Pediatric Loss-of-Control Eating and Anxiety in Relation to Components of Metabolic Syndrome

Associations of social and cognitive-behavioral variables with disinhibited eating and anxiety: An ecological momentary assessment study

OBJECTIVE

Among adolescents, disinhibited eating and anxiety commonly co-occur. Precision intervention approaches targeting unique mechanistic vulnerabilities that contribute to disinhibited eating and anxiety may therefore be helpful. However, the effectiveness of such interventions hinges on knowledge of between- and within-person associations related to disinhibited eating, anxiety, and related processes.

METHOD

A sample of 39 adolescent females (12-17 years) with elevated anxiety and above-average weight (BMI %ile ≥ 75th) completed measures of theoretically driven social and cognitive-behavioral variables, disinhibited eating, and anxiety via ecological momentary assessment over 7 days. Data were analyzed using mixed-effects models.

RESULTS

Between-person differences in social stressors were linked to emotional eating, eating in the absence of hunger, and anxiety, whereas between-person differences in negative thoughts were associated with all disinhibited eating variables and anxiety. Between-person differences in avoidance were not related to any outcome. Additionally, between-person differences in social stressors and negative thoughts-as well as within-person deviations (from person-average levels) of social stressors, negative thoughts, and avoidance-were associated with anxiety. In turn, between-person differences in anxiety predicted eating in the absence of hunger and emotional eating, and within-person deviations in anxiety were associated with emotional eating at any given time point.

DISCUSSION

Findings support elements of both the interpersonal and cognitive-behavioral models of disinhibited eating. Differential trigger effects on anxiety, both at the between- and within-person levels, and significant associations between anxiety and all eating-related outcomes, highlight the potential utility of interventions targeting individual differences in sensitivity to anxiety triggers.

PUBLIC SIGNIFICANCE

Findings provide support for the interpersonal and cognitive-behavioral models of disinhibited eating, highlighting anxiety as a salient vulnerability and potential mechanistic factor underlying disinhibited eating. Social, cognitive, and behavioral variables were differentially related to anxiety across participants, suggesting potential for future intervention tailoring and intervention selection based on adolescents' sensitivity to anxiety as a trigger for disinhibited eating behavior.

Neural underpinnings of threat bias in relation to loss-of-control eating behaviors among adolescent girls with high weight

Introduction

Loss-of-control (LOC) eating, a key feature of binge-eating disorder, may relate attentional bias (AB) to highly salient interpersonal stimuli. The current pilot study used magnetoencephalography (MEG) to explore neural features of AB to socially threatening cues in adolescent girls with and without LOC-eating.

Methods

Girls (12-17 years old) with overweight or obesity (BMI >85th percentile) completed an AB measure on an affective dot-probe AB task during MEG and evoked neural responses to angry or happy (vs. neutral) face cues were captured. A laboratory test meal paradigm measured energy intake and macronutrient consumption patterns.

Results

Girls (N = 34; Mage = 15.5 ± 1.5 years; BMI-z = 1.7 ± 0.4) showed a blunted evoked response to the presentation of angry face compared with neutral face cues in the left dorsolateral prefrontal cortex, a neural region implicated in executive control and regulation processes, during attention deployment (p < 0.01). Compared with those without LOC-eating (N = 21), girls with LOC-eating (N = 13) demonstrated a stronger evoked response to angry faces in the visual cortex during attention deployment (p < 0.001). Visual and cognitive control ROIs had trends suggesting interaction with test meal intake patterns among girls with LOC-eating (ps = 0.01).

Discussion

These findings suggest that girls with overweight or obesity may fail to adaptively engage neural regions implicated in higher-order executive processes. This difficulty may relate to disinhibited eating patterns that could lead to excess weight gain.

Loss of control eating in relation to blood pressure among adolescent girls with elevated anxiety at-risk for excess weight gain

Loss of control (LOC)-eating, excess weight, and anxiety are robustly linked, and are independently associated with markers of poorer cardiometabolic health, including hypertension. However, no study has examined whether frequency of LOC-eating episodes among youth with anxiety symptoms and elevated weight status may confer increased risk for hypertension. We examined the relationship between LOC-eating frequency and blood pressure among 39 adolescent girls (14.9 ± 1.8 years; body mass index [BMI] = 29.9 ± 5.6; 61.5 % White; 20.5 % African American/Black; 5 % Multiple Races; 2.5 % Asian; 12.8 % Hispanic/Latino; 30.8 % with reported LOC-eating) with elevated anxiety and above average BMI who enrolled in a clinical trial aimed at preventing excess weight gain. LOC-eating over the past three months was assessed via clinical interview, and blood pressure (systolic and diastolic) was measured with an automatic blood pressure monitor. Adjusting for age, fat mass, and height, LOC-eating episode frequency was significantly, positively associated with diastolic blood pressure (β = 0.38, p = 0.02), but not with systolic blood pressure (β = 0.13, p = 0.41). Replication studies, with larger sample sizes, participants of varying weight-strata, and prospective data are required to elucidate the relationship between LOC-eating and cardiovascular functioning in youth with elevated anxiety.

Associations of Food Reinforcement and Food- Related Inhibitory Control with Adiposity and Weight Gain in Children and Adolescents

Some, but not all studies have reported that, among youth with disordered eating and high weight, the relative reinforcing value of food (RRV-F, i.e., how hard a person will work for a high-energy-dense food when another reward is available) is greater, and food-related inhibitory control (i.e., ability to withhold a response to food-related stimuli) is lower, compared to peers without disordered eating or overweight. In most studies, high RRV-F and low food-related inhibitory control have been studied separately, as independent factors, with each suggested to predict excess weight and adiposity (fat mass) gain. We hypothesized that the interaction of these factors would prospectively exacerbate risk for weight and adiposity (fat mass) gain three years later in a sample of healthy youth. At baseline, RRV-F was measured using a Behavior Choice Task with the rewards being standardized servings of chocolate candies, cheese crackers, or fruit snacks. Food-related inhibitory control was determined by performance in response to food and non-food stimuli during a Food Go/No-Go task. At baseline and 3-year visits, total body adiposity was measured by dual-energy X-ray absorptiometry (DXA) and body mass index (BMI) was obtained using measured weight and height. A linear regression was conducted with 3-year adiposity as the dependent variable. RRV-F, food-related inhibitory control, and the RRV-F x food-related inhibitory control interaction as independent variables. Baseline adiposity, age, height, sex, race/ethnicity, and days between visits were included as covariates for model predicting 3-year adiposity. Baseline BMI, age, sex, race/ethnicity, and days between visits were included as covariates for model predicting 3-year BMI. One-hundred and nine youth (mean 12.4±2.7y, mean 0.50±1.02 BMIz, 30.3% with overweight/obesity, 45.9% female, 51.4% non-Hispanic White), 8-17 years at baseline, were studied. Baseline food-related inhibitory control (β_{unstandardized} = .33, p = .037, 95% CI [.02, .64]), but not baseline RRV-F (β_{unstandardized} = -.003, p = .914), 95% CI [-.05, .05]) was significantly associated with 3-year adiposity such that those with the lowest food-related inhibitory control had the greatest adiposity gain. The interaction between RRV-F and food-related inhibitory control did not predict 3-year adiposity (β_{unstandardized} = -.07, p = .648, 95% CI [-.39, .25]). The pattern of findings was the same for models examining non-food related inhibitory control. Neither baseline food-related inhibitory control (β_{unstandardized} = 2.16, p = .256, 95% CI [-1.59, 5.92]), baseline RRV-F (β_{unstandardized} = .14, p = .660, 95% CI [-.48, .75]), nor their interaction (β_{unstandardized} = -1.18, p = .547, 95% CI [-5.04, 2.69]) were significantly associated with 3-year BMI. However, non-food related inhibitory control (β_{unstandardized} = .54, p = .038, 95% CI [.22, 7.15]) was significantly associated with 3-year BMI. In summary, food-related inhibitory control but not RRV-F, was associated with changes in adiposity in a sample of children and adolescents. Among generally healthy youth, food-related inhibitory control may be a more relevant risk factor than food reinforcement for adiposity gain. Additional data are needed to determine how impulsivity and reward systems, as well as other disinhibited eating behaviors/traits, may interact to promote excess weight gain over time in youth.

Trait anxiety is associated with amygdala expectation and caloric taste receipt response across eating disorders

Anxious traits are elevated in eating disorders (EDs), are considered risk factors for ED development, and trait anxiety has been linked to ED psychopathology. How trait anxiety relates to ED neurobiology is not well understood. In this study 197 individuals across the ED spectrum (anorexia nervosa n = 91; other specified EDs n = 34; bulimia nervosa n = 56; binge ED n = 16), and 120 healthy controls were assessed for anxious traits and learned to expect and receive caloric or neutral taste stimuli during brain imaging. Amygdala sucrose expectation response differed across groups (Wilk's lambda = 0.945, p = 0.023), and was higher on the left in anorexia nervosa compared to healthy controls (p = 0.002). Expected sucrose receipt response across taste reward regions was not different between groups. In the ED sample, trait anxiety negatively moderated the relationship between amygdala expectation and right dorsal (p = 0.0062) and ventral (p = 0.0046) anterior insula receipt response. A subgroup analysis showed similar results for anorexia nervosa, and partially in bulimia nervosa. Across EDs, appetitive motivation correlated positively with bilateral orbitofrontal cortex, caudate head, and ventral striatal sucrose receipt response (r = 0.215 to 0.179, p = 0.002 to 0.012). Across the study sample, trait anxiety showed an inverted-U-shaped relationship with right (r = 0.147, p = 0.034) and left (r = 0.162, p = 0.016) amygdala expectation response. Amygdala sucrose expectation response is elevated in anorexia nervosa, correlates with sucrose receipt response, and this relationship is negatively moderated by trait anxiety across EDs. Trait anxiety may have an important role in how expectation drives taste stimulus receipt brain response and perhaps food approach in individuals with EDs.

What next for eating disorder genetics? Replacing myths with facts to sharpen our understanding

Substantial progress has been made in the understanding of anorexia nervosa (AN) and eating disorder (ED) genetics through the efforts of large-scale collaborative consortia, yielding the first genome-wide significant loci, AN-associated genes, and insights into metabo-psychiatric underpinnings of the disorders. However, the translatability, generalizability, and reach of these insights are hampered by an overly narrow focus in our research. In particular, stereotypes, myths, assumptions and misconceptions have resulted in incomplete or incorrect understandings of ED presentations and trajectories, and exclusion of certain patient groups from our studies. In this review, we aim to counteract these historical imbalances. Taking as our starting point the Academy for Eating Disorders (AED) Truth #5 "Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses", we discuss what we do and do not know about the genetic underpinnings of EDs among people in each of these groups, and suggest strategies to design more inclusive studies. In the second half of our review, we outline broad strategic goals whereby ED researchers can expand the diversity, insights, and clinical translatability of their studies.

Loss-of-Control Eating and Cardiometabolic Health in Relation to Overweight and Obesity

PURPOSE OF REVIEW

Loss-of-control (LOC) eating, the subjective feeling of being unable to control what or how much is being consumed, is common. The purpose of this review was to examine the relationships among LOC eating, cardiometabolic health, and weight management intervention outcomes.

RECENT FINDINGS

In youth and adults, LOC eating is associated with and predictive of psychological symptoms, high weight, and worsened cardiometabolic health. While LOC eating pre-intervention does not appear to impact outcomes, LOC eating during or following is associated with worsened outcomes from behavioral and surgical weight management interventions. When individuals are undergoing weight management interventions, it may be important to regularly assess for LOC eating. There is limited research on the examined relationships in diverse populations (e.g., males, individuals of a lower socio-economic status, racial/ethnic minority groups). Future research should examine these relationships across the lifespan in diverse populations, with a focus on how these relationships can be impacted through targeted interventions.

A comparison of negative affect and disinhibited eating between children with and without parents with type 2 diabetes

BACKGROUND

Children whose parents have type 2 diabetes (T2D) are at high-risk for developing T2D. In youth, negative affect has been shown to predict insulin resistance (IR), and disinhibited-eating behaviors have been linked to IR. It is unknown if youth with a parent with T2D (P-T2D) report greater psychological and behavioral symptoms than those without a P-T2D.

OBJECTIVE

To compare youth with and without a P-T2D on symptoms of negative affect and disinhibited-eating.

METHODS

Nine-hundred thirty-two youth (13.3 ± 2.6 years; BMIz 1.06 ± 1.06; 67.8% female; 53.6% people of color; 10.7% with a P-T2D) completed questionnaires of anxiety and depressive symptoms, eating in the absence of hunger, and emotional-eating. Loss-of-control (LOC)-eating was assessed by interview. In two separate subsamples, energy intake was explored using laboratory test meals simulating eating in the absence of hunger and LOC-eating, respectively. Analyses were adjusted for age, sex, race/ethnicity. In follow-up analyses, fat mass (kg) and height, and IR were included as covariates, respectively.

RESULTS

Adjusting for all covariates including adiposity and IR, compared to youth without a P-T2D, youth with a P-T2D reported more anxiety and depression symptoms, greater eating in the absence of hunger, and emotional-eating (ps < 0.05). No significant differences were found for LOC-eating, or in exploratory analyses of energy intake for either test meal (ps > 0.16).

CONCLUSIONS

Self-reported negative affect and disinhibited-eating may be higher among youth with P-T2D compared to those without P-T2D. Prospective studies should examine, among those with a P-T2D, what role such symptoms may play for their subsequent risk for T2D.

General and Eating Disorder Psychopathology in Relation to Short- and Long-Term Weight Change in Treatment-Seeking Children: A Latent Profile Analysis

BACKGROUND

Concurrent general psychopathology (GP) and eating disorder psychopathology (EDP) are commonly reported among youth with overweight/obesity and may impact weight change.

PURPOSE

We identified patterns of GP and EDP in children with overweight/obesity and examined the impact on weight change following family-based behavioral obesity treatment (FBT) and maintenance interventions.

METHODS

Children (N = 172) participated in 4 month FBT and subsequent 8 month weight maintenance interventions. GP and EDP were assessed prior to FBT (baseline). Child percentage overweight was assessed at baseline, post-FBT (4 months), and post-maintenance (12 months). Latent profile analysis identified patterns of baseline GP and EDP. Linear mixed-effects models examined if profiles predicted 4- and 12-month change in percentage overweight and if there were two-way and three-way interactions among these variables, adjusting for relevant covariates.

RESULTS

Results indicated a three-profile structure: lower GP and EDP (LOWER); subclinically elevated GP and EDP without loss of control (LOC; HIGHER); and subclinically elevated GP and EDP with LOC (HIGHER + LOC). Across profiles, children on average achieved clinically meaningful weight loss (i.e., ≥9 unit change in percentage overweight) from baseline to 4 month FBT and sustained these improvements at 12 month maintenance. There was no evidence that latent profiles were related to percentage overweight change from baseline to FBT (p > .05) or baseline to maintenance (p > .05). There was no evidence for two-way or three-way interactions (p > .05).

CONCLUSION

Concurrent GP and EDP do not portend differential short- or long-term weight change following FBT and maintenance. Future research is warranted on the durability of weight change among youth with GP and EDP.

TRIAL REGISTRATION

NCT00759746.

Inhibitory control and negative affect in relation to food intake among youth

Negative affect and poor inhibitory control are related to disinhibited eating behaviors in youth and may contribute to the development and/or maintenance of obesity. Although few studies have jointly examined these constructs in youth, it has been theorized that poor inhibitory control may be driven by negative affect. If supported, impaired inhibitory control, driven by negative affect, could represent a modifiable neurocognitive treatment target for disinhibited eating. The current study examined whether inhibitory control mediates the relationship between negative affect and eating among youth. Youth (8-17 years) participated in a Food Go/No-Go neurocognitive task to measure inhibitory control as the percentage of commission errors. A composite negative affect score was created from self-report measures of anxiety and depression. A laboratory buffet meal modeled to simulate disinhibited eating was used to measure total and snack food intake. Cross-sectional mediation models with bias-corrected bootstrap confidence intervals (CI) were conducted using negative affect as the independent variable, inhibitory control as the mediator, and intake patterns as dependent variables. One-hundred-eighty-one youths (13.2 ± 2.7y; 55% female; BMIz 0.6 ± 1.0) were studied. Total Go/No-Go commission errors mediated the relationship between negative affect and total intake (95%CI = [0.3, 31.6]), but not snack intake (95%CI = [-2.5, 7.3]). Commission errors for Food-Go blocks significantly mediated the relationship between negative affect and total intake (95%CI = [7.7, 44.4]), but not snack intake (95%CI = [-3.4, 9.5]). Commission errors on Neutral-Go blocks did not significantly mediate any of these relationships. Negative affect may lead to poorer inhibitory control as well as a stronger approach tendency toward food, increasing the likelihood of engaging in disinhibited eating. Future research should determine if, in combination with approaches to reduce negative affect, improved inhibitory control could help prevent overeating in youths with depressive or anxiety symptoms.

Low body mass and ethnic identity exploration exacerbate the association between body image concerns and loss of control eating in Hispanic/Latino men

OBJECTIVE

Although Hispanic/Latino populations have some of the highest rates of obesity in the United States, little is known about their loss of control (LOC) eating, a robust predictor of excess weight gain. This study examined the association between body image concerns and LOC eating frequency in a sample of young Hispanic/Latino men. Body mass index (BMI), ethnic identity, and acculturation were examined as potential moderators.

METHOD

The sample included 271 Hispanic/Latino men between the ages of 18 and 30 years (M_age = 23.89 ± 3.54; M_BMI = 26.46 ± 5.82). Participants completed an online survey and reported on height, weight, and demographic characteristics; concerns with muscularity and body fat; LOC eating frequency in the last 28 days; ethnic identity; and perceived acculturation.

RESULTS

Negative binomial regression models were conducted, adjusting for BMI, income, education, and presence of a psychiatric diagnosis. Concerns with muscularity and body fat were positively associated with LOC eating frequency (ps < .001). Low BMI exacerbated the link between concerns with body fat and LOC eating frequency (p = .03). The positive association between concerns with muscularity and LOC eating frequency was exacerbated among those who reported low ethnic identity exploration (p = .01). While acculturation did not function as a moderator (ps = .14-.27), it was inversely associated with LOC eating frequency (p < .001).

DISCUSSION

BMI and ethnic identity are important individual factors to consider in the link between body image concerns and LOC eating among young Hispanic/Latino men.

Relationships of Trait Anxiety and Loss of Control Eating with Serum Leptin Concentrations among Youth

Loss of control (LOC) eating in youth is associated with elevated fasting serum leptin, even after accounting for adiposity. Anxiety is closely linked to, and may exacerbate, LOC eating. Yet, it remains unclear how anxiety relates to leptin, or if the relationship is moderated by the presence of LOC eating. We examined whether self-reported trait anxiety interacted with LOC eating in relation to leptin in a convenience sample of youths (n = 592; 13.1 ± 2.7 years; body mass index z-score (BMIz) = 0.9 ± 1.1; 61.8% girls; 53.5% non-Hispanic White; 36.6% with LOC eating). LOC eating was assessed by interview. Leptin was measured after an overnight fast. Exploratory analyses were conducted to examine anxiety and LOC eating in relation to laboratory intake patterns in three sub-samples. In a generalized linear model adjusting for relevant covariates, anxiety significantly interacted with LOC eating in relation to leptin (p = 0.02), such that greater trait anxiety related to higher concentrations of leptin only among youth with LOC eating. Trait anxiety was not significantly related to fasting serum leptin independently in a generalized linear model adjusting for age, race, height, sex, study type, and fat mass (kg). Exploratory mechanistic analyses of food intake patterns did not identify consistent results for participants with both anxiety and LOC eating. Among youth with LOC eating, anxiety may be associated with higher serum leptin. Prospective data are required to elucidate the directionality and mechanisms of these relationships.

The association between alexithymia and eating behavior in children and adolescents

OBJECTIVE

Alexithymia, or the difficulty identifying or describing one's own emotions, may be a risk factor for dysregulated eating and excess weight gain. However, the relationships between alexithymia and eating behaviors in community samples of non-clinical youth have not been well-characterized. We hypothesized that alexithymia would be positively associated with disordered and disinhibited eating in a community-based sample of boys and girls without an eating disorder.

METHOD

Two hundred children (8-17 years old) across the weight spectrum completed an interview to assess loss of control (LOC) eating and eating-related psychopathology, a laboratory test meal designed to induce disinhibited eating, and questionnaires to assess alexithymia, eating in the absence of hunger, and emotional eating. Linear and logistic regressions were conducted to examine the relationship between alexithymia and eating variables, with age, sex, race, and fat mass as covariates. Test meal analyses also adjusted for lean mass. Given the overlap between alexithymia and depression, all models were repeated with depressive symptoms as an additional covariate.

RESULTS

Alexithymia was associated with an increased likelihood of reporting LOC eating (p < .05). Moreover, alexithymia was positively associated with disordered eating attitudes, emotional eating, and eating in the absence of hunger (ps < .05). Greater alexithymia was associated with more carbohydrate and less fat intake at the test meal (ps < .05). After adjusting for depressive symptoms, alexithymia remained associated with eating in the absence of hunger and carbohydrate and fat intake (ps < .05).

DISCUSSION

In healthy children, alexithymia is associated with some facets of eating behavior and food intake. If supported prospectively, these preliminary findings suggest alexithymia may be a modifiable risk factor to reduce disordered eating and excess weight gain in youth.

Loss-of-Control Eating and Obesity Among Children and Adolescents

PURPOSE OF REVIEW

This review summarizes findings on pediatric loss-of-control (LOC) eating and obesity published since 2013 in relation to physiological, socioenvironmental, and psychological factors.

RECENT FINDINGS

LOC eating and obesity are highly comorbid in youth. Genetic and physiological risk factors are associated with the development of LOC eating. Adverse physiological outcomes of LOC eating include increased risk for overweight and obesity and greater dysfunction in components of metabolic syndrome. Socioenvironmental, psychological, and behavioral factors, such as weight-based teasing, dieting, negative affect, emotion dysregulation, and aspects of cognitive functioning, are consistently related to LOC eating in youth, independent of weight. Prospectively, LOC eating may predict the onset of anxiety disorders, depression, and more severe eating psychopathology later in life. Updates on interventions and future directions are discussed. LOC eating may be a key symptom to target adverse physiological and psychological outcomes; however, treatments are limited and require further examination.