Rates and correlates of study enrolment and use of a chatbot aimed to promote mental health services use for eating disorders following online screening

OBJECTIVE

We developed a chatbot aimed to facilitate mental health services use for eating disorders (EDs) and offered the opportunity to enrol in a research study and use the chatbot to all adult respondents to a publicly available online ED screen who screened positive for clinical/subclinical EDs and reported not currently being in treatment. We examined the rates and correlates of enrolment in the study and uptake of the chatbot.

METHOD

Following screening, eligible respondents (≥18 years, screened positive for a clinical/subclinical ED, not in treatment for an ED) were shown the study opportunity. Chi-square tests and logistic regressions explored differences in demographics, ED symptoms, suicidality, weight, and probable ED diagnoses between those who enroled and engaged with the chatbot versus those who did not.

RESULTS

6747 respondents were shown the opportunity (80.0% of all adult screens). 3.0% enroled, of whom 90.2% subsequently used the chatbot. Enrolment and chatbot uptake were more common among respondents aged ≥25 years old versus those aged 18-24 and less common among respondents who reported engaging in regular dietary restriction.

CONCLUSIONS

Overall enrolment was low, yet uptake was high among those that enroled and did not differ across most demographics and symptom presentations. Future directions include evaluating respondents' attitudes towards treatment-promoting tools and removing barriers to uptake.

Preferred treatment focus among college students with eating disorders and comorbid mental health problems in a digital cognitive-behavioral guided self-help program

OBJECTIVE

To examine the mental health problems that college students with eating disorders (EDs) and comorbid depression and/or anxiety disorders preferred to target first in a digital treatment program and explore correlates of preferred treatment focus.

METHODS

Four hundred and eighty nine college student users of a digital cognitive-behavioral guided self-help program targeting common mental health problems (76.7% female, Mage  = 20.4 ± 4.4, 64.8% White) screened positive for an ED and ≥one other clinical mental health problem (i.e., depression, generalized anxiety disorder, social phobia, and/or panic disorder). Students also reported on insomnia, post-traumatic stress, alcohol use, and suicide risk. Before treatment, they indicated the mental health problem that they preferred to target first in treatment. Preferred treatment focus was characterized by diagnostic profile (i.e., ED + Depression, ED + Anxiety, ED + Depression + Anxiety), symptom severity, and demographics.

RESULTS

58% of students with ED + Anxiety, 47% of those with ED + Depression, and 27% of those with ED + Depression + Anxiety chose to target EDs first. Across diagnostic profiles, those who chose to target EDs first had more severe ED symptoms than those who chose to target anxiety or depression (ps < .05). Among students with ED + Depression + Anxiety, those who chose to target EDs first had lower depression symptoms than those who chose to target depression, lower generalized anxiety than those who chose to target anxiety, and lower suicidality than those who chose to target anxiety or depression (ps < .01).

CONCLUSIONS

Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles. Research should explore specific symptom presentations associated with preferred treatment focus.

PUBLIC SIGNIFICANCE

Findings indicate that a sizable percentage of college students with depression/anxiety who also have EDs prefer to target EDs first in treatment, highlighting the importance of increasing availability of ED interventions to college students. Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles, and preference to target EDs was associated with greater ED psychopathology across diagnostic profiles.

The relation of food insecurity to eating disorder characteristics and treatment-seeking among adult respondents to the National Eating Disorders Association online screen

BACKGROUND

Food insecurity (FI), characterized by limited or uncertain access to adequate food, has been associated with eating disorders (EDs). This study explored whether FI was associated with ED behaviors, ED diagnosis, current treatment status, and treatment-seeking intentions among adults who completed an online ED screen.

METHODS

Respondents to the National Eating Disorders Association online screening tool self-reported demographics, FI, height and weight, past 3-month ED behaviors, and current treatment status. Respondents were also asked an optional question about treatment-seeking intentions. Hierarchical regressions evaluated relations between FI and ED behaviors, treatment status, and treatment-seeking intentions. Logistic regressions explored differences in probable ED diagnosis by FI status.

RESULTS

Of 8714 respondents, 25 % screened at risk for FI. FI was associated with greater binge eating (R2Change = 0.006), laxative use (R2Change = 0.001), and presence of dietary restriction (R2Change = 0.001, OR: 1.32) (ps < .05). Having FI was associated with greater odds of screening positive for a probable ED or as high risk for an ED (ps < .05). FI was not associated with current treatment status or treatment-seeking intentions (ps > .05).

CONCLUSIONS

Findings add to existing literature supporting a relation between FI and EDs. Implications include a need to disseminate EDs screening and treatment resources to populations affected by FI and to tailor treatments to account for barriers caused by FI.

Evaluation of a combined, online intervention for binge-type eating disorders and high body weight in young adults

BACKGROUND

Binge-type eating disorders (EDs; i.e., bulimia nervosa, binge eating disorder) are common among young adults with high body weight, yet few interventions target both conditions. This study tested an online guided self-help intervention that provided cognitive behavioral therapy (CBT) tools for EDs and behavioral weight loss (BWL) content to young adults with binge-type EDs and high body weight.

METHOD

60 adults aged 18-39 with clinical/subclinical binge-type EDs and high body weight were randomized to a combined condition or a CBT-only condition. Participants received self-help content for 8 weeks and self-reported ED attitudes, frequency of binge eating and compensatory behaviors, and weight at baseline, 4-weeks, and 8-weeks. Linear mixed models and negative binomial models compared changes between conditions in ED attitudes, ED behaviors, and weight at each timepoint. Chi-square test and independent samples t-test compared program completion and session engagement between conditions.

RESULTS

No significant differences in weight change or ED symptom change emerged between the conditions. Both conditions achieved significant reductions in ED attitudes, binge episodes, and compensatory behaviors from baseline to 8-weeks (ps < .05). Neither condition demonstrated significant weight loss from baseline to 8-weeks. Program completion (47 %) and session engagement (57 %) were equally high across conditions.

DISCUSSION

Both conditions achieved ED symptom change; however, neither condition was associated with weight change. Research is needed to identify the types of strategies and doses of BWL that promote clinically significant weight and ED symptom change in young adults.

Reach and uptake of digital mental health interventions based on cognitive-behavioral therapy for college students: A systematic review

Background

Mental health problems are increasing in prevalence among college students, yet few students receive treatment due to barriers such as insufficient resources in college counseling centers. Digital mental health interventions (DMHIs) have potential to overcome barriers and offer accessible, evidence-based care to college students. However, to evaluate the true public health impact of evidence-based DMHIs, it is important to assess the reach and uptake rates of DMHIs on college campuses.

Objectives

We conducted a systematic review to examine the reach (i.e., % of invited students who express interest) and uptake (i.e., % of enrolled participants who initiate an intervention) of DMHIs based on cognitive-behavioral therapy (CBT) for college students.

Methods

Eight databases were searched. Inclusion criteria included: (1) college population; (2) experimental design; (3) CBT-based intervention; (4) intervention targeting specific mental health conditions; and (5) digital intervention. Reach and uptake rates were calculated from data reported. A systematic narrative review framework was used to synthesize results.

Results

Of 10,315 articles screened, 90 were included. Seventeen studies (19%) reported sufficient data to calculate reach; 35 studies (39%) reported uptake rates. Of studies that reported reach or uptake, most evaluated unguided (n = 20) or guided (n = 16) self-help programs. Measurement methods varied widely. Overall reach was low, whereas uptake was high among enrolled participants.

Discussion

Despite evidence that improving reach and uptake can increase the public health impact of DMHIs, most studies did not report on either outcome. Suggested practices to improve these outcomes, and their reporting, are discussed.

Change in parent and child psychopathology following obesity treatment and maintenance: A secondary data analysis

BACKGROUND

General and eating disorder (ED) psychopathology are common among children and adults with overweight/obesity; few studies have examined their course of change throughout family-based behavioural obesity treatment (FBT) and maintenance.

OBJECTIVES

Examine: (1) the changes in the parent and child general and ED psychopathology during FBT and maintenance interventions; (2) the associations between change in psychopathology and change in weight among children or parents; (3) the associations between change in psychopathology within parent-child dyads.

METHODS

172 parent-child dyads participated in 4-month FBT and were subsequently randomized to one of three 8-month maintenance interventions. General psychopathology (child anxiety/depressive symptoms, parent severity of global psychological distress), ED psychopathology (shape/weight concern), and percent overweight were assessed at baseline, post-FBT, and post-maintenance. Separate linear mixed-effects models evaluated change in general and ED psychopathology, including an interaction between maintenance condition and time. Partial correlations examined associations between change in psychopathology and percent overweight among children or parents, and associations between change in psychopathology within parent-child dyads.

RESULTS

Among children, significant reductions were observed from baseline to post-FBT in all forms of psychopathology and from post-FBT to post-maintenance in general psychopathology. Among parents, significant reductions were observed from baseline to post-FBT in all forms of psychopathology; reductions were maintained from post-FBT to post-maintenance. There was no significant interaction between maintenance condition and time. Correlations between change in most forms of parent or child psychopathology and percent overweight were observed.

CONCLUSIONS

Participation in FBT and maintenance was associated with improvements in general and ED psychopathology in both parents and children.

Predictors of treatment seeking and uptake among respondents to a widely disseminated online eating disorders screen in the United States

OBJECTIVE

To explore predictors of treatment seeking and uptake among individuals following an online eating disorders (EDs) screen in the U.S. disseminated by the National Eating Disorders Association.

METHOD

Respondents who screened at risk or positive for a probable ED from 04/2019 to 05/2021 (N = 263,530) were eligible to complete a 2-month follow-up survey that assessed treatment seeking and uptake after being offered referral options following screening. Analyses were conducted using chi-square tests or logistic regressions.

RESULTS

Sixty thousand thirty-four respondents (22.8%) opted-in to the follow-up survey, of whom 2276 (3.8%) completed it. Of the final analytic sample (n = 1922), 35.7% of respondents reported seeking and 22.4% reported receiving treatment. Treatment seeking and uptake were more common among respondents who were female, White, or >24 years of age; uptake was more common among respondents who were non-Hispanic or higher income. Elevated shape/weight concerns were significantly, albeit modestly, associated with reduced likelihood to receive treatment.

DISCUSSION

Demographic differences in treatment seeking and uptake highlight the need to optimize ED screening tools/feedback to meet the needs of underserved groups and to address stereotypes and structural barriers that may interfere. Research is also needed to identify barriers to uptake among those with elevated shape/weight concerns.

PUBLIC SIGNIFICANCE

Relatively low rates of treatment seeking and uptake were observed, particularly among underserved groups, 2 months following a widely disseminated online eating disorders screen. Optimization of online eating disorder screening tools and delivery of feedback and referral information may be needed to increase health care utilization.

Internalization of Appearance Ideals and Not Religiosity Indirectly Impacts the Relationship Between Acculturation and Disordered Eating Risk in South and Southeast Asian Women Living in the United States

Objective

Studies that examine disordered eating in samples of Asian individuals living in the United States frequently combine all individuals of Asian descent into a single group, which can obscure important differences between groups and their experiences of acculturation. The goal of the present study was to establish the relation of acculturation, internalization of appearance ideals, and religiosity as predicting body dissatisfaction and disordered eating in women of South and Southeast Asian (SSEA) descent.

Method

Women of SSEA descent (N = 112) aged 18-51 years (M = 23.10, SD = 6.4) completed a battery of questionnaires that inquire about these variables. A path analysis was conducted with acculturation serving as the independent (exogenous) variable, religiosity and internalization of the thin ideal as mediators, and body dissatisfaction and disordered eating as dependent (endogenous) variables.

Results

Direct paths from acculturation to both body dissatisfaction and disordered eating were not significant. Thin ideal internalization completely accounted for the path from acculturation to both endogenous variables; whereas, religiosity did not significantly account for any indirect effect.

Discussion

For SSEA women, internalization of appearance ideals is a potentially greater risk factor for disordered eating than acculturation or religiosity. As this was an atemporal mediation analysis, more work needs to be done exploring predictors of internalization in this population and how that may impact the development of disordered eating.

Parent-Child influences on child eating self-regulation and weight in early childhood: A systematic review

Individual differences in child eating self-regulation are associated with excess weight gain and may be explained, in part, by the family feeding environment and a child's general propensity to self-regulate outside of the context of eating (i.e., general self-regulation). Several studies have examined the associations between food parenting behaviors, child eating and general self-regulation, and child weight separately. However, there are a paucity of data on whether and how these factors interact to confer risk for weight gain in early childhood. The current systematic review identified 32 longitudinal studies that examined unidirectional or bidirectional associations among one or more of the following paths: food parenting behaviors and child eating self-regulation (path 1); child eating self-regulation and child weight (path 2); child eating self-regulation and child general self-regulation (path 3); food parenting behaviors and child general self-regulation (path 4); and child general self-regulation and child weight (path 5). Results indicated relationships of food parenting behaviors to child eating self-regulation, child weight to child eating self-regulation, and child general self-regulation to child weight. However, there were scant longitudinal data that examined paths 3 and 4. Further research on the developmental correlates of child eating self-regulation is needed to identify parent and child targets for early childhood obesity prevention.

Implementation of a Scalable Family-Based Behavioral Treatment for Childhood Obesity Delivered through Primary Care Clinics: Description of the Missouri Childhood Obesity Research Demonstration Study Protocol

Background: Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families who are disproportionately affected by obesity. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project (CORD 3.0), the Missouri team (MO-CORD) aims to increase access to and dissemination of an efficacious pediatric obesity treatment, specifically family-based behavioral treatment (FBT), for low-income families. Methods/Design: The implementation pilot study is a multisite matched-comparison group pilot of packaged FBT in pediatric clinics for low-income children with obesity, of ages 5 to 12 years old. The study is implemented in two Missouri pediatric primary care clinical sites, Freeman Health System Pediatric Clinics (rural Joplin) and Children's Mercy Hospital Pediatric Clinics (urban Kansas City). The design focuses on pragmatism through utilization of PRECIS (Pragmatic Explanatory Continuum Indicator Summary) domains, such as open eligibility criteria, limited follow-up intensity, reliance on medical records for creating a usual care comparison group data, and unobtrusive measurement of participant and provider adherence. The evaluation focuses on effectiveness as well as implementation outcomes and barriers to inform implementation scale up. Conclusions: Findings from this study will advance both science and practice by providing novel and immediately useful information to families, health care providers, health care organizations, payers, and other state Medicaid plans by developing and optimizing evidence-based pediatric weight management treatment for implementation and dissemination in health systems to address health disparities among low-income populations most affected by overweight and obesity.

Characterizing eating disorder diagnosis and related outcomes by sexual orientation and gender identity in a national sample of college students

OBJECTIVE

In a national sample of college students, the current study aimed to: 1) examine differences in probable diagnoses of EDs (i.e., anorexia nervosa (AN), clinical/subthreshold bulimia nervosa (BN), or binge eating disorder (BED)) and weight and shape concerns by sexual orientation and gender identity, and 2) examine differences in ED chronicity and probable comorbid psychiatric diagnoses by sexual orientation and gender identity.

METHOD

Students across nine U.S. universities completed an online screener for DSM-5 clinical or subthreshold ED diagnoses, comorbid depression and anxiety disorders, and self-reported ED chronicity. Self-reported sexual orientation and gender identity were also collected. Tukey-corrected logistic and linear regressions examined differences in outcomes separately by sexual orientation and gender identity, adjusting for age, race, and ethnicity.

RESULTS

A total of 8,531 students (24% sexually diverse (SD); 2.7% gender diverse (GD)) were studied. Students who identified as bisexual or other sexual orientation reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to heterosexual students. Cisgender female students and GD students reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to cisgender male students. Some SD students and GD students who met criteria for probable EDs were also more likely to report chronic ED symptoms and probable comorbid psychiatric diagnoses compared to heterosexual students and cisgender males, respectively.

DISCUSSION

Some SGD students may be at heightened risk for EDs, highlighting the need to identify mechanisms that contribute to disparities.

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.

Overweight and obesity are associated with increased eating disorder correlates and general psychopathology in university women with eating disorders

OBJECTIVE

Examine how eating disorder (ED) correlates, ED-related clinical impairment, general psychopathology, and ED diagnoses differ across weight statuses in a sample of university women with EDs.

METHOD

Participants were 690 women from 28 U.S. universities who screened positive for an ED (with the exception of anorexia nervosa [AN]) and participated in the Healthy Body Image Program study. ED correlates, ED-related clinical impairment, general psychopathology (i.e., depression and anxiety), and ED diagnoses were compared across weight statuses (i.e., healthy weight, overweight, obesity) using analyses of variance and chi-square tests.

RESULTS

Women with EDs and overweight or obesity had higher levels of, perceived benefit of thinness, depressive symptoms, anxiety, and weight/shape concerns (obesity only) than those with healthy weight (ps ≤ .017). Compared to those with healthy weight, those with obesity had higher rates of clinical and sub-clinical binge eating disorder and lower rates of bulimia nervosa (p < .001).

DISCUSSION

Overweight and obesity in individuals with EDs, excluding AN, are associated with greater severity of ED correlates, ED-related clinical impairment, and co-morbid general psychopathology. The current study highlights the need to consider weight status in ED treatment and for optimization of ED treatments to address shared risk factors between EDs and overweight and obesity.

Harnessing technological solutions for childhood obesity prevention and treatment: a systematic review and meta-analysis of current applications

BACKGROUND

Technology holds promise for delivery of accessible, individualized, and destigmatized obesity prevention and treatment to youth.

OBJECTIVES

This review examined the efficacy of recent technology-based interventions on weight outcomes.

METHODS

Seven databases were searched in April 2020 following PRISMA guidelines. Inclusion criteria were: participants aged 1-18 y, use of technology in a prevention/treatment intervention for overweight/obesity; weight outcome; randomized controlled trial (RCT); and published after January 2014. Random effects models with inverse variance weighting estimated pooled mean effect sizes separately for treatment and prevention interventions. Meta-regressions examined the effect of technology type (telemedicine or technology-based), technology purpose (stand-alone or adjunct), comparator (active or no-contact control), delivery (to parent, child, or both), study type (pilot or not), child age, and intervention duration.

FINDINGS

In total, 3406 records were screened for inclusion; 55 studies representing 54 unique RCTs met inclusion criteria. Most (89%) included articles were of high or moderate quality. Thirty studies relied mostly or solely on technology for intervention delivery. Meta-analyses of the 20 prevention RCTs did not show a significant effect of prevention interventions on weight outcomes (d = 0.05, p = 0.52). The pooled mean effect size of n = 32 treatment RCTs showed a small, significant effect on weight outcomes (d = ‒0.13, p = 0.001), although 27 of 33 treatment studies (79%) did not find significant differences between treatment and comparators. There were significantly greater treatment effects on outcomes for pilot interventions, interventions delivered to the child compared to parent-delivered interventions, and as child age increased and intervention duration decreased. No other subgroup analyses were significant.

CONCLUSIONS

Recent technology-based interventions for the treatment of pediatric obesity show small effects on weight; however, evidence is inconclusive on the efficacy of technology based prevention interventions. Research is needed to determine the comparative effectiveness of technology-based interventions to gold-standard interventions and elucidate the potential for mHealth/eHealth to increase scalability and reduce costs while maximizing impact.

Examining the interdependence of parent-child dyads: Effects on weight loss and maintenance

BACKGROUND

This study aimed to further elucidate correlated weight changes in parent-child dyads enrolled in family-based treatment (FBT) by modeling the interdependence of weight changes during treatment.

METHODS

Parent-child dyads (n = 172) with overweight/obesity (child mean zBMI = 2.16 ± 0.39; parent mean BMI = 37.9 ± 9.4 kg/m2 ) completed 4 months of FBT and were randomized to one of three 8-month maintenance interventions (Social Facilitation Maintenance [SFM]-high dose, SFM-low dose or control). Weight/height was measured at 0, 4 and 12 months. Structural equation models simultaneously estimated the effect that an individual had on their own (actor effect) and on one another's (partner effect) weight-status across time using the actor-partner interdependence model.

RESULTS

Actor paths were significant over time for parent and child. Partner paths were significant for child zBMI predicting parent BMI at 4 and 12 months. Maintenance condition moderated actor/partner paths in the model.

CONCLUSIONS

Child weight change may motivate parents to make environmental and behavioural changes that impact their own weight.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00759746.

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

Objective

Pediatric loss-of-control (LOC) eating is associated with, and predictive of, gains in adiposity and adverse metabolic outcomes. In addition, some preliminary data suggest that anxiety may exacerbate the relationship of LOC eating with weight and metabolic syndrome (MetS)-related measures. We therefore examined whether anxiety moderated the relationship between LOC eating and body mass index z (BMIz), adiposity, and MetS-related measures in youth.

Methods

A convenience sample of non-treatment-seeking boys and girls of varying weight strata were interviewed to determine the presence of LOC eating and completed a questionnaire assessing trait anxiety. BMIz and MetS-related measures (blood pressure, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, glucose, and insulin) were measured after an overnight fast. Adiposity was assessed by air displacement plethysmography or dual-energy x-ray absorptiometry. Analyses adjusted for age, sex, race, height, fat mass, and depressive symptoms, as appropriate.

Results

In all, 379 youths (13.0 ± 2.8 years; 53% female; BMIz = 0.8 ± 1.1; 22% with LOC eating) were studied. Anxiety was not significantly related to BMIz, adiposity, or MetS-related measures. However, anxiety and LOC eating interacted such that only among youth with LOC eating, anxiety was positively associated with fasting insulin (p = .02) and insulin resistance (p = .01). The interaction of anxiety and LOC eating was not significantly related to BMIz, adiposity, or any other MetS-related measure (ps = ns).

Conclusions

Only among non-treatment-seeking youth with LOC eating, anxiety may be associated with increased insulin secretion and insulin resistance. Longitudinal studies are required to confirm these findings and explore mechanisms for these relationships.

Overweight and obesity in sexual and gender minority adolescents: A systematic review

Population data indicate that sexual and gender minority adolescents may be at increased risk for excess weight gain compared with cisgender, heterosexual youth. However, no studies, to our knowledge, have systematically reviewed the literature on weight disparities in this population nor explored risk for overweight and obesity by sexual and gender minority subgroup across studies. The current systematic review, therefore, identified 21 studies that assessed the relationship between sexual and gender minority status and weight among adolescents. Results indicated an overall greater prevalence of overweight and obesity among sexual and gender minority adolescents compared with cisgender, heterosexual youth. However, cisgender sexual minority males demonstrated lower or no added risk for overweight and obesity, whereas cisgender sexual minority females demonstrated greater risk for overweight and obesity. Findings were mixed among gender minority adolescents. This study highlights weight disparities in sexual and gender minority youth, although important subgroup differences exist. Additional research is needed to elucidate the mechanisms that may contribute to differential weight trajectories in this population and to develop tailored approaches for prevention and treatment.

Associations of sleep patterns with metabolic syndrome indices, body composition, and energy intake in children and adolescents

BACKGROUND

Self-reported short sleep duration is associated with greater risk for metabolic syndrome (MetS), obesity, and higher energy intake (EI). However, studies of these associations in children using objective methods are sparse.

OBJECTIVES

The study aims to determine the associations for sleep patterns with MetS indices, body composition, and EI using objective measures in children.

METHODS

Free-living sleep and physical activity were measured in 125 children (aged 8-17 years, BMI z = 0.57 ± 1.0, 55% female) using wrist-worn actigraphs for 14 nights. Blood pressure, fasting blood levels of lipids, insulin, glucose, waist circumference, and body composition (dual-energy X-ray absorptiometry [DXA]) were obtained during outpatient visits. EI was assessed during an ad libitum buffet meal.

RESULTS

Later weekday and weekend bedtimes were associated with higher systolic blood pressure (Ps < 0.05). Sleep duration and bedtime were not significantly associated with other components of MetS, body composition, or EI. Short sleepers (duration less than 7 hours) consumed a greater percentage of carbohydrates than those with adequate (greater than or equal to 7 hours) sleep (P < 0.05).

CONCLUSION

Indicators of sleep duration were variably associated with children's eating patterns and risk for chronic disease. Prospective data are needed to determine whether these indicators of sleep quality represent unique or shared risk factors for poor health outcomes.

An examination of the associations between pediatric loss of control eating, anxiety, and body composition in children and adolescents

BACKGROUND

Data on the link between anxiety and body composition in youth are mixed. Yet, anxiety and disordered eating are highly correlated. One pathway between anxiety and excess body weight and fat mass may be through loss of control (LOC) eating. We examined whether LOC eating mediated the relationship between anxiety and body composition in youth with and without overweight.

METHOD

Non-treatment-seeking youth (8-17 years) participated in studies examining weight and eating behaviors. Anxiety (child- and parent-report of child) and LOC eating were assessed by self-report questionnaires and interviews, respectively. Fat mass was assessed by dual-energy x-ray absorptiometry or air displacement plethysmography. Cross-sectional mediation models with bias-corrected bootstrap confidence intervals (CI) were conducted.

RESULTS

257 youth (12.91 ± 2.76 years; 52.5% female; BMI-z 0.93 ± 1.07) were studied. There was a significant indirect path between child-reported anxiety and both BMI-z (ab = .005, SE = 0.003, 95% CI = 0.001-0.01) and body fat mass (ab = 0.001, SE = 0.001, 95% CI ≤0.001-0.003) through the number of LOC episodes in the past month. No significant indirect paths through the number of LOC episodes was observed for parent-report of child anxiety on BMI-z (ab = 0.004, SE = 0.01, 95% CI = -0.01-0.03) or body fat mass (ab = 0.001, SE = 0.002, 95% CI = -0.002-0.01). No direct paths were observed between anxiety and body composition regardless of the informant.

DISCUSSION

LOC eating appears to mediate the relationship of child-reported anxiety with body composition in non-treatment seeking boys and girls. Prospective data are needed to determine if anxiety promotes LOC eating that results in increased risk for excess body weight and fat gain.

Examination of the interpersonal model of loss of control eating in the laboratory

BACKGROUND

The interpersonal model of loss of control (LOC) eating proposes that interpersonal problems lead to negative affect, which in turn contributes to the onset and/or persistence of LOC eating. Despite preliminary support, there are no data examining the construct validity of the interpersonal model of LOC eating using temporally sensitive reports of social stress, distinct negative affective states, and laboratory energy intake.

METHOD

117 healthy adolescent girls (BMI: 75th-97th %ile) were recruited for a prevention trial targeting excess weight gain in adolescent girls who reported LOC eating. Prior to the intervention, participants completed questionnaires of recent social stress and consumed lunch from a multi-item laboratory test meal. Immediately before the test meal, participants completed a questionnaire of five negative affective states (anger, confusion, depression, fatigue, anxiety). Bootstrapping mediation models were conducted to evaluate pre-meal negative affect states as explanatory mediators of the association between recent social stress and palatable (desserts and snack-type) food intake. All analyses adjusted for age, race, pubertal stage, height, fat mass percentage, and lean mass.

RESULTS

Pre-meal state anxiety was a significant mediator for recent social stress and palatable food intake (ps<.05). By contrast, pre-meal state anger, confusion, depression, and fatigue did not mediate the relationship between social stress and palatable food intake (ps>.05).

DISCUSSION

Pre-meal anxiety appears to be the salient mood state for the interpersonal model among adolescent girls with LOC eating. Interventions that focus on improving both social functioning and anxiety may prove most effective at preventing and/or ameliorating disordered eating and obesity in these adolescents.

Drug repositioning in SLE: crowd-sourcing, literature-mining and Big Data analysis

Lupus patients are in need of modern drugs to treat specific manifestations of their disease effectively and safely. In the past half century, only one new treatment has been approved by the US Food and Drug Administration (FDA) for systemic lupus erythematosus (SLE). In 2014–2015, the FDA approved 71 new drugs, only one of which targeted a rheumatic disease and none of which was approved for use in SLE. Repositioning/repurposing drugs approved for other diseases using multiple approaches is one possible means to find new treatment options for lupus patients. “Big Data” analysis approaches this challenge from an unbiased standpoint whereas literature mining and crowd sourcing for candidates assessed by the CoLTs (Combined Lupus Treatment Scoring) system provide a hypothesis-based approach to rank potential therapeutic candidates for possible clinical application. Both approaches mitigate risk since the candidates assessed have largely been extensively tested in clinical trials for other indications. The usefulness of a multi-pronged approach to drug repositioning in lupus is highlighted by orthogonal confirmation of hypothesis-based drug repositioning predictions by “Big Data” analysis of differentially expressed genes from lupus patient samples. The goal is to identify novel therapies that have the potential to affect disease processes specifically. Involvement of SLE patients and the scientists that study this disease in thinking about new drugs that may be effective in lupus though crowd-sourcing sites such as LRxL-STAT ( www.linkedin.com/in/lrxlstat ) is important in stimulating the momentum needed to test these novel drug targets for efficacy in lupus rapidly in small, proof-of-concept trials conducted by LuCIN, the Lupus Clinical Investigators Network ( www.linkedin.com/in/lucinstat ).

Comparative characteristics of mu chain and alpha chain transcripts expressed by individual tonsil plasma cells

Plasma cells (PCs) are one of the two major cell types generated during germinal center reactions. To test the hypothesis that PCs express a unique repertoire of immunoglobulin (Ig) genes resulting from intensive antigenic stimulation and selection, the mutational pattern and distribution of V(H) gene segments within 178 transcripts amplified from individual IgM and IgA secreting tonsil PCs were analyzed. The results demonstrated that both mu and alpha transcripts expressed repertoires with limited diversity. Moreover, both mu and alpha transcripts were heavily mutated, with a significantly increased mutational frequency noted for alpha compared to mu transcripts (5.0 x 10(-2) vs 1.8 x 10(-2), P<0.001). In addition, both mu and alpha transcripts showed significantly greater targeting of mutations to RGYW motifs (purine/guanine/pyrimidine/A or T) compared to memory B cells. Finally, clonally expanded cells were detected in alpha but not mu PC compartments. These results indicate that antigen driven stimulation and selection shape the entire expressed PC repertoire, but the impact is greater in alpha expressing PCs.

RAG1 and RAG2 expression by B cell subsets from human tonsil and peripheral blood

It has been suggested that B cells acquire the capacity for secondary V(D)J recombination during germinal center (GC) reactions. The nature of these B cells remains controversial. Subsets of tonsil and blood B cells and also individual B cells were examined for the expression of recombination-activating gene (RAG) mRNA. Semiquantitative analysis indicated that RAG1 mRNA was present in all tonsil B cell subsets, with the largest amount found in naive B cells. RAG2 mRNA was only found in tonsil naive B cells, centrocytes, and to a lesser extent in centroblasts. Neither RAG1 nor RAG2 mRNA was routinely found in normal peripheral blood B cells. In individual tonsil B cells, RAG1 and RAG2 mRNAs were found in 18% of naive B cells, 22% of GC founder cells, 0% of centroblasts, 13% of centrocytes, and 9% of memory B cells. Individual naive tonsil B cells containing both RAG1 and RAG2 mRNA were activated (CD69(+)). In normal peripheral blood approximately 5% of B cells expressed both RAG1 and RAG2. These cells were uniformly postswitch memory B cells as documented by the coexpression of IgG mRNA. These results indicate that coordinate RAG expression is not found in normal peripheral naive B cells but is up-regulated in naive B cells which are activated in the tonsil. With the exception of centroblasts, RAG1 and RAG2 expression can be found in all components of the GC, including postswitch memory B cells, some of which may circulate in the blood of normal subjects.

Expression, regulation, and function of B cell-expressed CD154 in germinal centers

Activated B cells and T cells express CD154/CD40 ligand in vitro. The in vivo expression and function of B cell CD154 remain unclear and therefore were examined. Tonsillar B and T cells expressed CD154 at a similar density both in situ and immediately ex vivo, whereas a significantly higher percentage of the former expressed CD154. CD154-expressing B cells were most frequent in the CD38positiveIgD+ pre-germinal center (GC)/GC founder, CD38positive GC and CD38-IgD- memory populations, and were also found in the CD38-IgD+ naive and CD38brightIgD+ plasmablast subsets, but not in the CD38brightIgD- plasma cell subset. B cell expression of CD154 was induced by engaging surface Ig or CD40 by signals that predominantly involved activation of AP-1/NF-AT and NF-kappaB, respectively. The functional importance of CD154-mediated homotypic B cell interactions in vivo was indicated by the finding that mAb to CD154 inhibited differentiation of CD38positiveIgD- GC B cells to CD38-IgD- memory cells. In addition, mAb to CD154 inhibited proliferation induced by engaging sIg or CD40, indicating the role of up-regulation of this molecule in facilitating B cell responsiveness. Of note, CD154 itself not only functioned as a ligand but also as a direct signaling molecule as anti-CD154-conjugated Sepharose beads costimulated B cell responses induced by engaging surface Ig. These results indicate that CD154 is expressed by human B cells in vivo and plays an important role in mediating B cell responses.

TNF receptor-associated factor-3 signaling mediates activation of p38 and Jun N-terminal kinase, cytokine secretion, and Ig production following ligation of CD40 on human B cells

CD40 engagement induces a variety of functional outcomes following association with adaptor molecules of the TNF receptor-associated factor (TRAF) family. Whereas TRAF2, -5, and -6 initiate NF-kappaB activation, the outcomes of TRAF3-initiated signaling are less characterized. To delineate CD40-induced TRAF3-dependent events, Ramos B cells stably transfected with a dominant negative TRAF3 were stimulated with membranes expressing recombinant CD154/CD40 ligand. In the absence of TRAF3 signaling, activation of p38 and control of Ig production were abrogated, whereas Jun N-terminal kinase activation and secretion of IL-10, lymphotoxin-alpha, and TNF-alpha were partially blocked. By contrast, induction of apoptosis, activation of NF-kappaB, generation of granulocyte-macrophage CSF, and up-regulation of CD54, MHC class II, and CD95 were unaffected by the TRAF3 dominant negative. Together, these results indicate that TRAF3 initiates independent signaling pathways via p38 and JNK that are associated with specific functional outcomes.

Bidirectional regulation of human B cell responses by CD40-CD40 ligand interactions

Positive and negative effects of CD40 ligation on human B cell function were suggested by the observation that mAb to CD40 ligand partially blocked the suppressive influences of anti-CD3-stimulated control CD4+ T cells, as well as the B cell stimulatory effects of anti-CD3 activated mitomycin C-treated CD4+ T cells. To examine the negative effects of CD40 ligation in greater detail, B cells were cultured with anti-CD3 activated mitomycin C-treated CD4+ T cells that expressed optimal levels of CD40 ligand; additional recombinant human CD40 ligand significantly suppressed Ig production, but not proliferation. In contrast, when B cells were stimulated with SAC (formalinized Cowan I strain Staphylococcus aureus) and IL-2 in the absence of T cells, small amounts of recombinant CD40 ligand-stimulated Ig production, whereas larger quantities directly suppressed Ig secretion. The suppressive action of CD40 ligation on Ig production was most apparent after initial B cell activation. Moreover, IgD-memory B cells were significantly more sensitive to inhibition by CD40 ligation than IgD+ naive B cells. Engagement of CD40 not only suppressed Ig secretion by IgD- memory B cells, but also expression of CD38. Finally, activated B cells acquired the capacity to down-regulate CD40 ligand expression by stimulated CD4+ T cells more effectively than resting B cells. These results indicate that during T cell-B cell collaboration, engagement of CD40 can influence Ig production both positively and negatively, depending on the density of CD40 ligand as well as the stage of B cell activation and differentiation.

Bidirectional regulation of human B cell responses by CD40-CD40 ligand interactions

Positive and negative effects of CD40 ligation on human B cell function were suggested by the observation that mAb to CD40 ligand partially blocked the suppressive influences of anti-CD3-stimulated control CD4+ T cells, as well as the B cell stimulatory effects of anti-CD3 activated mitomycin C-treated CD4+ T cells. To examine the negative effects of CD40 ligation in greater detail, B cells were cultured with anti-CD3 activated mitomycin C-treated CD4+ T cells that expressed optimal levels of CD40 ligand; additional recombinant human CD40 ligand significantly suppressed Ig production, but not proliferation. In contrast, when B cells were stimulated with SAC (formalinized Cowan I strain Staphylococcus aureus) and IL-2 in the absence of T cells, small amounts of recombinant CD40 ligand-stimulated Ig production, whereas larger quantities directly suppressed Ig secretion. The suppressive action of CD40 ligation on Ig production was most apparent after initial B cell activation. Moreover, IgD-memory B cells were significantly more sensitive to inhibition by CD40 ligation than IgD+ naive B cells. Engagement of CD40 not only suppressed Ig secretion by IgD- memory B cells, but also expression of CD38. Finally, activated B cells acquired the capacity to down-regulate CD40 ligand expression by stimulated CD4+ T cells more effectively than resting B cells. These results indicate that during T cell-B cell collaboration, engagement of CD40 can influence Ig production both positively and negatively, depending on the density of CD40 ligand as well as the stage of B cell activation and differentiation.

Analysis of CD40-CD40 ligand interactions in the regulation of human B cell function

CD40-CD40 ligand interactions play an essential role in T cell/B cell collaboration. The data presented in this review have served to widen the scope of CD40-CD40 ligand interactions to include initial activation, proliferation, differentiation, and isotype switching of B cells, as well as subsequent downregulation of B cell function. Moreover, CD40 ligand expression by activated B cells is likely to play an essential role in facilitating ongoing responses of stimulated B cells maturing in germinal centers. Finally, CD40 expression by activated T cells may also play an important role in regulating the function of helper T cells within germinal centers. In summary, emerging data have expanded the role of CD40-CD40 ligand interaction during T cell/B cell collaboration and have emphasized its potential to regulate many of the functions of both partners in this essential interaction involved in antibody production.

Ligation of CD40 influences the function of human Ig-secreting B cell hybridomas both positively and negatively

The effect of ligation of CD40 on the proliferation and Ig secretion of a battery of human Ig-secreting hybridomas was examined to determine the regulatory activity of this surface molecule on B cells after initial activation. B cell hybridomas were generated by fusing activated peripheral blood B cells with SPAZ-4, a non-Ig-secreting fusion partner, and were cloned before analysis. All hybridomas expressed CD40 comparably. These hybridomas were stimulated with either recombinant baculovirus-expressed membrane-bound CD40L or a soluble murine CD40L/CD8 construct in the presence or the absence of various cytokines. Concentrations of CD40L that saturated 40 to 100% of CD40 induced initial homotypic aggregation followed by Fas (CD95)-independent apoptosis, with resultant decreases in growth and Ig secretion. Concentrations of CD40L that saturated 15 to 25% of CD40 also stimulated aggregation of all hybridomas. However, proliferation and Ig secretion of 9 of 13 IgM-secreting hybridomas, but none of 14 IgG- or IgA-secreting hybridomas, were enhanced by these concentrations of CD40L. These responses were independent of interactions mediated by the adhesion pair CD1la/CD18-CD54. These results indicate that the impact of CD40 ligation on human Ig-secreting hybridomas varies with the extent of CD40 engagement and depending on whether the hybridoma derived from an activated B cell that had previously undergone switch recombination.

Ligation of CD40 influences the function of human Ig-secreting B cell hybridomas both positively and negatively

The effect of ligation of CD40 on the proliferation and Ig secretion of a battery of human Ig-secreting hybridomas was examined to determine the regulatory activity of this surface molecule on B cells after initial activation. B cell hybridomas were generated by fusing activated peripheral blood B cells with SPAZ-4, a non-Ig-secreting fusion partner, and were cloned before analysis. All hybridomas expressed CD40 comparably. These hybridomas were stimulated with either recombinant baculovirus-expressed membrane-bound CD40L or a soluble murine CD40L/CD8 construct in the presence or the absence of various cytokines. Concentrations of CD40L that saturated 40 to 100% of CD40 induced initial homotypic aggregation followed by Fas (CD95)-independent apoptosis, with resultant decreases in growth and Ig secretion. Concentrations of CD40L that saturated 15 to 25% of CD40 also stimulated aggregation of all hybridomas. However, proliferation and Ig secretion of 9 of 13 IgM-secreting hybridomas, but none of 14 IgG- or IgA-secreting hybridomas, were enhanced by these concentrations of CD40L. These responses were independent of interactions mediated by the adhesion pair CD1la/CD18-CD54. These results indicate that the impact of CD40 ligation on human Ig-secreting hybridomas varies with the extent of CD40 engagement and depending on whether the hybridoma derived from an activated B cell that had previously undergone switch recombination.

The CD40 ligand expressed by human B cells costimulates B cell responses

The possibility that activated B cells might express a ligand for CD40 that was of functional importance for B cell responses was examined by using highly purified human peripheral blood B cells, as well as a variety of B lymphoblastoid cell lines and hybridomas. Following stimulation with the combination of a calcium ionophore and a phorbol ester, human B cells bound a soluble fusion protein containing the extracellular portion of CD40 and the Fc region of IgG1 (CD40.Ig). A variety of B cell lines and hybridomas also bound CD40.Ig, either constitutively or after activation. In addition, CD40.Ig specifically immunoprecipitated a 33-kDa glycoprotein from surface 125I-labeled activated B cells. The nucleotide sequence of the coding region of the CD40 ligand mRNA amplified by RT-PCR from activated T cells and B cell lines was identical. The CD40 ligand expressed on human B cells was important functionally because homotypic aggregation of CD40 ligand-expressing B cells was inhibited by the CD40.Ig construct. Additionally, RNA and DNA synthesis as well as Ig production by polyclonally activated, highly purified peripheral B cells and a variety of B cell lines were inhibited significantly by the CD40.Ig construct. Finally, B cell lines expressing the CD40 ligand induced Ig production from resting normal B cells in a CD40-dependent manner. These results indicate that human B cells express a ligand for CD40 that is identical with that expressed by activated T cells and that the B cell-expressed CD40 ligand plays an important role in facilitating responses of activated B cells.

The CD40 ligand expressed by human B cells costimulates B cell responses

The possibility that activated B cells might express a ligand for CD40 that was of functional importance for B cell responses was examined by using highly purified human peripheral blood B cells, as well as a variety of B lymphoblastoid cell lines and hybridomas. Following stimulation with the combination of a calcium ionophore and a phorbol ester, human B cells bound a soluble fusion protein containing the extracellular portion of CD40 and the Fc region of IgG1 (CD40.Ig). A variety of B cell lines and hybridomas also bound CD40.Ig, either constitutively or after activation. In addition, CD40.Ig specifically immunoprecipitated a 33-kDa glycoprotein from surface 125I-labeled activated B cells. The nucleotide sequence of the coding region of the CD40 ligand mRNA amplified by RT-PCR from activated T cells and B cell lines was identical. The CD40 ligand expressed on human B cells was important functionally because homotypic aggregation of CD40 ligand-expressing B cells was inhibited by the CD40.Ig construct. Additionally, RNA and DNA synthesis as well as Ig production by polyclonally activated, highly purified peripheral B cells and a variety of B cell lines were inhibited significantly by the CD40.Ig construct. Finally, B cell lines expressing the CD40 ligand induced Ig production from resting normal B cells in a CD40-dependent manner. These results indicate that human B cells express a ligand for CD40 that is identical with that expressed by activated T cells and that the B cell-expressed CD40 ligand plays an important role in facilitating responses of activated B cells.