Eating disorders

Eating Episode Detection with Jawbone-Mounted Inertial Sensing

Recent work in Automated Dietary Monitoring (ADM) has shown promising results in eating detection by tracking jawbone movements with a proximity sensor mounted on a necklace. A significant challenge with this approach, however, is that motion artifacts introduced by natural body movements cause the necklace to move freely and the sensor to become misaligned. In this paper, we propose a different but related approach: we developed a small wireless inertial sensing platform and perform eating detection by mounting the sensor directly on the underside of the jawbone. We implemented a data analysis pipeline to recognize eating episodes from the inertial sensor data, and evaluated our approach in two different conditions: in the laboratory and in naturalistic settings. We demonstrated that in the lab (n=9), the system can detect eating with 91.7% precision and 91.3% recall using the leave-one-participant-out cross-validation (LOPO-CV) performance metric. In naturalistic settings, we obtained an average precision of 92.3% and a recall of 89.0% (n=14). These results represent a significant improvement (>10% in F1 score) over state-of-the-art necklace-based approaches. Additionally, this work presents a wearable device that is more inconspicuous and thus more likely to be adopted in clinical applications.

Overlaps and Disjunctures: A Cultural Case Study of a British Indian Young Woman's Experiences of Bulimia Nervosa

Eating disorder diagnoses are characterised by a pattern of disordered eating behaviour alongside symptoms such as body dissatisfaction and preoccupation with food, weight or shape (APA in Diagnostic and statistical manual of mental disorders, DSM-5, APA, Washington, DC, 2013). Incidence rates for eating disorders have increased during the last 50 years. However, epidemiological studies have suggested that such trends may not be a true representation of the occurrence of these illnesses in the general population, with figures underestimated due to reduced help seeking and poor access to care, particularly amongst ethnic minorities. This case study explores the experiences of a young British Indian woman with bulimia nervosa. Arising from an in-depth semi-structured interview, analysed with interpretative phenomenological analysis, her narrative offers a critical lens onto how diverse fragments of cultural practices and meanings come together to produce the clinical category of 'bulimia.' It thereby offers an alternative portrait of relationships between eating disorders and 'culture,' one that goes beyond a framing of these illnesses as culture inscribed on the body. Interrogating relationships between culture and the development, expression and maintenance of bulimia is suggested to be key to forging culturally-sensitive understandings of this illness; this paper begins to provide the evidence base for the design and development of appropriate support services, thereby aiming to contribute to a reduction in health inequalities and barriers to treatment.

Ethnic differences in eating disorder prevalence, risk factors, and predictive effects of risk factors among young women

Findings regarding ethnic differences in eating disorder diagnoses and risk factors have been mixed. This study evaluated whether there are ethnic differences in eating disorder prevalence, risk factors, and the predictive relations of the risk factors to future eating disorder onset. We used a large sample of young women followed longitudinally over three years to increase sensitivity to detect differences and to provide the first test of ethnic differences in the relation of risk factors to future onset of eating disorders. Females with body image concerns (N = 1177) were recruited from high schools and colleges for trials of a body acceptance eating disorder prevention program. They completed surveys and interviews at baseline and at 1-, 6-, 12-, 24-, and 36-month follow-up. Significant differences between ethnic groups were found for two of the 13 baseline risk factors: thin-ideal internalization and body mass index. No significant differences in later onset rates among ethnic groups were found. There were also no reliable ethnic differences in the relation of risk factors for future eating disorder onset. These findings suggest that eating disorders affect ethnic minorities as much as Whites and that there are more overlapping risk factors shared among various ethnic groups than differences.

The potential of calibrated fMRI in the understanding of stress in eating disorders

Eating disorders (ED), including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED), are medically dangerous psychiatric disorders of unknown etiology. Accumulating evidence supports a biopsychosocial model that includes genetic heritability, neurobiological vulnerability, and psychosocial factors, such as stress, in the development and maintenance of ED. Notably, stress hormones influence appetite and eating, and dysfunction of the physiological stress response has been implicated in ED pathophysiology. Stress signals also appear associated with food reward neurocircuitry response in ED, providing a possible mechanism for the role of stress in appetite dysregulation. This paper provides a review of some of the interacting psychological, behavioral, physiological, and neurobiological mechanisms involved in the stress response among individuals with ED, and discusses novel neuroimaging techniques to address potential physiological confounds of studying neural correlates of stress in ED, such as calibrated fMRI.

Registration-based methods applied to serial high-resolution T1-weighted magnetic resonance imaging for the assessment of brain volume changes in anorexia nervosa of the restricting type

We aimed to determine whether variation in the body mass index (BMI)—a marker of anorexia nervosa (AN) severity—is associated with brain volume changes longitudinally estimated using registration-based methods on serial high-resolution T1-weighted magnetic resonance images (MRI). Fifteen female patients (mean age = 21 years; standard deviation [SD] = 5.7; range: 15–33 years) with the diagnosis of AN of the restricting type (AN-r)—according to the Diagnostic and Statistic Manual of Mental Disorders, 5^th edition criteria—underwent T1-weighted MRI at baseline and after a mean follow-up period of 11 months (SD = 6.4). We used the brain boundary shift integral (BSI) and the ventricular BSI (VBSI) to estimate volume changes after registering voxels of follow-up onto baseline MRI. Very significant and strong correlations were found between BMI variation and the brain BSI, as well as between BMI variation and the VBSI. After adjustment for age at onset, duration of illness, and the BMI rate of change before baseline MRI, the statistical significance of both associations persisted. Registration-based methods on serial MRI represent an additional tool to estimate AN severity, because they provide measures of brain volume change strongly associated with BMI variation.

Abnormal fronto-striatal activation as a marker of threshold and subthreshold Bulimia Nervosa

This study aimed to determine whether functional disturbances in fronto-striatal control circuits characterize adolescents with Bulimia Nervosa (BN) spectrum eating disorders regardless of clinical severity. FMRI was used to assess conflict-related brain activations during performance of a Simon task in two samples of adolescents with BN symptoms compared with healthy adolescents. The BN samples differed in the severity of their clinical presentation, illness duration and age. Multi-voxel pattern analyses (MVPAs) based on machine learning were used to determine whether patterns of fronto-striatal activation characterized adolescents with BN spectrum disorders regardless of clinical severity, and whether accurate classification of less symptomatic adolescents (subthreshold BN; SBN) could be achieved based on patterns of activation in adolescents who met DSM5 criteria for BN. MVPA classification analyses revealed that both BN and SBN adolescents could be accurately discriminated from healthy adolescents based on fronto-striatal activation. Notably, the patterns detected in more severely ill BN compared with healthy adolescents accurately discriminated less symptomatic SBN from healthy adolescents. Deficient activation of fronto-striatal circuits can characterize BN early in its course, when clinical presentations are less severe, perhaps pointing to circuit-based disturbances as useful biomarker or risk factor for the disorder, and a tool for understanding its developmental trajectory, as well as the development of early interventions.

Applying neurobiology to the treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a severe, biologically based brain disorder with significant medical complications. It is critical that new, effective treatments are developed to interrupt the persistent course of the illness due to the medical and psychological sequelae. Several psychosocial, behavioral and pharmacologic interventions have been investigated in adult anorexia nervosa; however, evidence shows that their impact is weak and treatment effects are generally small.

METHOD

This paper describes a new neurobiological anorexia nervosa model that shifts focus from solely external influences, such as social and family, to include internal influences that integrate genetic and neurobiological contributions, across the age span. The model serves as a theoretical structure for a new, five-day treatment, outlined in this paper, targeting anorexia nervosa temperament, which integrates neurobiological dimensions into evidence-based treatment interventions. The treatment is in two phases. Phase I is a five day, 40 hour treatment for anorexia nervosa adults. Phase II is the follow-up and is currently being developed.

RESULTS

Preliminary qualitative acceptability data on 37 adults with anorexia nervosa and 60 supports (e.g., spouses, parents, aunts, friends, partners, children of anorexia nervosa adults) are promising from Phase I. Clients with anorexia nervosa and their supports report that learning neurobiological facts improved their understanding of the illness and helped equip them with better tools to manage anorexia nervosa traits and symptoms. In addition, nutritional knowledge changed significantly.

CONCLUSIONS

This is the first neurobiologically based, five-day treatment for adults with anorexia nervosa and their supports. It is a new model that outlines underlying genetic and neurobiological contributions to anorexia nervosa that serves as a foundation to treat both traits and symptoms. Preliminary qualitative findings are promising, with both clients and supports reporting that the neurobiological treatment approach helped them better understand the illness, while better conceptualizing how to respond to their traits and manage their symptoms. Data in Phase I shows promise as a neurobiologically based intervention for anorexia nervosa, and it serves as a foundation for the development of Phase II. Evidence of ongoing program efficacy will be described as data are reported on Phase II.

TRIAL REGISTRATION

NCT NCT02852538 Registered 1 August 2016.

Atypical Self-Focus Effect on Interoceptive Accuracy in Anorexia Nervosa

Background: Interoceptive abilities are known to be affected in anorexia nervosa (AN). Previous studies could show that private self-focus can enhance interoceptive accuracy (IAcc) in healthy participants. As body dissatisfaction is high in AN, confrontation with bodily features such as the own face might have a directly opposed effect in AN. Whether patients with AN can benefit from self-focus in their IAcc and whether this pattern changes over the time-course of cognitive behavioral therapy was investigated in this study.

Methods: Fifteen patients with AN from the Psychosomatic Clinic in Windach were assessed three times in the time course of a standardized cognitive-behavioral therapy. They were compared to 15 controls, recruited from Ulm University and tested in a comparable setting. Both groups performed the heartbeat perception task assessing IAcc under two conditions either enhancing (“Self”) or decreasing (“Other”) self-focused attention. Furthermore, body dissatisfaction was assessed by a subscale of the Eating Disorder (ED) Inventory 2.

Results: Patients with AN scored higher in IAcc when watching others’ faces as compared to one’s own face while performing the heartbeat perception task. The opposite pattern was observed in controls. IAcc remained reduced in AN as compared to controls in the time-course of cognitive-behavioral therapy, while body-dissatisfaction improved in AN. High body dissatisfaction was related to poorer IAcc in the “Self” condition.

Conclusions: Our findings suggest that using self-focused attention reduces IAcc in AN while the opposite pattern was observed in controls. Confronting anorexic patients with bodily features might increase body-related avoidance and therefore decrease IAcc. The current study introduces a new perspective concerning the role of interoceptive processes in AN and generates further questions regarding the therapeutic utility of methods targeting self-focus in the treatment of AN.

Neurobiologically informed treatment for adults with anorexia nervosa: a novel approach to a chronic disorder

Anorexia nervosa (AN) is a severe and debilitating disorder with significant medical and psychological sequelae. To date, there are no effective treatments for adults, resulting in high rates of chronicity, morbidity, and mortality. Recent advances in brain imaging research have led to an improved understanding of etiology and specific neurobiological mechanisms underlying symptoms. Despite this, there are no treatments focused on targeting symptoms using this empirically supported mechanistic understanding of the illness. Updated treatment approaches focused on targeting neurobiological mechanisms underlying core AN symptomatology are necessary to improve treatment out-comes for this population. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) is a neurobiologically informed treatment targeting key temperament constructs associated with the illness through the delivery of psychoeducation and skills training to patients and nominated carers.

Sensitivity to reward and adolescents' unhealthy snacking and drinking behavior: the role of hedonic eating styles and availability

Background

Although previous research found a positive association between sensitivity to reward (SR) and adolescents’ unhealthy snacking and drinking behavior, mechanisms explaining these associations remain to be explored. The present study will therefore examine whether the associations between SR and unhealthy snack and/or sugar-sweetened beverage (SSB) intake are mediated by external and/or emotional eating and if this mediation is moderated by availability at home or at school.

Methods

Cross-sectional data on snacking, availability of snacks at home and at school, SR (BAS drive scale) and external and emotional eating (Dutch eating behavior questionnaire) of Flemish adolescents (n = 1104, mean age = 14.7 ± 0.8 years; 51 % boys; 18.0 % overweight) in 20 schools spread across Flanders were collected. Moderated mediation analyses were conducted using generalized structural equation modeling in three steps: (1) direct association between SR and unhealthy snack or SSB intake, (2) mediation of either external or emotional eating and (3) interaction of home or school availability and emotional or external eating.

Results

Partial mediation of external eating (a*b = 0.69, p < 0.05) and of emotional eating (a*b = 0.92, p < 0.01) in the relation between SR and intake of unhealthy snacks was found (step 2). The relation between SR and SSB intake was not mediated by external or emotional eating (step 2). No moderation effects of home or school availability were found (step 3).

Conclusion

Our findings indicate that the association between SR and the consumption of unhealthy snacks is partially explained by external and emotional eating in a population-based sample of adolescents irrespective of the home or school availability of these foods.

Words on walls: Passive eating disorder education

This study examined the effect of a short-term passive intervention on nursing students' beliefs about eating disorders (EDs). Before and after a weeklong ED education poster campaign, participants completed questionnaires assessing their attitudes about individuals with EDs. Results showed a reduction in the belief that people with EDs are almost always women, increased attribution to biological and genetic factors, and decreased attribution to society's thin ideal. Personal connection moderated response to the items: [people with EDs] "are putting their lives at risk" and "would not improve with treatment." This intervention shows promise for reducing ED-associated stereotype endorsement among medical professionals.

Anatomical characteristics of the cerebral surface in bulimia nervosa

BACKGROUND

The aim of this study was to examine morphometric features of the cerebral surface in adolescent and adult female subjects with bulimia nervosa (BN).

METHODS

Anatomical magnetic resonance images were acquired from 34 adolescent and adult female subjects with BN and 34 healthy age-matched control subjects. We compared the groups in the morphological characteristics of their cerebral surfaces while controlling for age and illness duration.

RESULTS

Significant reductions of local volumes on the brain surface were detected in frontal and temporoparietal areas in the BN compared with control participants. Reductions in inferior frontal regions correlated inversely with symptom severity, age, and Stroop interference scores in the BN group.

CONCLUSIONS

These findings suggest that local volumes of inferior frontal regions are smaller in individuals with BN compared with healthy individuals. These reductions along the cerebral surface might contribute to functional deficits in self-regulation and to the persistence of these deficits over development in BN.

Disordered eating and food restrictions in children with PANDAS/PANS

OBJECTIVE

Sudden onset clinically significant eating restrictions are a defining feature of the clinical presentation of some of the cases of pediatric acute-onset neuropsychiatric syndrome (PANS). Restrictions in food intake are typically fueled by contamination fears; fears of choking, vomiting, or swallowing; and/or sensory issues, such as texture, taste, or olfactory concerns. However, body image distortions may also be present. We investigate the clinical presentation of PANS disordered eating and compare it with that of other eating disorders.

METHODS

We describe 29 patients who met diagnostic criteria for PANS. Most also exhibited evidence that the symptoms might be sequelae of infections with Group A streptococcal bacteria (the pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections [PANDAS] subgroup of PANS).

RESULTS

The clinical presentations are remarkable for a male predominance (2:1 M:F), young age of the affected children (mean=9 years; range 5-12 years), acuity of symptom onset, and comorbid neuropsychiatric symptoms.

CONCLUSIONS

The food refusal associated with PANS is compared with symptoms listed for the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) diagnosis of avoidant/restrictive food intake disorder (ARFID). Treatment implications are discussed, as well as directions for further research.

Are Extremes of Consumption in Eating Disorders Related to an Altered Balance between Reward and Inhibition?

The primary defining characteristic of a diagnosis of an eating disorder (ED) is the "disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food" (DSM V; American Psychiatric Association, 2013). There is a spectrum, ranging from those who severely restrict eating and become emaciated on one end to those who binge and overconsume, usually accompanied by some form of compensatory behaviors, on the other. How can we understand reasons for such extremes of food consummatory behaviors? Recent work on obesity and substance use disorders has identified behaviors and neural pathways that play a powerful role in human consummatory behaviors. That is, corticostriatal limbic and dorsal cognitive neural circuitry can make drugs and food rewarding, but also engage self-control mechanisms that may inhibit their use. Importantly, there is considerable evidence that alterations of these systems also occur in ED. This paper explores the hypothesis that an altered balance of reward and inhibition contributes to altered extremes of response to salient stimuli, such as food. We will review recent studies that show altered sensitivity to reward and punishment in ED, with evidence of altered activity in corticostriatal and insula processes with respect to monetary gains or losses, and tastes of palatable foods. We will also discuss evidence for a spectrum of extremes of inhibition and dysregulation behaviors in ED supported by studies suggesting that this is related to top-down self-control mechanisms. The lack of a mechanistic understanding of ED has thwarted efforts for evidence-based approaches to develop interventions. Understanding how ED behavior is encoded in neural circuits would provide a foundation for developing more specific and effective treatment approaches.

Restraint feeds stress: The relationship between eating disorder symptoms, stress generation, and the interpersonal theory of suicide

Integrating research on stress generation and the interpersonal theory of suicide we examined whether eating disorder symptoms are related to stress generation and whether negative life events (stressors) contribute to feelings of burdensomeness and low belongingness. At two time points (approximately 1month apart), participants (n=186; 75% female) completed questionnaires measuring eating disorder symptoms, negative life events, burdensomeness, and belongingness. Regression analyses indicated that while controlling for depression, anxiety, and baseline frequency of negative events, dietary restraint significantly predicted negative events at follow-up. Dietary restraint indirectly influenced higher levels of perceived burdensomeness and low belongingness through its influence on negative events. Thus, dietary restraint may contribute to stress generation, and in turn exacerbate feelings of burdensomeness and low belongingness, two important constructs of the interpersonal theory of suicide. Greater understanding of these factors could lead to more effective and targeted suicide interventions for individuals who restrict food intake.

Temperament-based treatment for anorexia nervosa

Anorexia nervosa (AN) tends to be a chronic and deadly disorder with no proven treatments that reverse core symptoms in adults. New insight into neurobiological mechanisms that contribute to symptoms may support development of more effective interventions. We describe the development of a temperament-based treatment for AN on the basis of empirically supported models. It uses a systemized approach and takes into consideration an understanding of how neurobiological mechanisms are expressed through behaviour and personality and contribute to specific AN symptomatology. This model integrates the development of AN-focused constructive coping strategies with carer-focused strategies to manage temperament traits that contribute to AN symptomatology. This intervention is consistent with the recent Novel Interventions for Mental Disorders initiative mandating that treatment trials follow an experimental medicine approach by identifying underlying mechanisms that are directly targeted by the intervention to influence symptoms.

Altered BOLD response during inhibitory and error processing in adolescents with anorexia nervosa

BACKGROUND

Individuals with anorexia nervosa (AN) are often cognitively rigid and behaviorally over-controlled. We previously showed that adult females recovered from AN relative to healthy comparison females had less prefrontal activation during an inhibition task, which suggested a functional brain correlate of altered inhibitory processing in individuals recovered from AN. However, the degree to which these functional brain alterations are related to disease state and whether error processing is altered in AN individuals is unknown.

METHODOLOGY/PRINCIPAL FINDINGS

In the current study, ill adolescent AN females (n = 11) and matched healthy comparison adolescents (CA) with no history of an eating disorder (n = 12) performed a validated stop signal task (SST) during functional magnetic resonance imaging (fMRI) to explore differences in error and inhibitory processing. The groups did not differ on sociodemographic variables or on SST performance. During inhibitory processing, a significant group x difficulty (hard, easy) interaction was detected in the right dorsal anterior cingulate cortex (ACC), right middle frontal gyrus (MFG), and left posterior cingulate cortex (PCC), which was characterized by less activation in AN compared to CA participants during hard trials. During error processing, a significant group x accuracy (successful inhibit, failed inhibit) interaction in bilateral MFG and right PCC was observed, which was characterized by less activation in AN compared to CA participants during error (i.e., failed inhibit) trials.

CONCLUSION/SIGNIFICANCE

Consistent with our prior findings in recovered AN, ill AN adolescents, relative to CA, showed less inhibition-related activation within the dorsal ACC, MFG and PCC as inhibitory demand increased. In addition, ill AN adolescents, relative to CA, also showed reduced activation to errors in the bilateral MFG and left PCC. These findings suggest that altered prefrontal and cingulate activation during inhibitory and error processing may represent a behavioral characteristic in AN that is independent of the state of recovery.

The expression of excessive exercise co-segregates with the risk of developing an eating disorder in women

Excessive exercise (EE) is an important symptom of eating disorders (ED) and is a likely risk factor for developing ED, however, no population-based studies have been performed on the relationship between EE and obtaining ED diagnosis. The aim of this study was to examine the co-occurrence of EE and ED diagnosis in a general population of women. Data for 778 females (age min=30, max=55) from the Saint Thomas Twin Registry, London were used. Phenotypes analyzed included self-reported time spent on physical activity per week, ED diagnosis, Eating Disorder Inventory results (EDI-III), age, BMI and kinship (twin pair). Generalized Estimating Equation analysis showed that only EE (>5 h of exercise per week) and Bulimia Subscale of EDI-III were significantly associated with obtaining ED diagnosis throughout the life. These data revealed that the odds of ever being diagnosed with an ED are more than 2.5 times higher for excessive exercisers compared to individuals with lower activity levels. These data support the notion that EE may be an important risk factor for developing an ED in women.

Altered brain response to reward and punishment in adolescents with Anorexia nervosa

Adults recovered from Anorexia nervosa (AN) have altered reward modulation within striatal limbic regions associated with the emotional significance of stimuli, and executive regions concerned with planning and consequences. We hypothesized that adolescents with AN would show similar disturbed reward modulation within the striatum and the anterior cingulate cortex, a region connected to the striatum and involved in reward-guided action selection. Using functional magnetic resonance imaging, twenty-two adolescent females (10 restricting-type AN, 12 healthy volunteers) performed a monetary guessing task. Time series data associated with monetary wins and losses within striatal and cingulate regions of interest were subjected to a linear mixed effects analysis. All participants responded more strongly to wins versus losses in limbic and anterior executive striatal territories. However, AN participants exhibited an exaggerated response to losses compared to wins in posterior executive and sensorimotor striatal regions, suggesting altered function in circuitry responsible for coding the affective context of stimuli and action selection based upon these valuations. As AN individuals are particularly sensitive to criticism, failure, and making mistakes, these findings may reflect the neural processes responsible for a bias in those with AN to exaggerate negative consequences.

The relationship between anorexia nervosa and body dysmorphic disorder

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are severe body image disorders that highly impair individuals in their daily functioning. They are discrete but overlapping nosological entities. In this review, we examine similarities between AN and BDD with regard to clinical, personality and demographic aspects, such as comorbidity, phenomenology, and treatment outcome. The review suggests that the two disorders are highly comorbid, and show similar ages of onset, illness trajectories, and comparable clinical and personality characteristics. However, important differences emerge in their responsiveness to psychosocial and psychopharmacological treatment, which are discussed. Clinical implications of these findings are summarized and directions for future research are delineated, with a focus on how current treatment components from each disorder may inform new interventions for both disorders.

Altered insula activation during pain anticipation in individuals recovered from anorexia nervosa: evidence of interoceptive dysregulation

OBJECTIVE

Recent evidence raises the possibility that symptoms of anorexia nervosa (AN) could be related to impaired interoception. Pain is an interoceptive process with well-characterized neuroanatomical pathways that may overlap to a large degree with neural systems that may be dysregulated in individuals with AN, such as the insula.

METHOD

Functional magnetic resonance imaging (fMRI) was used to assess neural substrates of pain anticipation and processing in 10 healthy control women (CW) and 12 individuals recovered from AN (REC AN) in order to avoid the confounding effects of malnutrition. Painful heat stimuli were applied while different colors signaled the intensity of the upcoming stimuli.

RESULTS

REC AN compared with CW showed greater activation within right anterior insula (rAI), dorsolateral prefrontal cortex (dlPFC) and cingulate during pain anticipation, and greater activation within dlPFC and decreased activation within posterior insula during painful stimulation. Greater anticipatory rAI activation correlated positively with alexithymic feelings in REC AN participants.

DISCUSSION

REC AN showed a mismatch between anticipation and objective responses, suggesting altered integration and, possibly, disconnection between reported and actual interoceptive state. Alexithymia assessment provided additional evidence of an altered ability to accurately perceive bodily signals in women recovered from AN.

Disordered eating, perfectionism, and food rules

Clinically significant trait perfectionism is often characteristic of individuals exhibiting symptoms of eating disorders. The present study reports on a measure developed to assess the use of food rules and evaluates the hypothesis that adherence to food rules may be one mechanism through which trait perfectionism exacerbates risk for developing eating disorder symptoms. Forty-eight female college students completed a battery of questionnaires, and multiple regression analyses were used to test a mediational model. Results indicated that adherence to food rules mediated the relationship between self-oriented perfectionism and three indices of disordered eating in this sample. This relationship was specific to self-oriented perfectionism and did not hold for other-oriented or socially prescribed perfectionism. These findings may have implications for designing early interventions for disordered eating and may be useful in tailoring treatment for individuals with disordered eating who also report high levels of perfectionism.

Examination of weight control practices in a non-clinical sample of college women

The current study examined healthy weight control practices among a sample of college women enrolled at an urban university (N=715; age=19.87±1.16; 77.2% Caucasian; 13.4% African American, 7.2% Asian, 2.2% other races). Participants completed measures as part of an on-line study about health habits, behaviors, and attitudes. Items from the Three Factor Eating Questionnaire were selected and evaluated with exploratory factor analysis to create a healthy weight control practices scale. Results revealed that college women, regardless of weight status, used a comparable number (four of eight) of practices. Examination of racial differences between Caucasian and African American women revealed that normal weight African American women used significantly fewer strategies than Caucasian women. Of note, greater use of healthy weight control practices was associated with higher cognitive restraint, drive for thinness, minutes of physical activity, and more frequent use of compensatory strategies. Higher scores on measures of binge and disinhibited eating, body dissatisfaction, negative affect, and depressive symptoms were associated with greater use of healthy weight control practices by underweight/normal weight but not by overweight/obese college women. Results suggest that among a sample of college females, a combination of healthy and potentially unhealthy weight control practices occurs. Implications of the findings suggest the need for effective weight management and eating disorder prevention programs for this critical developmental life stage. Such programs should be designed to help students learn how to appropriately use healthy weight control practices, as motivations for use may vary by weight status.

Large neutral amino acids: dietary effects on brain neurochemistry and function

The ingestion of large neutral amino acids (LNAA), notably tryptophan, tyrosine and the branched-chain amino acids (BCAA), modifies tryptophan and tyrosine uptake into brain and their conversion to serotonin and catecholamines, respectively. The particular effect reflects the competitive nature of the transporter for LNAA at the blood-brain barrier. For example, raising blood tryptophan or tyrosine levels raises their uptake into brain, while raising blood BCAA levels lowers tryptophan and tyrosine uptake; serotonin and catecholamine synthesis in brain parallel the tryptophan and tyrosine changes. By changing blood LNAA levels, the ingestion of particular proteins causes surprisingly large variations in brain tryptophan uptake and serotonin synthesis, with minimal effects on tyrosine uptake and catecholamine synthesis. Such variations elicit predictable effects on mood, cognition and hormone secretion (prolactin, cortisol). The ingestion of mixtures of LNAA, particularly BCAA, lowers brain tryptophan uptake and serotonin synthesis. Though argued to improve physical performance by reducing serotonin function, such effects are generally considered modest at best. However, BCAA ingestion also lowers tyrosine uptake, and dopamine synthesis in brain. Increasing dopamine function in brain improves performance, suggesting that BCAA may fail to increase performance because dopamine is reduced. Conceivably, BCAA administered with tyrosine could prevent the decline in dopamine, while still eliciting a drop in serotonin. Such an LNAA mixture might thus prove an effective enhancer of physical performance. The thoughtful development and application of dietary proteins and LNAA mixtures may thus produce treatments with predictable and useful functional effects.

Loss of control over eating in pre-adolescent youth: the role of attachment and self-esteem

OBJECTIVE

The present study aimed to add to the limited literature on the role of self-esteem and attachment for the explanation of loss of control over eating (LC) among pre-adolescent boys and girls.

METHOD

Self-report questionnaires were administered to a community sample of 555 children (8-11 years; 47% female).

RESULTS

Children reporting LC (17.6% of the sample) were characterized by a lower self-esteem and less secure attachment toward both of their parents. No gender differences emerged. Moreover, the relation between self-esteem and LC was fully mediated by attachment toward mother and partially mediated by attachment toward father.

DISCUSSION

The present study provides preliminary evidence for the idea that the influence of self-esteem on LC seems to operate through a third variable that is an insecure relationship with the parents. Longitudinal research is needed to further elucidate the influence of interpersonal factors on the development of LC.

An FMRI study of self-regulatory control and conflict resolution in adolescents with bulimia nervosa

OBJECTIVE

The authors examined functional activity in the frontostriatal systems that mediate self-regulatory capacities and conflict resolution in adolescents with bulimia nervosa.

METHOD

Functional magnetic resonance imaging was used to compare blood-oxygen-level-dependent response in 18 female adolescents with bulimia nervosa and 18 healthy female age-matched subjects during performance on a Simon spatial incompatibility task. Bayesian analyses were used to compare the two groups on patterns of brain activation during correct responses to conflict stimuli and to explore the effects of antecedent stimulus context on group differences in self-regulation and conflict resolution.

RESULTS

Adolescents with and without bulimia nervosa performed similarly on the task. During correct responses in conflict trials, frontostriatal circuits-including the right inferolateral and dorsolateral prefrontal cortices and putamen-failed to activate to the same degree in adolescents with bulimia nervosa as in healthy comparison subjects. Instead, deactivation was seen in the left inferior frontal gyrus as well as a neural system encompassing the posterior cingulate cortex and superior frontal gyrus. Group differences in cortical and striatal regions were driven by the differential responses to stimuli preceded by conflict and nonconflict stimuli, respectively.

CONCLUSIONS

When engaging the self-regulatory control processes necessary to resolve conflict, adolescents with bulimia nervosa displayed abnormal patterns of activation in frontostriatal and default-mode systems. Their abnormal processing of the antecedent stimulus context conditioned their brain response to conflict differently from that of healthy comparison subjects, specifically in frontal regions. It is suspected that functional disturbances in frontal portions of frontostriatal systems may release feeding behaviors from regulatory control, thereby perpetuating the conflicting desires to consume fattening foods and avoid weight gain that characterize bulimia nervosa.

Brain tissue volume changes following weight gain in adults with anorexia nervosa

OBJECTIVE

To measure brain volume deficits among underweight patients with anorexia nervosa (AN) compared to control participants and evaluate the reversibility of these deficits with short-term weight restoration.

METHOD

Brain volume changes in gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) were examined in 32 adult women with AN and compared to 21, age and body mass index-range matched control women.

RESULTS

Patients with AN had a significant increase in GM (p = .006, η(2) = 0.14) and WM volume (p = .001, η(2) = 0.19) following weight restoration. Patients on average had lower levels of GM at low weight (647.63 ± 62.07 ml) compared to controls (679.93 ± 53.31 ml), which increased with weight restoration (662.64 ± 69.71 ml), but did not fully normalize.

DISCUSSION

This study suggests that underweight adult patients with AN have reduced GM and WM volumes that increase with short-term weight restoration.

Long-term outcome of pediatric eating pathology and predictors for the onset of loss of control over eating following weight-loss treatment

OBJECTIVE

To investigate the stability of eating pathology over a 6-year period and predictors for the onset of loss of control (LC) over eating among overweight youngsters having undergone weight-loss treatment.

METHOD

Structured clinical interviews and self-report questionnaires were administered to a sample of 56 overweight youngsters (M age = 13 years) who were at the start of weight-loss treatment in 2000 and again 6 years later.

RESULTS

Mean levels of eating concerns, drive for thinness, bulimic symptoms, and body dissatisfaction decreased over the 6-year period. Dietary restraint, weight, and shape concerns were stable over time. Also, in 50% of those reporting objective binge eating at baseline, binge-eating episodes remained stable. Youngsters characterized by symptoms of depression in early adolescence were at a higher risk for developing new episodes of LC 6 years later. Neither concerns about eating, shape, and weight nor dietary restraint independently predicted LC.

DISCUSSION

Six years after following structured weight-loss treatment, some eating pathology variables still remain stable. Especially youngsters who already report LC at young ages appear to develop a more stable pattern of disordered eating behavior.

College students' perceptions of individuals with anorexia and bulimia nervosa

OBJECTIVE

Eating disorders (EDs) are highly stigmatized conditions. This study explored factors hypothesized to influence this stigmatization including ethnicity, gender, ED subtype, and proposed etiology.

METHOD

Undergraduates (N = 235) read scenarios depicting fictional characters varying on ethnicity, gender ED subtype, and etiology. Participants reported perceptions of each character, and completed the EAT-26 and the Level-of-Contact scale.

RESULTS

Characters with BN were viewed as more responsible for their ED and more self-destructive than those with AN, who were viewed as more self-controlled. Characters with a sociocultural etiology were rated as most likely to recover. Characters with a biological etiology were viewed as more likeable than characters with an ambiguous etiology. Characters in the ambiguous group were viewed as more self-destructive, more responsible for their ED, and less self-controlled. Differences in participants' perceptions of the characters also emerged when examining ethnicity and gender. Finally, participants' own ED symptoms and their level of contact with EDs were associated with viewing characters as more similar and self-controlled.

DISCUSSION

Findings highlight the need for increased education about ED etiology and course.

How do eating disorder patients eat after treatment? Dietary habits and eating behaviour three years after entering treatment

OBJECTIVE

Improvements in psychological symptoms and weight have often been demonstrated following eating disorder (ED) treatment, but it is not clear to what extent eating behaviour itself is normalised. This cross-sectional study aimed to investigate dietary habits and eating behaviour in ED patients three years after entering treatment.

METHOD

ED patients (N=70) were divided into those who had recovered (N=36), and those who still suffered from bulimic (N=18) or anorexic (N=16) psychopathology. Patients were compared to a female normal control group of similar age (N=61), and assessments were made on a dietary questionnaire, as well as the BDI, EDI-2, SASB and SCL-90.

RESULTS

With some notable exceptions eating patterns in recovered patients resembled those of controls. Dieting was most evident in recovered and current bulimic patients, while restrictive eating and vegetarianism was found in recovered or current anorexic patients. A majority of the patients with ongoing EDs avoided fatty foods.

DISCUSSION

Risk behaviours such as restrictive eating, dieting and food avoidance, may have an important impact on relapse rates, and it may therefore be imperative to continue to monitor eating behaviour in ED patients following treatment termination to ensure better long-term outcome.

Endocrine manifestations of eating disorders

CONTEXT

The endocrinopathies associated with eating disorders involve multiple systems and mechanisms designed to preserve energy and protect essential organs. Those systems that are most affected are in need of significant energy, such as the reproductive and skeletal systems. The changes in neuropeptides and in the hypothalamic axis that mediate these changes also receive input from neuroendocrine signals sensitive to satiety and food intake and in turn may be poised to provide significant energy conservation. These adaptive changes are described, including the thyroid, GH, and cortisol axes, as well as the gastrointestinal tract.

EVIDENCE ACQUISITION

Articles were found via PubMed search for both original articles and reviews summarizing current understanding of the endocrine changes of eating disorders based on peer review publications on the topic between 1974 and 2009.

CONCLUSION

The signals that control weight and food intake are complex and probably involve multiple pathways that appear to have as a central control the hypothalamus, in particular the medial central area. The hypothalamic dysfunction of eating disorders provides a reversible experiment of nature that gives insight into understanding the role of various neuropeptides signaling nutritional status, feeding behavior, skeletal repair, and reproductive function.

Role of the neurotrophin network in eating disorders' subphenotypes: body mass index and age at onset of the disease

Eating disorders (ED) are severe psychiatric diseases that most likely result from, and are sustained by socio-cultural, psychological and biological factors. We explored whether members of the neurotrophin family are disease-modifying factors of quantitative traits, potentially contributing to the outcome or prognosis of the disease. We studied lifetime minimum and maximum body mass index (minBMI and maxBMI) and age at onset of the disease in a sample of 991 ED patients from France, Germany, Italy and Spain and analysed 183 genetic variants located in 10 candidate genes encoding different neurotrophins and their receptors. We used a hierarchical model approach to include prior genetic knowledge of the specific and found that variants in CNTF, in its receptor CNTFR, and in NTRK2 were significantly associated with a lower age at onset of the ED. In addition, one variant in NTRK1 was associated with a higher minBMI. The results suggest that for these two subphenotypes, CNTF, CNTFR, NTRK1 and NTRK2 might act as disease-modifying factors and add preliminary evidence to the global hypothesis that EDs are the result of complex interactions and reciprocal controls between the immune, endocrine and central nervous systems.

The effects of social support and coping on the relationship between social anxiety and eating disorders

The current study examined the hypotheses that social support and coping moderate and or mediate the relationship between a broad and a narrow form of social anxiety and eating disorder symptoms. One hundred sixty-nine female undergraduates at a private Midwestern university, completed measures of social support, coping, social anxiety, fear of negative evaluation, and disordered eating attitudes and behaviors. Results of hierarchical multiple regression analyses indicated that higher levels of social support are associated with a weaker association between social anxiety and eating disorder symptomatology. Low use of task- and avoidant-oriented (distraction) coping and increased use of emotion-oriented coping are associated with a stronger association between social anxiety and eating disorder symptomatology. Implications for research and clinical intervention are discussed.

Towards a neurocircuitry in anorexia nervosa: evidence from functional neuroimaging studies

Functional neuroimaging is widely used to unravel changes in brain functioning in psychiatric disorders. In the current study, we review single-photon emission tomography (SPECT), positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) studies in anorexia nervosa (AN), a difficult-to-treat eating disorder with the highest mortality rate among psychiatric disorders. We discuss the role of the parietal cortex, anterior and subgenual cingulate cortex, frontal cortex and temporal lobe in light of the cardinal symptoms of AN. The insights of the current review may ultimately lead to the development of new treatments.

Deficient activity in the neural systems that mediate self-regulatory control in bulimia nervosa

CONTEXT

Disturbances in neural systems that mediate voluntary self-regulatory processes may contribute to bulimia nervosa (BN) by releasing feeding behaviors from regulatory control.

OBJECTIVE

To study the functional activity in neural circuits that subserve self-regulatory control in women with BN.

DESIGN

We compared functional magnetic resonance imaging blood oxygenation level-dependent responses in patients with BN with healthy controls during performance of the Simon Spatial Incompatibility task.

SETTING

University research institute.

PARTICIPANTS

Forty women: 20 patients with BN and 20 healthy control participants. Main Outcome Measure We used general linear modeling of Simon Spatial Incompatibility task-related activations to compare groups on their patterns of brain activation associated with the successful or unsuccessful engagement of self-regulatory control.

RESULTS

Patients with BN responded more impulsively and made more errors on the task than did healthy controls; patients with the most severe symptoms made the most errors. During correct responding on incongruent trials, patients failed to activate frontostriatal circuits to the same degree as healthy controls in the left inferolateral prefrontal cortex (Brodmann area [BA] 45), bilateral inferior frontal gyrus (BA 44), lenticular and caudate nuclei, and anterior cingulate cortex (BA 24/32). Patients activated the dorsal anterior cingulate cortex (BA 32) more when making errors than when responding correctly. In contrast, healthy participants activated the anterior cingulate cortex more during correct than incorrect responses, and they activated the striatum more when responding incorrectly, likely reflecting an automatic response tendency that, in the absence of concomitant anterior cingulate cortex activity, produced incorrect responses.

CONCLUSIONS

Self-regulatory processes are impaired in women with BN, likely because of their failure to engage frontostriatal circuits appropriately. These findings enhance our understanding of the pathogenesis of BN by pointing to functional abnormalities within a neural system that subserves self-regulatory control, which may contribute to binge eating and other impulsive behaviors in women with BN.

Reduced perception of bodily signals in anorexia nervosa

OBJECTIVE

Interoceptive awareness is known to be impaired in eating disorders. To date, it has remained unclear whether this variable is related to the construct of interoceptive sensitivity. Interoceptive sensitivity is considered to be an essential variable in emotional processes. The objective of the study was to elucidate this potential relationship and to clarify whether general interoceptive sensitivity is reduced in anorexia nervosa.

METHODS

Using a heartbeat perception task, interoceptive sensitivity was assessed in 28 female patients with anorexia nervosa and 28 matched healthy controls. Questionnaires assessing interoceptive awareness (EDI) and several other variables were also administered.

RESULTS

Patients with anorexia nervosa displayed significantly decreased interoceptive sensitivity. They also had more difficulties in interoceptive awareness.

CONCLUSIONS

In addition to a decreased ability to recognize certain visceral sensations related to hunger, there is a generally reduced capacity to accurately perceive bodily signals in anorexia nervosa. This highlights the potential importance of interoceptive sensitivity in the pathogenesis of eating disorders.

Evaluation of integrative medicine supplements for mitigation of chronic insomnia and constipation in an inpatient eating disorders setting

OBJECTIVE

The aim of this study was to determine whether patients with eating disorders used fewer conventional sleep and constipation medications when given integrative medicine interventions.

DESIGN

Retrospective data from two cohorts were compared; the eating disorder group (ED) received only conventional treatments for insomnia and constipation and the integrative medicine eating disorders group (IMED) received integrative medicine and conventional treatments if needed. Patient reports of insomnia and constipation as well as medication use for these conditions were collected and compared.

RESULTS

Patient demographics were similar in the two groups. Although reports of sleeping well were similar, use of conventional sleep medications was significantly lower for the IMED group. Reports of constipation and use of conventional constipation medications were also lower for IMED versus ED, but these differences were not all statistically significant.

CONCLUSION

Integrative medicine interventions for insomnia and constipation appear to benefit patients with eating disorders and may allow these patients more focus for the work of recovery.

Neurobiology of anorexia and bulimia nervosa

Anorexia nervosa (AN) and bulimia nervosa (BN) are related disorders of unknown etiology that most commonly begin during adolescence in women. AN and BN have unique and puzzling symptoms, such as restricted eating or binge-purge behaviors, body image distortions, denial of emaciation, and resistance to treatment. These are often chronic and relapsing disorders, and AN has the highest death rate of any psychiatric disorder. The lack of understanding of the pathogenesis of this illness has hindered the development of effective interventions, particularly for AN. Individuals with AN and BN are consistently characterized by perfectionism, obsessive-compulsiveness, and dysphoric mood. Individuals with AN tend to have high constraint, constriction of affect and emotional expressiveness, ahendonia and asceticism, whereas individuals with BN tend to be more impulsive and sensation seeking. Such symptoms often begin in childhood, before the onset of an eating disorder, and persist after recovery, suggesting they are traits that create a vulnerability for developing an ED. There is growing acknowledgement that neurobiological vulnerabilities make a substantial contribution to the pathogenesis of AN and BN. Considerable evidence suggests that altered brain serotonin (5-HT) function contributes to dysregulation of appetite, mood, and impulse control in AN and BN. Brain imaging studies, using 5-HT specific ligands, show that disturbances of 5-HT function occur when people are ill, and persist after recovery from AN and BN. It is possible that a trait-related disturbance of 5-HT neuronal modulation predates the onset of AN and contributes to premorbid symptoms of anxiety, obsessionality, and inhibition. This dysphoric temperament may involve an inherent dysregulation of emotional and reward pathways which also mediate the hedonic aspects of feeding, thus making these individuals vulnerable to disturbed appetitive behaviors. Restricting food intake may become powerfully reinforcing because it provides a temporary respite from dysphoric mood. Several factors may act on these vulnerabilities to cause AN to start in adolescence. First, puberty-related female gonadal steroids or age-related changes may exacerbate 5-HT dysregulation. Second, stress and/or cultural and societal pressures may contribute by increasing anxious and obsessional temperament. Individuals with AN may discover that reduced dietary intake, by reducing plasma tryptophan availability, is a means by which they can modulate brain 5-HT functional activity and anxious mood. People with AN enter a vicious cycle which accounts for the chronicity of this disorder because caloric restriction results in a brief respite from dysphoric mood. However, malnutrition and weight loss, in turn, produce alterations in many neuropeptides and monoamine function, perhaps in the service of conserving energy, but which also exaggerates dysphoric mood. In summary, this article reviews findings in brain chemistry and neuroimaging that shed new light on understanding the psychopathology of these difficult and frustrating disorders.

Presentation of eating disorders in the news media: What are the implications for patient diagnosis and treatment?

OBJECTIVE

Eating disorder (ED) specialists increasingly see anorexia nervosa and bulimia nervosa as complex mental illnesses with both genetic and social roots. The public, however, tends to view EDs more simply as a manifestation of personal or social problems among female, white, young women. This disconnect potentially prevents timely ED diagnosis and reinforces a stigma that limits treatment availability. We examine the presentation of EDs in daily newspapers, an important contributor to shaping public perception of EDs.

METHODS

We analyze 1 year of coverage about EDs by seven daily U.S. newspapers (252 articles), focusing on the messages conveyed about epidemiology, etiology, severity and treatment.

RESULTS

The highest proportion of articles about EDs (48%) ran in arts and entertainment sections. Articles primarily covered those who are female, young and white, and mentioned mainly environmental causal factors. Only 8% of patient profiles discussed treatment and recovery within a medical context.

CONCLUSION

News coverage rarely presents EDs as complex medical phenomena, but rather simplifies and sensationalizes these conditions.

PRACTICE IMPLICATIONS

Educators would benefit from recognizing the news media's role in shaping public perceptions of EDs in ways that differ from clinical perspectives, potentially limiting diagnosis and treatment. Three communication improvements are suggested.

Stress, health complaints and self-confidence: a comparison between young adult women in Sweden and USA

Transition to adulthood is a period in life when women encounter conflicts, ambiguities and rapidly expanding roles that may be stressful and difficult to manage. The aim of this study was to compare stress in daily life, health complaints and self-confidence in 26-year old women in two different cultures. A health survey study was performed among Swedish women (n = 386) and American women (n = 201) living in urban areas at the West coast of Sweden and in Minnesota. Both Swedish and American women reported stress in their everyday life, with higher figures for the Americans. Overall health was rated lower by the Swedish women and they reported more health complaints such as headache, general tiredness, irritability, depression and sleeping disorders. There was a difference between groups in self-confidence with higher figures for excellent self-confidence among American women. However, low self-confidence was reported by more American than Swedish women. A good work situation predicted self-confidence in Swedish women and financial confidence in American women. Physical fitness was associated with self-confidence in both groups. Young women in both cultures experienced high level of stress but health related complaints were more common among Swedish women. High stress and health complaints must be taken seriously and interventions to support young women in the midst of transition to adulthood should contain stress reduction as well as empowerment performed in a more effective way than today in different health care settings and at place of work.

Screening disordered eating attitudes and eating disorders in a sample of Turkish female college students

It has been hypothesized that college women are particularly susceptible to the development and maintenance of disturbed eating behaviors. The purpose of this study was to determine the frequency of disordered eating attitudes and eating disorders in a sample of Turkish female college students. The Eating Attitudes Test was administered to a sample of 414 female college students. The subjects who had a score of 30 or higher were accepted as having disordered eating attitudes, and all of them have been examined using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for eating disorders. Of the overall sample, 17.1% of subjects were classified as having disordered eating attitudes. This subgroup of subjects was then compared with the remainder on all the other measures. The differences between students with disordered eating attitudes and those without on sociodemographic variables (except for age) were not statistically significant. The rate was 1% for eating disorders including anorexia nervosa (0.5%) and bulimia nervosa (0.5%). This study suggested that the prevalences of disordered eating attitudes and anorexia nervosa among female college students in Turkey were similar to those found in Western societies, but the rate for bulimia nervosa was lower compared with Western societies.