ARFID and its association with eating problems, body mass index (BMI), gender, internalizing and externalizing symptoms, cognitive performance, and academic difficulties.

Methods

Data from 71 ARFID patients from our partial hospitalization program (PHP) for children and adolescents were examined. Sleep data were extracted from measures administered at admission including Achenbach Child Behavior Checklist (CBCL), Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS). Correlational analyses were conducted to evaluate the convergent validity of parent-reported and participant-reported sleep problems. Association with the severity of eating problems, BMI, percentage of median body weight (% MBW), age, gender, psychotropic medication, psychopathology, and academic difficulties was examined using analysis of variance (ANOVA) and Pearson’s correlation. 

Results

Fifty-two percent of parents and 74% of participants reported two or more sleep symptoms. Trouble sleeping was reported by 46.48% and nightmares by 35.21% of parents. Parent-reported trouble sleeping highly correlated with internalizing disorders. Parent-reported trouble sleeping and participant-reported difficulty sleeping positively correlated with attention and attention-deficit/hyperactivity disorder (ADHD) problems. Parent-reported less sleep and feeling tired correlated with sluggish cognitive tempo, while walking/talking in sleep negatively correlated with school performance. Gender differences were noted in parent-reported sleep problems. Sleep disturbances were not associated with lower BMI or median body weight at intake. Parent-reported talking/walking in sleep and participant-reported bad dreams and bedtime worries positively correlated with Children's Eating Attitudes Test (ChEAT) scores at intake and discharge.

Discussion

Our results provide compelling evidence to screen for sleep disturbance in ARFID patients regardless of median body weight and BMI. Exploration of sleep disturbances in ARFID using objective measures is warranted.

Subjective sleep disorders and daytime sleepiness in patients with restrictive type anorexia nervosa and effects on quality of life: a case-control study

To evaluate sleep disorders and daytime drowsiness in a cohort of patients affected by anorexia nervosa and their impact on health-related quality of life. We evaluated patients affected by restricting-type of anorexia nervosa (AN-R) and healthy controls by the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale, Beck Depression Index. We also used the Short-Form Health Survey (SF-36) questionnaire to assess the quality of life in both AN-R and controls. Twenty-eight out of 34 AN-R patients (82.3%) in contrast with ten out of 34 healthy subjects (29.4%) had a pathological PSQI score compared to HC (p < 0.0001). The overall PSQI score (p < 0.001), sleep quality (p < 0.001), sleep duration (p = 0.02), sleep efficiency (p = 0.002), sleep disturbances (p = 0.03) and daytime dysfunction (p = 0.004) were significantly higher in AN-R than in controls. SF36 showed significantly reduced scores of standardized physical components (p = 0.01) and standardized mental components (p < 0.001), physical function (p < 0.001), physical role (p < 0.001) and general health (p < 0.001), vitality (p < 0.001), social functioning (p  < 0.001) emotional role (p = 0.001) and mental health (p < 0.001) in AN-R. We found a significant correlation between the PSQI score and both the physical role (r = - 0.35, p = 0.03) and level of education (r = 0.38, p = 0.02). Our data showed reduced overall sleep quality without excessive daytime sleepiness in AN-R. Sleep quality correlated significantly with quality of life (physical role) and level of education.

Eating Disorders and Posttraumatic Stress Disorder: A Network Analysis of the Comorbidity

Eating disorders (EDs) and posttraumatic stress disorder (PTSD) commonly co-occur, but the mechanisms driving this co-occurrence are not well understood. The current study explored the relationships between symptoms of ED and PTSD in a sample of male and female undergraduate students in order to identify pathways that may maintain the comorbidity. Network analysis was conducted in a sample of 344 first-year undergraduates to visualize partial correlations between each symptom in the comorbidity. Core symptoms, bridge symptoms, and direct pathways between ED and PTSD symptoms were identified. The PTSD symptoms negative emotions (strength = 1.13) and negative beliefs (strength = 1.11) were the strongest symptoms in the network. The strongest bridge nodes were the ED symptoms restriction (bridge strength = 3.32) and binge eating (bridge strength = 2.63). The strongest edges between ED and PTSD nodes were between binge eating and concentration (part r = .16), restriction and sleep (part r = .14), and binge eating and positive emotions (part r = .11). Findings suggest that PTSD symptoms related to negative alterations in cognitions and mood may be highly influential in the ED-PTSD network due to their relatedness to all other symptoms. The pathway between binge eating and inability to experience positive emotions suggest that the comorbidity may be partially maintained through an affect regulation function of binge eating.

Pinpointing core and pathway symptoms among sleep disturbance, anxiety, worry, and eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa

BACKGROUND

Sleep, anxiety, and worry are strongly related to psychiatric illness and in particular to eating disorder (ED) symptoms. However, it is unclear how these specific sleep and anxiety symptoms are interrelated with anorexia nervosa (AN) pathology.

METHODS

We utilized network analysis to test our theoretically-based conceptual model, by identifying core features and illness (i.e., bridge) pathways among sleep disturbance, anxiety, worry, and ED symptoms in 267 participants with a diagnosis of AN or atypical AN.

RESULTS

The following core symptoms were identified: shape judgement, restriction, and feeling tired. The strongest bridge symptoms included worry, feeling tired, loss of energy, and physical anxiety. Worry was connected positively to fasting, fear of gaining weight or becoming fat, loss of energy, and feeling tired, and negatively to changes in sleeping patterns. Feeling tired was connected to restriction, fasting, binge eating, and worry. Loss of energy was connected to loss of control over eating and worry. Physical anxiety was negatively connected to restriction.

CONCLUSIONS

We identified specific core symptoms and illness pathways supporting our theoretical conceptual model of how ED symptoms, anxiety, worry, and sleep disturbances inter-relate in AN and atypical AN. In particular we found that symptoms associated with sleep and anxiety were central and had strong connections with AN symptoms. In addition to targeting AN symptoms, these data suggest that targeting sleep disturbance, anxiety, and worry could improve treatment for AN.

Sleep disturbances in anorexia nervosa subtypes in adolescence

PURPOSE

This retrospective study investigated, for the first time, sleep characteristics in anorexia nervosa (AN) subtypes and the clinical profile in adolescents, as well as the quality of life (QoL) and emotionality in these patients with poor sleep.

METHODS

The sample included 111 adolescents with AN. First, restrictive AN (ANR) and binge eating/purging AN (ANB/P) groups were compared in terms of self-reported sleep characteristics, sleepiness and chronotype. Second, the clinical profile, QoL, and emotionality of good sleepers (GS) and poor sleepers (PS) were compared.

RESULTS

Compared to the ANR group, participants with ANB/P showed significantly greater sleep disturbances and sleepiness, and also a higher preference for an eveningness chronotype. Results also showed a clinical profile significantly more severe in PS than in GS. After adjustment, only the ANB/P subtype and the EDI-2 ineffectiveness subscale remained significantly linked to poor sleep. Moreover, the QoL was lower and emotionality more negative in PS with respect to GS.

CONCLUSION

Findings suggest that subjective sleep disturbances may be used as a clinical marker for AN severity and for ANB/P subtype. Importantly, findings suggest that improving sleep quality in adolescents with AN may help managing their ED and their comorbidities, but also improve their QoL.

LEVEL OF EVIDENCE

Level V, descriptive study (evaluation data retrospectively studied).

Mediterranean Diet Adherence and Eating Disorders in Spanish Nurses with Shift Patterns: A Cross-Sectional Study

Background and Objectives: Shift work has a significant influence on the mental health of workers. Nursing is characterised by a rotational work system. This study aimed to determine whether there was a link between adherence to the Mediterranean diet (MD) and the risk of suffering an eating disorder (ED) in nurses according to their work shift. Materials and Methods: A total of 240 women (nurses and nursing assistants) were evaluated and completed the PREDIMED-PLUS questionnaire on adherence to the MD and the EAT-26 (Eating Attitude Test, 26 items). Results: The results indicate that there are no differences in adherence to the MD depending on the work shift, being that adherence to the diet is already low. Statistically significant differences appear depending on the work shift in the following dimensions: restrictive behaviours and bulimia subscales (presenting higher scores in the 7-h rotating shift versus the fixed morning shift or 12-h rotating shift) and for total EAT-26 score. Conclusion: Whilst they do not condition adherence to a MD, the nursing shifts that are the most changing in terms of time patterns may condition restrictive behaviours and compensatory risk behaviours related to an ED.

The case for investigating a bidirectional association between insomnia symptoms and eating disorder pathology

Many people with eating disorders (EDs) report symptoms of insomnia (i.e., frequent difficulty falling asleep, staying asleep, and/or early morning wakening) and sleep problems have been linked to alterations in eating behaviors; however, mechanisms of these bidirectional associations remain poorly understood and under researched. This is a problem because higher insomnia symptom severity is a risk factor for the onset and perpetuation of anxiety, mood, trauma, and substance use disorders and, potentially, ED symptoms. Furthermore, insomnia symptoms may hinder recovery and increase relapse rates following successful psychotherapy. In this article, we describe potential mechanisms underlying bidirectional associations between insomnia and eating psychopathology that may contribute to the etiology and maintenance of both disorders. We suggest novel directions for future research to characterize the association between dysregulated sleep and ED symptoms and to evaluate impacts of insomnia symptoms on relapse and recovery for people with co-occurring pathology. Finally, we discuss options for testing the incorporation of existing evidence-based treatments for insomnia disorder (e.g., Cognitive-Behavioral Therapy for Insomnia) with ED care. Overall, insomnia symptoms present a promising intervention point for ED treatment that has not been systematically tested, yet would be highly feasible to address in routine clinical care.

Self-reported eating disorders and sleep disturbances in young adults: a prospective cohort study

PURPOSE

To evaluate the prospective association between eating disorders, disordered eating behaviors, and sleep disturbances in young adults.

METHODS

We used prospective cohort data of young adults aged 18-26 from the National Longitudinal Study of Adolescent to Adult Health (N = 12,082). Self-reported exposures of interest (at 18-26 years) included (1) an eating disorder diagnosis proxy; disordered eating behaviors such as (2) restrictive eating behaviors including fasting/skipping meals, (3) compensatory behaviors including vomiting, laxatives/diuretics, or weight loss pills; and (4) loss of control/overeating. Self-reported sleep disturbances at 7-year follow-up included trouble falling or staying asleep.

RESULTS

In negative binomial regression models, all four exposures predicted both sleep disturbance outcomes at 7-year follow-up, when adjusting for demographic covariates and baseline sleep disturbances. When additionally adjusting for baseline depressive symptoms, the associations between eating disorder diagnosis proxies and trouble falling (incidence rate ratio [IRR] 1.24; 95% CI 1.05-1.46) and staying (IRR 1.16; 95% CI 1.01-1.35) asleep remained statistically significant; however, the associations between eating behaviors and sleep disturbances were attenuated.

CONCLUSIONS

Eating disorders in young adulthood predict sleep disturbances at 7-year follow-up. Young adults with eating disorders or who engage in disordered eating behaviors may be assessed for sleep disturbances.

LEVEL III

Evidence obtained from well-designed cohort or case-control analytic studies.

The Role of Problematic Smartphone Uses and Psychological Distress in the Relationship Between Sleep Quality and Disordered Eating Behaviors Among Chinese College Students

Background: Sleep problems and eating disorders (EDs) are both serious public health concerns often seen in young adults. Yet, the underlying mechanisms for such associations are largely unknown. This study aims to examine potential serial multiple mediation effects of problematic smartphone use (PSU) and psychological distress (i.e., depressive and anxiety symptoms) in the relationship between sleep quality and disordered eating behaviors/attitudes (DEBs). Methods: A total of 4,325 students from two Tibet universities in China (2,657 females and 1,668 males) completed an online survey that included the following measurements: Eating Attitude Test-26 for disordered eating behaviors/attitudes, the Chinese Version of Pittsburgh Sleep Quality Index (CPSQI), Smartphone Addiction Scale-Short Version (SAS-SV) for problematic smartphone use, Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) for psychological distress. Results: While the direct path linking sleep quality and DEBs was not found to be significant (Standardized β = 0.006, 95% CI = -0.0667~0.0970), both PSU (Standardized β = 0.016, 95% CI = 0.0256~0.0591) and anxiety symptoms (Standardized β = 0.014, 95% CI = 0.0203~0.0526) may mediate a link between sleep quality and DEBs; serial multiple mediation analysis revealed that a serial indirect pathway of "sleep quality -> PSU -> anxiety symptoms -> DEBs" existed(Standardized β = 0.001, 95% CI = 0.0002~0.0012). Similarly, while the direct path linking sleep quality and DEBs was not found to be significant (Standardized β = 0.006, 95% CI = -0.0667~0.0970), both PSU (Standardized β = 0.020, 95% CI = 0.0337~0.0692) and depressive symptoms (Standardized β = 0.015, 95% CI = 0.0139~0.0652) may mediate a link between sleep quality and DEBs; serial multiple mediation analysis revealed that a serial indirect pathway of "sleep quality -> PSU -> depressive symptoms -> DEBs" existed (Standardized β = 0.001, 95% CI = 0.0006~0.0038). Conclusions: Psychological and behavioral factors may comprehensively work together, leading to flow-on effects from sleep problems to disordered eating behaviors among university students. Appropriate interventions that target problematic smartphone use could thus potentially reduce anxiety and depression levels, which in turn will provide a buffer against the negative impact of poor sleep quality on eating disorder symptoms.