Meal patterning in the treatment of bulimia nervosa

Continuous glucose monitoring as an objective measure of meal consumption in individuals with binge-spectrum eating disorders: A proof-of-concept study

OBJECTIVE

Going extended periods of time without eating increases risk for binge eating and is a primary target of leading interventions for binge-spectrum eating disorders (B-EDs). However, existing treatments for B-EDs yield insufficient improvements in regular eating and subsequently, binge eating. These unsatisfactory clinical outcomes may result from limitations in assessment and promotion of regular eating in therapy. Detecting the absence of eating using passive sensing may improve clinical outcomes by facilitating more accurate monitoring of eating behaviours and powering just-in-time adaptive interventions. We developed an algorithm for detecting meal consumption (and extended periods without eating) using continuous glucose monitor (CGM) data and machine learning.

METHOD

Adults with B-EDs (N = 22) wore CGMs and reported eating episodes on self-monitoring surveys for 2 weeks. Random forest models were run on CGM data to distinguish between eating and non-eating episodes.

RESULTS

The optimal model distinguished eating and non-eating episodes with high accuracy (0.82), sensitivity (0.71), and specificity (0.94).

CONCLUSIONS

These findings suggest that meal consumption and extended periods without eating can be detected from CGM data with high accuracy among individuals with B-EDs, which may improve clinical efforts to target dietary restriction and improve the field's understanding of its antecedents and consequences.

Changes in evening-shifted loss of control eating severity following treatment for binge-eating disorder

BACKGROUND

Loss of control eating is more likely to occur in the evening and is uniquely associated with distress. No studies have examined the effect of treatment on within-day timing of loss of control eating severity. We examined whether time of day differentially predicted loss of control eating severity at baseline (i.e. pretreatment), end-of-treatment, and 6-month follow-up for individuals with binge-eating disorder (BED), hypothesizing that loss of control eating severity would increase throughout the day pretreatment and that this pattern would be less pronounced following treatment. We explored differential treatment effects of cognitive-behavioral guided self-help (CBTgsh) and Integrative Cognitive-Affective Therapy (ICAT).

METHODS

Individuals with BED (N = 112) were randomized to receive CBTgsh or ICAT and completed a 1-week ecological momentary assessment protocol at baseline, end-of-treatment, and 6-month follow-up to assess loss of control eating severity. We used multilevel models to assess within-day slope trajectories of loss of control eating severity across assessment periods and treatment type.

RESULTS

Within-day increases in loss of control eating severity were reduced at end-of-treatment and 6-month follow-up relative to baseline. Evening acceleration of loss of control eating severity was greater at 6-month follow-up relative to end-of-treatment. Within-day increases in loss of control severity did not differ between treatments at end-of-treatment; however, evening loss of control severity intensified for individuals who received CBTgsh relative to those who received ICAT at 6-month follow-up.

CONCLUSIONS

Findings suggest that treatment reduces evening-shifted loss of control eating severity, and that this effect may be more durable following ICAT relative to CBTgsh.

A systematic review of associations between day-to-day variability in meal pattern and body weight, components of the metabolic syndrome and cognitive function

BACKGROUND

Meal pattern is a potential health determinant. Previously, mean values for properties of meal pattern, such as daily meal frequency, have been considered. Means, however, obscure variability between-day (irregular or chaotic eating). This systematic review aimed to identify and critique published methods used to characterise between-day variability in meal pattern, and to explore relationships between this and obesity, as well as associated health outcomes.

METHODS

Using relevant databases, a systematic search was undertaken for studies with adults and children in which between-day variability in meal pattern was measured, and related to body weight, metabolic syndrome components and cognitive function.

RESULTS

In 34 papers identified (28 observational and six intervention studies), between-day variability in meal pattern was characterised by a variety of methods. These ranged from single questions about intake regularity to more complex methods quantifying the degree of variability. Assumptions were made, such as there being three main meals, resulting in dissociation from the "clock time" of eating. In 24 of the papers, between-day variability in meal pattern was associated with negative weight and health outcomes including higher weight, reduced thermogenic response to meals and poorer academic achievement.

CONCLUSIONS

Between-day variability in meal pattern is a promising research area that might inform low-cost public health interventions. However, current methods of characterising between-day variability tend to make assumptions and be inconsistent in the meal pattern properties considered. Well controlled dietary intervention studies are required to confirm causation.

Loss of control eating exhibits an evening diurnal shift among females with bulimia nervosa and binge-eating disorder

Loss of control (LOC) is a hallmark feature of binge eating that is associated with significant distress and impairment. Despite the central role diurnal rhythms may play in the development and maintenance of LOC eating, diurnal patterns of LOC remain understudied and poorly characterised. We assessed the diurnal timing of LOC in a sample of females with bulimia nervosa and binge-eating disorder who participated in a study assessing the impact of bright light exposure on binge eating, hypothesising that higher ratings of LOC would be more likely to occur later in the day. Participants (N = 34) completed a 22-day protocol during which they provided LOC ratings six times daily. Kernel density estimates describing LOC ratings across times of day were compared using permutation tests of equality. Results demonstrated an evening shift in LOC, wherein higher LOC was more likely to occur later in the day and lower LOC was more likely to occur earlier in the day. This study is the first to clearly depict the phenomenon that the likelihood of experiencing higher LOC increases throughout the day, pointing to the potential role diurnal rhythms, such as disrupted appetitive rhythms or mood variations, may play in maintaining binge eating.

Using Continuous Glucose Monitoring to Detect and Intervene on Dietary Restriction in Individuals With Binge Eating: The SenseSupport Withdrawal Design Study

BACKGROUND

Dietary restraint is a key factor for maintaining engagement in binge eating among individuals with binge eating disorder (BED) and bulimia nervosa (BN). Reducing dietary restraint is a mechanism of change in cognitive behavioral therapy (CBT) for individuals with BN and BED. However, many individuals who undergo CBT fail to adequately reduce dietary restraint during treatment, perhaps owing to difficulty in using treatment skills (eg, regular eating) to reduce dietary restraint during their daily lives. The SenseSupport system, a novel just-in-time, adaptive intervention (JITAI) system that uses continuous glucose monitoring to detect periods of dietary restraint, may improve CBT to reduce dietary restraint during treatment by providing real-time interventions.

OBJECTIVE

This study aimed to describe the feasibility, acceptability, and initial evaluation of SenseSupport. We presented feasibility, acceptability, target engagement, and initial treatment outcome data from a small trial using an ABAB (A=continuous glucose monitoring data sharing and JITAIs-Off, B=continuous glucose monitoring data sharing and JITAIs-On) design (in which JITAIs were turned on for 2 weeks and then turned off for 2 weeks throughout the treatment).

METHODS

Participants (N=30) were individuals with BED or BN engaging in ≥3 episodes of ≥5 hours without eating per week at baseline. Participants received 12 sessions of CBT and wore continuous glucose monitors to detect eating behaviors and inform the delivery of JITAIs. Participants completed 4 assessments and reported eating disorder behaviors, dietary restraint, and barriers to app use weekly throughout treatment.

RESULTS

Retention was high (25/30, 83% after treatment). However, the rates of continuous glucose monitoring data collection were low (67.4% of expected glucose data were collected), and therapists and participants reported frequent app-related issues. Participants reported that the SenseSupport system was comfortable, minimally disruptive, and easy to use. The only form of dietary restraint that decreased significantly more rapidly during JITAIs-On periods relative to JITAIs-Off periods was the desire for an empty stomach (t₄₃=1.69; P=.049; Cohen d=0.25). There was also a trend toward greater decrease in overall restraint during JITAs-On periods compared with JITAIs-Off periods, but these results were not statistically significant (t₄₃=1.60; P=.06; Cohen d=0.24). There was no significant difference in change in the frequency of binge eating during JITAIs-On periods compared with JITAIs-Off periods (P=.23). Participants demonstrated clinically significant, large decreases in binge eating (t₂₄=10.36; P<.001; Cohen d=2.07), compensatory behaviors (t₂₄=3.40; P=.001; Cohen d=0.68), and global eating pathology (t₂₄=6.25; P<.001; Cohen d=1.25) from pre- to posttreatment.

CONCLUSIONS

This study describes the successful development and implementation of the first intervention system combining passive continuous glucose monitors and JITAIs to augment CBT for binge-spectrum eating disorders. Despite the lower-than-anticipated collection of glucose data, the high acceptability and promising treatment outcomes suggest that the SenseSupport system warrants additional investigation via future, fully powered clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04126694; https://clinicaltrials.gov/ct2/show/NCT04126694.

A matter of time: A systematic scoping review on a potential role of the circadian system in binge eating behavior

Background

Emerging research suggests that food intake timing, eating behavior and food preference are associated with aspects of the circadian system function but the role that the circadian system may play in binge eating (BE) behavior in humans remains unclear.

Objective

To systematically evaluate the evidence for circadian system involvement in BE behavior.

Methods

Systematic searches of PubMed, EMBASE, and Scopus were performed for reports published from inception until May 2020 (PROSPERO Registration CRD42020186325). Searches were conducted by combining Medical Subject Headings related to the circadian system, BE behavior, and/or interventions. Observational and interventional studies in humans with BE behavior published in peer-review journals in the English language were included. Studies were assessed using quality and risk of bias tools (AXIS, ROB 2.0, or ROBINS).

Results

The search produced 660 articles, 51 of which were included in this review. Of these articles, 46 were observational studies and 5 were interventional trials. Evidence from these studies suggests that individuals with BE behavior tend to have more food intake, more binge cravings, and more BE episodes later in the day. Hormonal and day/night locomotor activity rhythm disturbances may be associated with BE behavior. Furthermore, late diurnal preference ("eveningness") was associated with BE behavior and chronobiological interventions that shift the circadian clock earlier (e.g., morning bright light therapy) were found to possibly decrease BE behavior. Substantive clinical overlap exists between BE and night eating behavior. However, there is a significant knowledge gap regarding their potential relationship with the circadian system. Limitations include the lack of studies that use best-established techniques to assess the chronobiology of BE behavior, heterogeneity of participants, diagnostic criteria, and study design, which preclude a meta-analytic approach.

Conclusion

Current evidence, although limited, suggests that the circadian system may play a role in the etiology of BE behavior. Further mechanistic studies are needed to fully characterize a potential role of the circadian system in BE behavior. A chronobiological approach to studying BE behavior may lead to identification of its neurobiological components and development of novel therapeutic interventions.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186325], identifier [CRD42020186325].

Behavioral Approaches to Nutrition Counseling in the Primary Care Setting

Primary care providers encounter significant time and resource constraints in their efforts to provide patients with behavioral nutrition counseling. Here, several evidence-based and low-burden strategies are identified that may be used in the primary care setting to assist patients in making dietary changes toward improved health. These strategies include brief dietary intake screening, core elements of motivational interviewing and cognitive behavioral therapy, and recommendation for normalized eating.

A Clinician-Controlled Just-in-time Adaptive Intervention System (CBT+) Designed to Promote Acquisition and Utilization of Cognitive Behavioral Therapy Skills in Bulimia Nervosa: Development and Preliminary Evaluation Study

Background

Cognitive behavioral therapy (CBT) for bulimia nervosa (BN) is most effective when patients demonstrate adequate skill utilization (ie, the frequency with which a patient practices or uses therapeutic skills) and skill acquisition (ie, the ability to successfully perform a skill learned in treatment). However, rates of utilization and acquisition of key treatment skills (eg, regular eating, urge management skills, and mood management skills) by the end of the treatment are frequently low; as a result, outcomes from CBT for BN are affected. Just-in-time adaptive interventions (JITAIs) may improve skill acquisition and utilization by delivering real-time interventions during algorithm-identified opportunities for skill practice.

Objective

In this manuscript, we describe a newly developed JITAI system called CBT+ that is designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation. We also present feasibility, acceptability, and preliminary outcomes data from a small proof-of-concept pilot trial (n=5 patients and n=3 clinicians) designed to identify opportunities for iterative development of CBT+ ahead of a larger ongoing randomized controlled trial.

Methods

A total of 5 individuals with BN received 16 sessions of outpatient CBT for BN while using the CBT+ app. Data were collected from patients and clinicians to evaluate the feasibility (eg, app use and user adherence), acceptability (eg, qualitative patient and clinician feedback, including usefulness ratings of CBT+ on a 6-point Likert scale ranging from 1=extremely useless to 6=extremely useful), and preliminary outcomes (eg, improvements in skill utilization and acquisition and BN symptoms) of the CBT+ system.

Results

Patients reported that CBT+ was a relatively low burden (eg, quick and easy-to-use self-monitoring interface), and adherence to in-app self-monitoring was high (mean entries per day 3.13, SD 1.03). JITAIs were perceived as useful by both patients (median rating 5/6) and clinicians (median rating 5/6) for encouraging the use of CBT skills. Large improvements in CBT skills and clinically significant reductions in BN symptoms were observed post treatment. Although preliminary findings indicated that the CBT+ system was acceptable to most patients and clinicians, the overall study dropout was relatively high (ie, 2/5, 40% patients), which could indicate some moderate concerns regarding feasibility.

Conclusions

CBT+, the first-ever JITAI system designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation, was shown to be feasible and acceptable. The results indicate that the CBT+ system should be subjected to more rigorous evaluations with larger samples and should be considered for wider implementation if found effective. Areas for iterative improvement of the CBT+ system ahead of a randomized controlled trial are also discussed.

Eating patterns and unhealthy weight control behaviors are associated with loss-of-control eating following bariatric surgery

BACKGROUND

Loss-of-control (LOC) eating is associated with poor weight-loss outcomes following bariatric surgery. It is not clear whether eating patterns (e.g., total number of daily meals/snacks, eating after suppertime, eating when not hungry) and unhealthy weight control behaviors (e.g., smoking, using laxatives) are associated with or predictive of LOC eating.

OBJECTIVES

To examine whether eating patterns and unhealthy weight-control behaviors are associated with LOC eating and, if so, whether they predict LOC eating in bariatric patients.

SETTING

Multicenter study, United States.

METHODS

This is a secondary analysis of the Longitudinal Assessment of Bariatric Surgery-2 study. Assessments were conducted before surgery and at 12, 24, 36, 48, 60, and 84 months after surgery. Logistic mixed models were used to examine the longitudinal associations between eating patterns, unhealthy weight-control behaviors, and LOC eating. Time-lag techniques were applied to examine whether the associated patterns and behaviors predict LOC eating.

RESULTS

The participants (n = 1477) were mostly women (80%), white (86.9%), and married (62.5%). At the time of surgery, the mean age was 45.4 ± 11.0 years and the mean body mass index was 47.8 ± 7.5 kg/m². The total number of daily meals/snacks, food intake after suppertime, eating when not hungry, eating when feeling full, and use of any unhealthy weight-control behaviors were positively associated with LOC eating (P < .05). Food intake after suppertime, eating when not hungry, and eating when feeling full predicted LOC eating (P < .05).

CONCLUSION

Meal patterns and unhealthy weight control behaviors may be important intervention targets for addressing LOC eating after bariatric surgery.

Mediators of change in cognitive behavior therapy and interpersonal psychotherapy for eating disorders: A secondary analysis of a transdiagnostic randomized controlled trial

OBJECTIVE

Understanding the mechanisms of action of psychological treatments is a key first step in refining and developing more effective treatments. The present study examined hypothesized mediators of change of enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy for eating disorders (IPT-ED).

METHOD

A series of mediation studies were embedded in a randomized controlled trial (RCT) comparing 20 weeks of CBT-E and IPT-ED in a transdiagnostic, non-underweight sample of patients with eating disorders (N = 130) consecutively referred to the service. Three hypothesized mediators of change in CBT-E (regular eating, weighing frequency, and shape checking) and the key hypothesized mediator of IPT-ED (interpersonal problem severity) were studied.

RESULTS

The data supported regular eating as being a mediator of the effect of CBT-E on binge-eating frequency. The findings were inconclusive regarding the role of the other putative mediators of the effects of CBT-E; and were similarly inconclusive for interpersonal problem severity as a mediator of the effect of IPT-ED.

DISCUSSION

This research highlights the potential benefits of embedding mediation studies within RCTs to better understand how treatments work. The findings supported the role of regular eating in reducing patients' binge-eating frequency. Other key hypothesized mediators of CBT-E and IPT-ED were not supported, although the data were not inconsistent with them. Key methodological issues to address in future work include the need to capture both behavioral and cognitive processes of change in CBT-E, and identifying key time points for change in IPT-ED.

Late and Instable Sleep Phasing is Associated With Irregular Eating Patterns in Eating Disorders

BACKGROUND

Sleep problems are common in eating disorders (EDs).

PURPOSE

We evaluated whether sleep-phasing regularity associates with the regularity of daily eating events.

METHODS

ED patients (n = 29) completed hourly charts of mood and eating occasions for 2 weeks. Locomotor activity was recorded continuously by wrist actigraphy for a minimum of 10 days, and sleep was calculated based on periods of inactivity. We computed the center of daily inactivity (CenDI) as a measure of sleep phasing and consolidation of the daily inactivity (ConDI) as a measure of daily sleep rhythm strength. We assessed interday irregularities in the temporal structure of food intake using the standard deviation (SD) of frequency (IFRQ), timing (ITIM), and interval (IINT) of food intake. A self-evaluation of other characteristics included mood, anxiety, and early trauma.

RESULTS

A later phasing of sleep associated with a lower frequency of eating (eating frequency with the CenDI rho = -0.49, p = .007). The phasing and rhythmic strength of sleep correlated with the degree of eating irregularity (CenDI with ITIM rho = 0.48, p = .008 and with IINT rho = 0.56, p = .002; SD of CenDI with ITIM rho = 0.47, p = .010, and SD of ConDI with IINT rho = 0.37, p = .048). Childhood Trauma Questionnaire showed associations with variation of sleep onset (rho = -0.51, p = .005) and with IFRQ (rho = 0.43, p = .023).

CONCLUSIONS

Late and variable phasing of sleep associated robustly with irregular pattern of eating. Larger data sets are warranted to enable the analysis of diagnostic subgroups, current medication, and current symptomatology and to confirm the likely bidirectional association between eating pattern stability and the timing of sleep.

Cognitive Behavior Therapy for the Eating Disorders

Cognitive behavioral therapy (CBT) is an evidence-based treatment for bulimia nervosa and binge-eating disorder and is regarded as the first-line treatment for both eating disorders. An enhanced version of the treatment (CBT-E) appears more effective in treating patients with severe comorbidity. There is less evidence that CBT is effective for the treatment of anorexia nervosa. Evidence suggests that CBT-E is no more effective than specialist care involving regular medical follow-up and supportive psychotherapy in the persistent adult form of anorexia nervosa (AN). Early studies suggest that CBT-E may be useful in treating the adolescent form of AN.

Associations between meal patterns, binge eating, and weight for Latinas

Establishing a regular pattern of eating is a core element of treatment for binge eating, yet no research to date has examined meal patterns of Latina women.

OBJECTIVE

Compare eating patterns of Latinas who binge eat and those who do not, and examine associations between meal patterns and binge episodes, associated distress and concerns, and body mass index (BMI).

METHOD

One-hundred fifty-five Latinas [65 Binge Eating Disorder (BED), 22 Bulimia Nervosa (BN), 68 with no eating disorder] were assessed with the Eating Disorder Examination.

RESULTS

There were no significant differences in eating patterns between groups. Breakfast was the least and dinner the most consumed meal. For the BED group: greater frequency of lunch consumption was associated with higher BMI while more frequent evening snacking was associated with lower BMI and with less weight importance; more frequent breakfast consumption, mid-morning snack consumption and total meals were associated with greater distress regarding binge eating. For the BN group, evening snack frequency was associated with less dietary restriction and more weight and shape concern; total snack frequency was associated with more weight concern. Regular meal eaters reported more episodes of binge eating than those who did not eat meals regularly.

DISCUSSION

Associations with meal patterns differed by eating disorder diagnosis. Study findings mostly are not consistent with results from prior research on primarily White women. CBT treatments may need to be tailored to address the association between binge eating and regular meal consumption for Latinas. Culturally, appropriate modifications that address traditional eating patterns should be considered. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:32-39).