Physical activity and sleep changes among children during the COVID-19 pandemic

Daily routines, including in-person school and extracurricular activities, are important for maintaining healthy physical activity and sleep habits in children. The COVID-19 pandemic significantly disrupted daily routines as in-person school and activities closed to prevent spread of SARS-CoV-2. We aimed to examine and assess differences in objectively measured physical activity levels and sleep patterns from wearable sensors in children with obesity before, during, and after a period of school and extracurricular activity closures associated with the COVID-19 pandemic. We compared average step count and sleep patterns (using the Mann-Whitney U Test) before and during the pandemic-associated school closures by using data from activity tracker wristbands (Garmin VivoFit 3). Data were collected from 94 children (aged 5-17) with obesity, who were enrolled in a randomized controlled trial testing a community-based lifestyle intervention for a duration of 12-months. During the period that in-person school and extracurricular activities were closed due to the COVID-19 pandemic, children with obesity experienced objectively-measured decreases in physical activity, and sleep duration. From March 15, 2020 to March 31, 2021, corresponding with local school closures, average daily step count decreased by 1655 steps. Sleep onset and wake time were delayed by about an hour and 45 min, respectively, while sleep duration decreased by over 12 min as compared with the pre-closure period. Step counts increased with the resumption of in-person activities. These findings provide objective evidence for parents, clinicians, and public health professionals on the importance of in-person daily activities and routines on health behaviors, particularly for children with pre-existing obesity. Trial Registration: Clinical trial registration: NCT03339440.

Physical activity and sleep changes among children with obesity during a period of school closures related to the COVID-19 pandemic

Daily routines, including in-person school and extracurricular activities, are important for maintaining healthy physical activity and sleep habits in children. The COVID-19 pandemic significantly disrupted daily routines as in-person school and activities closed to prevent spread of SARS-CoV-2. We aimed to examine and assess differences in objectively measured physical activity levels and sleep patterns from wearable sensors in children with obesity before, during, and after a period of school and extracurricular activity closures associated with the COVID-19 pandemic. We compared average step count and sleep patterns (using the Mann Whitney U Test) before and during the pandemic-associated school closures by using data from activity tracker wristbands (Garmin VivoFit 3). Data was collected from 94 children (aged 5-17) with obesity, who were enrolled in a randomized controlled trial testing a community-based lifestyle intervention for a duration of 12-months. During the period that in-person school and extracurricular activities were closed due to the COVID-19 pandemic, children with obesity experienced objectively-measured decreases in physical activity, and sleep duration. From March 15, 2020 to March 31, 2021, corresponding with local school closures, average daily step count decreased by 1,655 steps. Sleep onset and wake time were delayed by about an hour and 45 minutes, respectively, while sleep duration decreased by over 12 minutes as compared with the pre-closure period. Step counts increased with the resumption of in-person activities. These findings provide objective evidence for parents, clinicians, and public health professionals on the importance of in-person daily activities and routines on health behaviors, particularly for children with pre-existing obesity. We demonstrate the utility of wearable sensors in objectively measuring longitudinal physical activity and sleep behavior patterns in children with obesity and in quantifying changes in their health behaviors due to disruption of structured, daily routines following in-person school closures during the COVID-19 pandemic.

Trial Registration

Clinical trial registration: NCT03339440.

Intervening on Social Comparisons on Social Media: Electronic Daily Diary Pilot Study

BACKGROUND

Literature has underscored the dark aspects of social media use, including associations with depressive symptoms, feelings of social isolation, and diminished self-esteem. Social comparison, the process of evaluating oneself relative to another person, is thought to contribute to these negative experiences such that people with a stronger tendency to compare themselves with others are particularly susceptible to the detrimental effects of social media. Social media as a form of social connection and communication is nevertheless an inevitable-and arguably integral-part of life, particularly for young adults. Therefore, there is a need to investigate strategies that could alter the manner in which people interact with social media to minimize its detrimental effects and maximize the feelings of affiliation and connection.

OBJECTIVE

This pilot study examined the feasibility, acceptability, and effectiveness of a brief web-based intervention designed to alter engagement with social media and promote psychological well-being by encouraging social savoring as an alternative to social comparison. Social savoring was operationalized as experiencing joyful emotions related to the happiness of someone else's experiences (ie, feeling happy for someone else).

METHODS

Following an intensive longitudinal design, 55 college students (mean age 19.29, SD 0.93 years; n=43, 78% women and n=23, 42% White) completed baseline measures (individual differences, psychological well-being, connectedness, and social media use) and then 14 days of daily surveys on their social media activity and well-being. On day 8, the group that was randomized to receive the intervention watched a video instructing them on the skill of social savoring and was asked to practice this skill during days 8 to 14.

RESULTS

Overall, participants reported positive perceptions of the intervention. Participants who watched the intervention video reported significantly higher performance self-esteem (P=.02) at posttest than those in the control condition, after controlling for baseline levels. Participants also reported significantly higher state self-esteem (P=.01) on days in which they engaged in more social savoring while using social media, and the use of social savoring increased significantly (P=.01) over time, suggesting that participants found it helpful. Participants in both conditions reported significantly lower levels of social comparison (control: P=.01; intervention: P=.002) and higher levels of connectedness (control: P<.001; intervention: P=.001) at posttest than at baseline.

CONCLUSIONS

Initial evidence from this pilot study suggests that a web-based social savoring intervention may help minimize the potentially harmful consequences of social media use, at least in some domains. Future work is needed to examine the effectiveness and acceptance of this intervention in different age groups and in clinical samples that are in part characterized by higher levels of comparison with others (eg, people with eating disorders).

Complex functional brain network properties in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a disorder characterized by an incapacitating fear of weight gain and by a disturbance in the way the body is experienced, facets that motivate dangerous weight loss behaviors. Multimodal neuroimaging studies highlight atypical neural activity in brain networks involved in interoceptive awareness and reward processing.

METHODS

The current study used resting-state neuroimaging to model the architecture of large-scale functional brain networks and characterize network properties of individual brain regions to clinical measures. Resting-state neuroimaging was conducted in 62 adolescents, 22 (21 female) with a history of AN and 40 (39 female) healthy controls (HCs). Sensorimotor and basal ganglia regions, as part of a 165-region whole-brain network, were investigated. Subject-specific functional brain networks were computed to index centrality. A contrast analysis within the general linear model covarying for age was performed. Correlations between network properties and behavioral measures were conducted (significance q < .05).

RESULTS

Compared to HCs, AN had lower connectivity from sensorimotor regions, and greater connectivity from the left caudate nucleus to the right postcentral gyrus. AN demonstrated lower sensorimotor centrality, but higher basal ganglia centrality. Sensorimotor connectivity dyads and centrality exhibited negative correlations with body dissatisfaction and drive for thinness, two essential features of AN.

CONCLUSIONS

These findings suggest that AN is associated with greater communication from the basal ganglia, and lower information propagation in sensorimotor cortices. This is consistent with the clinical presentation of AN, where individuals exhibit patterns of rigid habitual behavior that is not responsive to bodily needs, and seem "disconnected" from their bodies.

Parent strategies for expanding food variety: Reflections of 19,239 adults with symptoms of Avoidant/Restrictive Food Intake Disorder

OBJECTIVE

To characterize helpful parent feeding strategies using reflections on childhood eating experiences of adults with symptoms of Avoidant/Restrictive Food Intake Disorder (ARFID).

METHOD

We explored a unique text-based dataset gathered from a population of N = 19,239 self-identified adult "picky eaters." The sample included adults with symptoms of ARFID as evidenced by marked interference in psychosocial functioning, weight loss/sustained low weight, and/or nutritional deficiency (likely ARFID), and non-ARFID participants. We leveraged state-of-the-art natural language processing (NLP) methods to classify feeding strategies that were perceived as helpful or not helpful. The best classifiers that distinguished helpful approaches were further analyzed using qualitative coding according to a grounded theory approach.

RESULTS

NLP reliably and accurately classified the perceived helpfulness of caregivers' feeding strategies (82%) and provided information about features of helpful parent strategies using recollections of adults with varying degrees of food avoidance. Strategies perceived as forceful were regarded as not helpful. Positive and encouraging strategies were perceived as helpful in improving attitudes toward food and minimizing social discomfort around eating. Although food variety improved, adults still struggled with a degree of avoidance/restriction.

DISCUSSION

Adults perceived that positive parent feeding strategies were helpful even though they continued to experience some degree of food avoidance. Creating a positive emotional context surrounding food and eating with others may help to eliminate psychosocial impairment and increase food approach in those with severe food avoidance. Nevertheless, additional tools to optimize parent strategies and improve individuals' capacity to incorporate avoided foods and cope with challenging eating situations are needed.

A mixed-methods approach to conceptualizing friendships in anorexia nervosa

BACKGROUND

Individuals with anorexia nervosa have reported feelings of loneliness, social anhedonia, and interpersonal difficulties. This study sought to clarify the nature of interpersonal relationships in adults with anorexia, which may help improve existing interventions while also facilitating the attainment of something that might compete with the drive for thinness: friendships.

METHODS

The present study used a mixed-methods approach to investigate friendship experiences in three groups: anorexia (n = 27), participants with a history of anorexia who are weight restored (n = 20), and healthy controls (n = 24). Thematic analysis was used to isolate the most prevalent themes that emerged from an open-ended interview of experiencing friendships in a subset of participants. Three self-report questionnaires investigating friendship valuation and attachment styles were also administered.

RESULTS

11 unique themes emerged in the data: social comparison, reciprocity, trust, fear of negative evaluation, perceived skills deficit, logistical barriers, reliability, identity issue, low interest, similarity, and conflict avoidance. Only 17% of those with anorexia reported experiencing friendships as positive, relative to 82% of healthy controls and 52% of weight restored participants. Lastly, on self-report measures, participants with anorexia reported greater reliance on themselves versus others, greater use of care-seeking behaviors, and more fear/anger at the thought of losing an attachment figure (p < .05 in all cases).

CONCLUSION

Results suggest that individuals with anorexia have particular challenges which interfere with the formation and maintenance of friendships, such as viewing friendships negatively and struggling with social comparisons in friendships. Assessing and addressing barriers to intimacy may motivate those with anorexia to relinquish dangerous symptoms that maintain the illness.

Weight-Related Behaviors of Children with Obesity during the COVID-19 Pandemic

Background: During the coronavirus disease 2019 (COVID-19) pandemic, children and families have had to adapt their daily lives. The purpose of this study was to describe changes in the weight-related behaviors of children with obesity after the onset of the COVID-19 pandemic. Methods: Semistructured interviews (n = 51) were conducted from April to June 2020 with parents of children with obesity. Families were participants in a randomized trial testing a clinic-community pediatric obesity treatment model. During interviews, families described their experience during the COVID-19 pandemic, with a particular emphasis on children's diet, physical activity, sleep, and screen time behaviors. Rapid qualitative analysis methods were used to identify themes around changes in children's weight-related behaviors. Results: The mean child age was 9.7 (±2.8) years and the majority of children were Black (46%) or Hispanic (39%) and from low-income families (62%). Most parent participants were mothers (88%). There were differences in the perceived physical activity level of children, with some parents attributing increases in activity or maintenance of activity level to increased outdoor time, whereas others reported a decline due to lack of outdoor time, school, and structured activities. Key dietary changes included increased snacking and more meals prepared and consumed at home. There was a shift in sleep schedules with children going to bed and waking up later and an increase in leisure-based screen time. Parents played a role in promoting activity and managing children's screen time. Conclusions: The COVID-19 pandemic has created unique lifestyle challenges and opportunities for lifestyle modification. Clinical Trials ID: NCT03339440.

Do children with recurrent abdominal pain grow up to become adolescents who control their weight by fasting? Results from a UK population-based cohort

OBJECTIVE

Gastrointestinal (GI) problems are common in eating disorders, but it is unclear whether these problems predate the onset of disordered eating. Recurrent abdominal pain (RAP) is the most prevalent GI problem of childhood, and this study aimed to explore longitudinal associations between persistent RAP (at ages 7 and 9) and fasting for weight control at 16.

METHOD

The Avon Longitudinal Study of Parents and Children (ALSPAC) is a UK population cohort of children. Childhood RAP was reported by mothers and defined as RAP 5+ (5 pain episodes in the past year) in our primary analysis, and RAP 3+ (3 pain episodes) in our sensitivity analysis. Fasting for weight control was reported by adolescents at 16. We used logistic regression models to examine associations, with adjustments for potential confounders.

RESULTS

After adjustments, we found no association between childhood RAP 5+ and adolescent fasting for weight control at 16 (OR 1.30 (95% Confidence Intervals [CI] 0.87, 1.94) p = .197). However, we did find an association between RAP 3+ and later fasting, in the fully adjusted model (OR 1.50 [95% CI 1.16, 1.94] p = .002), and after excluding those with pre-existing anxiety (OR 1.52 [95% CI 1.17, 1.97] p = .002).

DISCUSSION

Our findings suggest a possible independent contribution of RAP to later risk of fasting for weight control, and RAP should be enquired about in the assessment of eating disorders. However, frequency of childhood abdominal pain (as captured by ALSPAC) may be less important to long-term outcomes than functional impairment.

The clash of culture and cuisine: A qualitative exploration of cultural tensions and attitudes toward food and body in Chinese young adult women

OBJECTIVE

Accumulating evidence suggests that the prevalence of eating disorders among Chinese women is a public health concern. Prior studies have drawn linkages between conflicting cultural values, identity confusion, and eating disorder symptomatology, which may be relevant for understanding the rise of eating disorders amidst China's rapid economic and sociocultural transformation. Here, we explore how women's experiences with traditional eating norms and modernizing norms of femininity may shape their food and body attitudes.

METHOD

Chinese young adult women (N = 34; aged 18-22 years) participated in semi-structured interviews focusing on experiences with norms surrounding eating and ideal feminine appearance, perceived conflict between these norms, and their responses to perceived conflict. Interviews were conducted via email (n = 27) or via Skype (n = 7). Participants were not asked about past or present diagnoses of eating disorders. Analysis of responses was guided by the principles of thematic analysis.

RESULTS

Women reported encounters with cultural eating norms and feminine appearance norms, and described factors that motivated continued or discontinued adherence to these norms. Women reported strategies of conflict resolution, which resulted in different emotional and behavioral outcomes including eating disorder symptoms.

DISCUSSION

Women's experiences with norms surrounding eating and appearance indicate the centrality of these encounters in the formation of individual and interpersonal values. Our findings suggest the importance for clinicians to assist clients in exploring the meanings behind internalized attitudes toward food and body, and to help clients balance interpersonal and individual needs.

Increased emotional eating behaviors in children with autism: Sex differences and links with dietary variety

LAY ABSTRACT

Although "picky" eating is well documented in autism spectrum disorder, emotional eating has rarely been investigated. This study examined emotional over- and under-eating based on parent ratings of these behaviors in 4- to 17-year-old children with autism spectrum disorder (n = 190) as compared to same-age typically developing children (n = 119). Children with autism spectrum disorder were rated as exhibiting both more emotional over-eating and more emotional under-eating behaviors than their typically developing peers. Furthermore, while sex differences in these emotional eating behaviors were not observed in the typically developing children, girls with autism spectrum disorder were rated as experiencing more emotional over-eating behaviors than boys with autism spectrum disorder. Finally, among all children with autism spectrum disorder, emotional over-eating was linked with increased consumption of sweet foods and decreased consumption of vegetables. These findings have implications for better understanding eating habits in children with autism spectrum disorder and suggest that emotional eating behaviors might have both immediate and downstream health impacts.

Associations between attention deficit hyperactivity disorder symptoms and eating behaviors in early childhood

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) symptoms have been linked with eating behaviors and obesity adolescence and young adulthood. Yet, little is known about whether these associations occur during early childhood and few studies have examined these associations prospectively.

OBJECTIVES

To assess magnitude and direction of associations between childhood ADHD symptoms and eating behaviors.

METHODS

Participants were from the Newborn Epigenetics Study (N = 470, M age = 4 years). Multivariable linear regression models were used to examine cross-sectional associations between ADHD symptoms and eating behaviors. Latent Change Score (LCS) modeling was performed to examine prospective association among a subset of children with available follow-up data. (N = 100, M age = 7 years).

RESULTS

The cross-sectional results showed that attention problem (AP) and hyperactivity (HY) were positively associated with food responsiveness, emotional overeating, desire to drink, and slowness in eating. AP, but not HY, was inversely associated with enjoyment of food. Results of the LCS models revealed AP and HY were both positively associated with prospective changes in emotional overeating and satiety responsiveness. AP was further positively associated with prospective changes in food responsiveness. The reverse relationship predicting changes in ADHD symptoms from earlier assessments of eating behaviors was not significant.

CONCLUSION

Results suggest a link between ADHD symptoms and obesity-related eating behaviors in early childhood, highlighting the need to address self-regulation and healthy eating behaviors in the prevention of childhood obesity.

Rationale and design of "Hearts & Parks": study protocol for a pragmatic randomized clinical trial of an integrated clinic-community intervention to treat pediatric obesity

BACKGROUND

The prevalence of child and adolescent obesity and severe obesity continues to increase despite decades of policy and research aimed at prevention. Obesity strongly predicts cardiovascular and metabolic disease risk; both begin in childhood. Children who receive intensive behavioral interventions can reduce body mass index (BMI) and reverse disease risk. However, delivering these interventions with fidelity at scale remains a challenge. Clinic-community partnerships offer a promising strategy to provide high-quality clinical care and deliver behavioral treatment in local park and recreation settings. The Hearts & Parks study has three broad objectives: (1) evaluate the effectiveness of the clinic-community model for the treatment of child obesity, (2) define microbiome and metabolomic signatures of obesity and response to lifestyle change, and (3) inform the implementation of similar models in clinical systems.

METHODS

Methods are designed for a pragmatic randomized, controlled clinical trial (n = 270) to test the effectiveness of an integrated clinic-community child obesity intervention as compared with usual care. We are powered to detect a difference in body mass index (BMI) between groups at 6 months, with follow up to 12 months. Secondary outcomes include changes in biomarkers for cardiovascular disease, psychosocial risk, and quality of life. Through collection of biospecimens (serum and stool), additional exploratory outcomes include microbiome and metabolomics biomarkers of response to lifestyle modification.

DISCUSSION

We present the study design, enrollment strategy, and intervention details for a randomized clinical trial to measure the effectiveness of a clinic-community child obesity treatment intervention. This study will inform a critical area in child obesity and cardiovascular risk research-defining outcomes, implementation feasibility, and identifying potential molecular mechanisms of treatment response.

CLINICAL TRIAL REGISTRATION

NCT03339440 .

Family-Based Treatment for Anorexia Nervosa Symptoms in High-Risk Youth: A Partially-Randomized Preference-Design Study

This pilot study adapted family-based treatment (FBT) for youth with potentially prodromal anorexia nervosa (AN). Fifty-nine youth with clinically significant AN symptom constellations, but who never met full Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (DSM-IV) criteria for AN, were enrolled in a partially randomized preference design study. Participants were offered randomization to FBT or supportive psychotherapy (SPT); those who declined to be randomized because of a strong treatment preference were entered into a parallel, non-randomized self-selected intervention study. Without accessing outcome data, an observational analysis with three diagnostic subclasses was designed based on AN symptom severity profiles, combining randomized and non-randomized participants, such that participants receiving FBT and SPT within each subclass were similar on key baseline characteristics. Outcomes of this pilot study were explored by calculating effect sizes for end-of-treatment values within each subclass, and also with a longitudinal mixed effect model that accounted for subclass. Weight trajectory was measured by percent expected body weight. Psychological outcomes were fear of weight gain, feeling fat, importance of weight, and importance of shape. Results show that the pattern of symptom observations over time was dependent on subclass of SAN (least symptomatic, moderately symptomatic, or most symptomatic) and on the target outcome variable category (weight or psychological). Results from this study, which should be considered in the context of the small sample sizes overall and within groups, can generate hypotheses for future, larger research trials on early treatment strategies. Feasibility findings illustrate how the innovative partially randomized preference design has potential broader application for AN intervention research.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT00418977.

Eating disorder recovery in men: A pilot study

OBJECTIVE

This pilot study examined the validity of a comprehensive definition of recovery (physical, behavioral, and cognitive recovery indices) for the first time in men.

METHOD

Men with an eating disorder history were recruited from former patients at eating disorder centers, university campuses, and fitness centers/gyms. At baseline and a 12-month follow-up, data were collected via online surveys, diagnostic interviews, and measured weight and height from men with an eating disorder history (n = 36) and men with no eating disorder history (n = 27).

RESULTS

Of the men with an eating disorder history, 15 met criteria for an eating disorder, 7 met criteria for partial recovery, and 5 for full recovery. Men who met criteria for full recovery did not differ significantly from men with no eating disorder history and had significantly lower levels of broad eating pathology, thinness and restricting expectancies, body shame, difficulties in stopping thoughts about body, food, or exercise, and male body attitudes related to muscularity and body fat than men with an eating disorder. Men meeting criteria for full recovery had higher levels of body acceptance and intuitive eating than men who met criteria for partial recovery or an eating disorder. In terms of predictive validity, of those fully recovered at baseline, 60% also met full recovery criteria at follow-up.

DISCUSSION

Preliminary findings suggest that a comprehensive definition of recovery applies to men. Although research with larger samples is needed, this research provides some optimism for the potential of recovery in men.

Sensory Over-Responsivity: An Early Risk Factor for Anxiety and Behavioral Challenges in Young Children

Anxiety disorders are prevalent and significantly impact young children and their families. One hypothesized risk factor for anxiety is heightened responses to sensory input. Few studies have explored this hypothesis prospectively. This study had two goals: (1) examine whether sensory over-responsivity is predictive of the development of anxiety in a large prospective sample of children, and (2) identify whether anxiety mediates the relationship between sensory over-responsivity and behavioral challenges. Children's sensory and anxiety symptoms were assessed in a community sample of 917 at 2-5 and again in 191 of these children at 6 years old. Parents also reported on a number of additional behavioral challenges previously found to be associated with both sensory over-responsivity and anxiety separately: irritability, food selectivity, sleep problems, and gastrointestinal problems. Forty three percent of preschool children with sensory over-responsivity also had a concurrent impairing anxiety disorder. Preschool sensory over-responsivity symptoms significantly and positively predicted anxiety symptoms at age six. This relationship was both specific and unidirectional. Finally, school-age anxiety symptoms mediated the relationship between preschool sensory over-responsivity symptoms and both irritability and sleep problems at school-age. These results suggest sensory over-responsivity is a risk factor for anxiety disorders. Furthermore, children who have symptoms of sensory over-responsivity as preschoolers have higher levels of anxiety symptoms at school-age, which in turn is associated with increased levels of school-age behavioral challenges.

Radcliffe ARFID Workgroup: Toward operationalization of research diagnostic criteria and directions for the field

OBJECTIVE

Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined.

METHOD

In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder.

RESULTS

By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment.

CONCLUSIONS

This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.

Avoidant restrictive food intake disorder: First do no harm

OBJECTIVE

This opinion piece offers some considerations, both medical and psychological, for the use of nasogastric tube (NGT) feedings in the treatment of avoidant restrictive food intake disorder (ARFID) in children and adolescents.

METHOD

Although there is empirical support for the use of NGT feedings in the treatment of anorexia nervosa, this evidence base does not exist for the treatment of ARFID. As such, there is need to delineate pragmatic considerations in the use of this procedure.

RESULTS

Issues of medical necessity notwithstanding, we advise that the use of this procedure be considered more cautiously due to the oral sensitivities inherent in many individuals with ARFID and the potential psychological consequences. These sensitivities may make the experience of NGT feedings particularly aversive, with the potential of creating iatrogenic conditioned food aversions.

DISCUSSION

This article encourages clinicians to give careful thought and attention when considering NGT feedings in children and adolescents with ARFID.

Avoidant Restrictive Food Intake Disorder

Avoidant restrictive food intake disorder (ARFID) is a rearticulated eating disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5), published in 2013. The purpose of this article is to review what is known about ARFID; specifically outline the DSM-5 diagnostic criteria; review the epidemiology; describe the clinical characteristics of patients with this disorder; and discuss evolving treatment approaches. Although this disorder occurs across the lifespan, the focus of recent research has been primarily in children and adolescents with ARFID. Therefore, most of this article is devoted to children and adolescents with ARFID.

Pre-Pregnancy Weight and Symptoms of Attention Deficit Hyperactivity Disorder and Executive Functioning Behaviors in Preschool Children

This study examines pre-pregnancy Body Mass Index (BMI) and gestational weight gain (GWG) in relation to early childhood Attention Deficit Hyperactivity Disorder (ADHD) symptoms and related executive self-regulation behaviors. The analyses sample (n = 331) included a subsample of participants from a birth cohort recruited from prenatal clinics and hospital facilities from April 2005 to June 2011 in Durham, North Carolina. Pre-pregnancy BMI was calculated from weight at the last menstrual period and height was extracted from medical records. Gestational weight gain was calculated from pre-pregnancy weight and weight measured at the time of delivery. ADHD symptoms and executive self-regulation behaviors were assessed by maternal report (mean age = 3 years). Multivariable regression methods with inverse probability weighting (IPW) were used to evaluate associations accounting for sample selection bias and confounding. Pre-pregnancy BMI at levels ≥35 was positively associated with higher ADHD symptoms and worse executive self-regulation behaviors (inhibitory control and attention). Compared to adequate GWG, less than adequate GWG was related to more ADHD hyperactive-impulsive symptoms, whereas greater than adequate GWG was related to more problematic behaviors related to working memory and planning. The findings support a link between maternal weight and child neurodevelopment. Continued research that help identify biological mechanisms are needed.

Associations between maternal cytokine levels during gestation and measures of child cognitive abilities and executive functioning

Preclinical studies demonstrate that environmentally-induced alterations in inflammatory cytokines generated by the maternal and fetal immune system can significantly impact fetal brain development. Yet, the relationship between maternal cytokines during gestation and later cognitive ability and executive function remains understudied. Children (n = 246) were born of mothers enrolled in the Newborn Epigenetic Study - a prospective pre-birth cohort in the Southeastern US. We characterized seven cytokines [IL-1β, IL-4,IL-6, IL-12p70, IL-17A, tumor necrosis factor-α (TNFα), and interferon-γ (IFNγ)] and one chemokine (IL-8) from maternal plasma collected during pregnancy. We assessed children's cognitive abilities and executive functioning at a mean age of 4.5 (SD = 1.1) years. Children's DAS-II and NIH toolbox scores were regressed on cytokines and the chemokine, controlling for maternal age, race, education, body mass index, IQ, parity, smoking status, delivery type, gestational weeks, and child birth weight and sex. Higher IL-12p70 (β_IL-12p70 = 4.26, p = 0.023) and IL-17A (β_IL-17A = 3.70, p = 0.042) levels were related to higher DAS-II GCA score, whereas higher IL-1β (β_IL-1B = -6.07, p = 0.003) was related to lower GCA score. Higher IL-12p70 was related to higher performance on NIH toolbox measures of executive functions related to inhibitory control and attention (β_IL-12p70 = 5.20, p = 0.046) and cognitive flexibility (β_IL-12p70 = 5.10, p = 0.047). Results suggest that dysregulation in gestational immune activity are associated with child cognitive ability and executive functioning.

The Application of Optimal Defaults to Improve Elementary School Lunch Selections: Proof of Concept

BACKGROUND

In this study, we applied behavioral economics to optimize elementary school lunch choices via parent-driven decisions. Specifically, this experiment tested an optimal defaults paradigm, examining whether strategically manipulating the health value of a default menu could be co-opted to improve school-based lunch selections.

METHODS

The design was a randomized comparison of optimal versus suboptimal (standard) default lunch menus for all first-graders in a school district for a period of 1 week. We hypothesized that making the default lunch option healthier, while providing parents the opportunity to access and choose from the standard school menu for their child, would yield more frequent selection of healthier items than when the default option was suboptimal.

RESULTS

Overall, 127 (93%) first-grade children's families participated. Among those families randomized to receive the nutritionally optimized default menu, all but one remained with these options; of those parents randomized to the standard menu (suboptimal default), all parents remained with these options (Χ² = 123.06, df = 1, p < .001).

CONCLUSIONS

The mere positioning of choices, without restricting options, significantly affected which menu items the children received during the test period. Results are proof of concept for a strategy to increase health-promoting school lunch content, procedures, and policies.

Building evidence for the use of descriptive subtypes in youth with avoidant restrictive food intake disorder

OBJECTIVE

To examine characteristics of patients with Avoidant/Restrictive Food Intake Disorder (ARFID) in an effort to identify and describe subtypes of the disorder.

METHOD

A retrospective chart review was completed for patients aged 8-17 years assessed over a 17-year period.

RESULTS

Seventy-seven patients were included in the study, the majority of whom were female (n = 56, 73%). The average age of patients was 13.7 years (SD = 2.4 years). Three specific subtypes of ARFID (aligning with example presentations outlined in the DSM-5) were identified: (a) those with weight loss and/or medical compromise as a consequence of apparent lack of interest in eating (n = 30, 39%); (b) restriction arising as a result of sensory sensitivity (n = 14, 18%); and (c) restriction based upon food avoidance and/or fear of aversive consequences of eating (n = 33, 43%). Clinical characteristics of patients varied depending on the assigned subtype.

DISCUSSION

Our findings highlight the need for further research into the relative merit of subtype-assignment in patients with ARFID and whether such practice would aid in the recommended treatment. Further research is required to understand whether these categories are generalizable and applicable to other samples such as young children or adults with ARFID, and how treatment options might differ according to subtype.

Attention-Deficit/Hyperactivity Disorder Symptoms Are Associated with Overeating with and without Loss of Control in Youth with Overweight/Obesity

BACKGROUND

There is growing evidence that attention-deficit/hyperactivity disorder (ADHD) and loss of control (LOC) eating, both prevalent in children and adolescents, may be related to one another. However, the relationship between ADHD and overeating without LOC has been largely unexamined, thus precluding an understanding of the independent contributions of LOC and episode size in these associations. The current study sought to examine associations between ADHD symptoms and maladaptive eating by evaluating three different types of eating episodes characterized by the presence/absence of LOC and the amount of food consumed: objectively large LOC episodes [objective binge eating (OBE)], subjectively large binge episodes [subjective binge eating (SBE)], and objectively large overeating episodes without LOC [objective overeating (OO)].

METHODS

Participants were 385 youth (M age = 10.89, SD = 2.25) drawn from five different research protocols at institutions across the United States. Participants and their parents completed questionnaires and semistructured interviews to assess ADHD symptoms, OBE, SBE, and OO.

RESULTS

As hypothesized, negative binomial regressions revealed that ADHD symptoms were significantly associated with OBE, χ²(1) = 16.61, p < 0.001, and with OO, χ²(1) = 10.64, p < 0.01. Contrary to expectations, they were not associated with SBE.

CONCLUSIONS

These results indicate the need for future studies to explore possible shared mechanisms (e.g., impulsivity) underlying associations between ADHD symptoms, OBE, and OO. Clinical implications include support for considering ADHD symptoms in programs that target both prevention of LOC eating and obesity more generally.

Secretive eating among youth with overweight or obesity

PURPOSE

Secretive eating, characterized by eating privately to conceal being seen, may reflect eating- and/or body-related shame, be associated with depression, and correlate with binge eating, which predicts weight gain and eating disorder onset. Increasing understanding of secretive eating in youth may improve weight status and reduce eating disorder risk. This study evaluated the prevalence and correlates of secretive eating in youth with overweight or obesity.

METHODS

Youth (N = 577) presented to five research/clinical institutions. Using a cross-sectional design, secretive eating was evaluated in relation to eating-related and general psychopathology via linear and logistic regression analyses.

RESULTS

Secretive eating was endorsed by 111 youth, who were, on average, older than youth who denied secretive eating (mean age = 12.07 ± 2.83 versus 10.97 ± 2.31). Controlling for study site and age, youth who endorsed secretive eating had higher eating-related psychopathology and were more likely to endorse loss of control eating and purging than their counterparts who did not endorse secretive eating. Groups did not differ in excessive exercise or behavioral problems. Dietary restraint and purging were elevated among adolescents (≥13y) but not children (<13y) who endorsed secretive eating; depression was elevated among children, but not adolescents, who endorsed secretive eating.

CONCLUSIONS

Secretive eating may portend heightened risk for eating disorders, and correlates of secretive eating may differ across pediatric development. Screening for secretive eating may inform identification of problematic eating behaviors, and understanding factors motivating secretive eating may improve intervention tailoring.

The Body Logic Program for Adolescents

The Body Logic Program for Adolescents was developed as a two-stage intervention to prevent the development of eating disorder symptoms. Preliminary results indicate that this program shows promise as an effective prevention effort. The current article provides a detailed description of the protocol for implementing Body Logic Part I, a school-based intervention. A brief review of Body Logic Part II, an intensive family-based intervention for high-risk students, is also provided. Examples of exercises are introduced and goals for practitioners are discussed. The authors hope that by providing this in-depth description of the protocol, researchers and clinicians can use this program in future prevention efforts.

Does childhood bullying predict eating disorder symptoms? A prospective, longitudinal analysis

OBJECTIVE

Bullying is a common childhood experience with enduring psychosocial consequences. The aim of this study was to test whether bullying increases risk for eating disorder symptoms.

METHOD

Ten waves of data on 1,420 participants between ages 9 and 25 were used from the prospective population-based Great Smoky Mountains Study. Structured interviews were used to assess bullying involvement and symptoms of anorexia nervosa and bulimia nervosa as well as associated features. Bullying involvement was categorized as not involved, bully only, victim only, or both bully and victim (bully-victims).

RESULTS

Within childhood/adolescence, victims of bullying were at increased risk for symptoms of anorexia nervosa and bulimia nervosa as well as associated features. These associations persisted after accounting for prior eating disorder symptom status as well as preexisting psychiatric status and family adversities. Bullies were at increased risk of symptoms of bulimia and associated features of eating disorders, and bully-victims had higher levels of anorexia symptoms. In terms of individual items, victims were at risk for binge eating, and bully-victims had more binge eating and use of vomiting as a compensatory behavior. There was little evidence in this sample that these effects differed by sex. Childhood bullying status was not associated with increased risk for persistent eating disorder symptoms into adulthood (ages 19, 21, and 25).

DISCUSSION

Bullying predicts eating disorder symptoms for both bullies and victims. Bullying involvement should be a part of risk assessment and treatment planning for children with eating problems.

Psychological and Psychosocial Impairment in Preschoolers With Selective Eating

OBJECTIVE

We examined the clinical significance of moderate and severe selective eating (SE). Two levels of SE were examined in relation to concurrent psychiatric symptoms and as a risk factor for the emergence of later psychiatric symptoms. Findings are intended to guide health care providers to recognize when SE is a problem worthy of intervention.

METHODS

A population cohort sample of 917 children aged 24 to 71 months and designated caregivers were recruited via primary care practices at a major medical center in the Southeast as part of an epidemiologic study of preschool anxiety. Caregivers were administered structured diagnostic interviews (the Preschool Age Psychiatric Assessment) regarding the child's eating and related self-regulatory capacities, psychiatric symptoms, functioning, and home environment variables. A subset of 188 dyads were assessed a second time ∼24.7 months from the initial assessment.

RESULTS

Both moderate and severe levels of SE were associated with psychopathological symptoms (anxiety, depression, attention-deficit/hyperactivity disorder) both concurrently and prospectively. However, the severity of psychopathological symptoms worsened as SE became more severe. Impairment in family functioning was reported at both levels of SE, as was sensory sensitivity in domains outside of food and the experience of food aversion.

CONCLUSIONS

Findings suggest that health care providers should intervene at even moderate levels of SE. SE associated with impairment in function should now be diagnosed as avoidant/restrictive food intake disorder, an eating disorder that encapsulates maladaptive food restriction, which is new to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Childhood somatic complaints predict generalized anxiety and depressive disorders during young adulthood in a community sample

BACKGROUND

Children with somatic complaints are at increased risk for emotional disorders during childhood. Whether this elevated risk extends into young adulthood - and to which specific disorders - has rarely been tested with long-term prospective-longitudinal community samples. Here we test whether frequent and recurring stomach aches, headaches, and muscle aches during childhood predict emotional disorders in adulthood after accounting for childhood psychiatric and physical health status and psychosocial adversity.

METHOD

The Great Smoky Mountains Study is a community representative sample with 1420 participants. Children/adolescents were assessed 4-7 times between ages 9-16 years. They were assessed again up to three times between ages 19-26 years. Childhood somatic complaints were coded when subjects or their parents reported frequent and recurrent headaches, stomach aches, or muscular/joint aches at some point when children were aged 9-16 years. Psychiatric disorders were assessed with the Child and Adolescent Psychiatric Assessment and the Young Adult Psychiatric Assessment.

RESULTS

Frequent and recurrent somatic complaints in childhood predicted adulthood emotional disorders. After controlling for potential confounders, predictions from childhood somatic complaints were specific to later depression and generalized anxiety disorder. Long-term predictions did not differ by sex. Somatic complaints that persisted across developmental periods were associated with the highest risk for young adult emotional distress disorders.

CONCLUSIONS

Children from the community with frequent and recurrent physical distress are at substantially increased risk for emotional distress disorders during young adulthood. Preventions and interventions for somatic complaints could help alleviate this risk.

The functional significance of shyness in anorexia nervosa

The defining features of anorexia nervosa (AN) include disordered eating and disturbance in the experience of their bodies; however, many women with AN also demonstrate higher harm avoidance (HA), lower novelty seeking, and challenges with interpersonal functioning. The current study explored whether HA and novelty seeking could explain variation in disordered eating and social functioning in healthy control women ( n = 18), weight-restored women with a history of AN (n = 17), and women currently-ill with AN (AN; n = 17). Our results indicated that clinical participants (AN + weight-restored women) reported poorer social skills than healthy control participants. Moreover, the relationship between eating disorder symptoms and social skill deficits was mediated by HA. Follow-up analyses indicated that only the 'shyness with strangers' factor of HA independently mediated this relationship. Collectively, our results suggest a better understanding of shyness in many individuals with eating disorders could inform models of interpersonal functioning in AN.

Self-focused attention in anorexia nervosa

OBJECTIVE

The clinical presentation of anorexia nervosa (AN) is characterized by preoccupation with body experience, intrusive concerns regarding shape, and pathological fears of weight gain. These symptoms are suggestive of unrelenting self-focused attention. No research to date has characterized self-focused attention (SFA) in AN nor examined neurocognitive features that may facilitate an excessive, rigid, or sustained focus on one's appearance.

METHOD

This study examined SFA, body image disturbance, and executive functioning in women with current anorexia nervosa (AN-C; n = 24), a history of AN who were weight-restored at the time of the study (WR; n = 19), and healthy controls (n = 24).

RESULTS

Private and public SFA were highest among WR and lowest among AN-C. Shape concerns were negatively correlated with SFA, especially among AN-C, after controlling for depression and social anxiety symptoms.

DISCUSSION

Lower levels of SFA among AN-C were unexpected and suggest the acute state of AN may lessen pathological self-focus, negatively reinforcing symptoms. In addition, body image concerns may distract from general SFA. Deficits in executive attention may explain these findings, as each one unit increase in perseverative errors among AN-C participants was associated with an almost one-half unit decrease in public SFA.

Design and implementation of a study evaluating extinction processes to food cues in obese children: the Intervention for Regulations of Cues Trial (iROC)

Obesity and its health sequelae affect a significant portion of children in the United States. Yet, the current gold-standard family-based behavioral weight-loss treatments are only effective for one-third of children long-term. Therefore, we developed iROC (Intervention for Regulation of Cues) to specifically target a method to decrease overeating in overweight children, based on learning theory, to inform and enhance interventions targeting diet and obesity in youth. This study will rigorously test extinction processes as a method of decreasing physiological and psychological responses to food cues in overweight and obese children. Through exposing children to their highly craved foods, and 'training the brain and body' to decrease overeating, we are hoping to produce longer-lasting weight loss or weight-gain prevention over time.

Are children and adolescents with food allergies at increased risk for psychopathology?

OBJECTIVE

Living with food allergy is a unique and potentially life-threatening stressor that requires constant vigilance to food-related stimuli, but little is known about whether adolescents with food allergies are at increased risk for psychopathology-concurrently and over time.

METHODS

Data came from the prospective-longitudinal Great Smoky Mountains Study. Adolescents (N=1420) were recruited from the community, and interviewed up to six times between ages 10 and 16 for the purpose of the present analyses. At each assessment, adolescents and one parent were interviewed using the Child and Adolescent Psychiatric Assessment, resulting in N=5165 pairs of interviews.

RESULTS

Cross-sectionally, food allergies were associated with more symptoms of separation and generalized anxiety, disorder, attention deficit and hyperactivity disorder, and anorexia nervosa. Longitudinally, adolescents with food allergy experienced increases in symptoms of generalized anxiety disorder and depression from one assessment to the next. Food allergies were not, however, associated with a higher likelihood of meeting diagnostic criteria for a psychiatric disorder.

CONCLUSION

The unique constellation of adolescents' increased symptoms of psychopathology in the context of food allergy likely reflects an adaptive increase in vigilance rather than cohesive syndromes of psychopathology. Support and guidance from health care providers is needed to help adolescents with food allergies and their caregivers achieve an optimal balance between necessary vigilance and hypervigilance and unnecessary restriction.

An intervention based on Schachter's externality theory for overweight children: the regulation of cues pilot

OBJECTIVE

This study evaluated the feasibility, acceptability, and initial efficacy of an intervention based on Schachter's externality theory; the Regulation of Cues (ROC) program.

METHODS

44 overweight and obese 8-12-year-old children and their parents were randomly assigned to a 4-month ROC program or the control group. Outcomes were assessed at baseline, posttreatment, and 4 months posttreatment and included acceptability and feasibility, body weight, and eating behaviors.

RESULTS

The ROC program had moderate to high acceptability ratings. Significant improvements were found for the ROC group compared with the control group on child food responsiveness at posttreatment and eating in the absence of hunger at 4 months posttreatment. Improvements were seen for the ROC group compared with the control group on body weight measures and food responsiveness, although these only approached significance.

CONCLUSION

The ROC intervention may be useful with overweight and obese children. Larger, fully powered studies are needed to further evaluate the efficacy of this model.

Overeating phenotypes in overweight and obese children

The purpose of this study was to identify overeating phenotypes and their correlates in overweight and obese children. One hundred and seventeen treatment-seeking overweight and obese 8-12year-old children and their parents completed the study. Children completed an eating in the absence of hunger (EAH) paradigm, the Eating Disorder Examination interview, and measurements of height and weight. Parents and children completed questionnaires that evaluated satiety responsiveness, food responsiveness, negative affect eating, external eating and eating in the absence of hunger. Latent profile analysis was used to identify heterogeneity in overeating phenotypes in the child participants. Latent classes were then compared on measures of demographics, obesity status and nutritional intake. Three latent classes of overweight and obese children were identified: High Satiety Responsive, High Food Responsive, and Moderate Satiety and Food Responsive. Results indicated that the High Food Responsive group had higher BMI and BMI-Z scores compared to the High Satiety Responsive group. No differences were found among classes in demographics or nutritional intake. This study identified three overeating phenotypes, supporting the heterogeneity of eating patterns associated with overweight and obesity in treatment-seeking children. These finding suggest that these phenotypes can potentially be used to identify high risk groups, inform prevention and intervention targets, and develop specific treatments for these behavioral phenotypes.

Parents of children with eating disorders: developing theory-based health communication messages to promote caregiver well-being

Parents of children with eating disorders experience extreme emotional burden because of the intensity and duration of the recovery process. While parental involvement in a child's eating disorder treatment improves outcomes, parents often neglect their own well-being, which can impede their child's recovery. This study extends the research on caregivers and on health theory in practice by conducting formative research to develop a theory-based communication intervention encouraging parents to engage in adaptive coping and self-care behaviors. The Transactional Model of Stress and Coping and the Transtheoretical Model guided qualitative assessments of the determinants of parents' coping behaviors. Three focus groups with 19 parents of children with eating disorders and 19 semi-structured interviews with experts specializing in eating disorders were conducted. Findings indicate that parents and experts see parents' need for permission to take time for themselves as the main barrier to self-care. The main motivator for parents to engage in coping behaviors is awareness of a connection between self-care and their child's health outcomes. Participant evaluation of six potential messages for main themes and effectiveness revealed that theory-based elements, such as certain processes of change within the Transtheoretical Model, were important to changing health behavior.

A pilot evaluation of appetite-awareness training in the treatment of childhood overweight and obesity: a preliminary investigation

OBJECTIVE

The aim of this study was to conduct a preliminary evaluation of Children's Appetite Awareness Training (CAAT), a treatment for childhood obesity which encourages overweight children to eat in response to internal appetite cues.

METHOD

Overweight children (ages 6-12 years old) were randomized to either the CAAT treatment group (N = 23), to receive 1-h treatment sessions over 6 weeks, or a wait-list group (N = 24). Weight and height of children and parents in both groups were assessed at pre- and post-treatment (or equivalent time for wait-list control) and at a 6-month follow-up for those in the CAAT group.

RESULTS

The intervention had a significant, short-term effect on the BMI of children who participated. Although at 6-month follow-up, children's BMI has not increased significantly, the difference between pretreatment and follow-up BMI was no longer significant.

DISCUSSION

These results are encouraging for the use of CAAT with overweight children. Long-term effectiveness could be enhanced through increasing the duration of the program, adding booster sessions and increased involvement of parents.

Optimal Defaults in the Prevention of Pediatric Obesity: From Platform to Practice

The term "optimal defaults" refers to imparting pre-selected choices which are designed to produce a desired behavior change. The concept is attractive to policymakers because it steers people toward desirable behaviors while preserving free choice through the ability to opt out. It has been found to be a powerful behavioral determinant in areas such as pension plan enrollment, organ donation, and green energy utilization. We discuss how optimal defaults can be applied to pediatric obesity prevention in several domains including public policy, institutional, private sector, and home environment. Although there are obstacles to overcome in implementing optimal defaults, it is a promising component to incorporate in a multi-level strategy for preventing pediatric obesity.

Perception of affect in biological motion cues in anorexia nervosa

OBJECTIVE

Nonverbal motion cues (a clenched fist) convey essential information about the intentions of the actor. Individuals with anorexia nervosa (AN) have demonstrated impairment in deciphering intention from facial affective cues, but it is unknown whether such deficits extend to deciphering affect from body motion cues.

METHOD

We examined the capacities of adults with AN (n = 21) or those weight restored for ≥12 months (WR; n = 20) to perceive affect in biological motion cues relative to healthy controls (HC; n = 23).

RESULTS

Overall, individuals with AN evidenced greater deficit in discriminating affect from biological motion cues than WR or HC. Follow-up analyses showed that individuals with AN differed especially across two of the five conditions--deviating most from normative data when discriminating sadness and more consistently discriminating anger relative to WR or HC.

DISCUSSION

Implications of these findings are discussed in relation to some puzzling interpersonal features of AN.

Overvaluation of shape and weight among overweight children and adolescents with loss of control eating

Little is known about the phenomenology of pediatric loss of control (LOC) eating. Overvaluation of shape and weight, however, appears to be diagnostically meaningful among binge eating adults. We explored the significance of shape and weight overvaluation among children and adolescents with LOC eating. Participants (n = 526) included 149 overweight youth with LOC eating and 377 overweight controls (CON). Participants were categorized as those reporting at least moderate overvaluation (LOC-Mod, n = 74; CON-Mod, n = 106) or less than moderate overvaluation (LOC-Low, n = 75; CON-Low, n = 271), and compared on measures of eating-related and general psychopathology. LOC-Mod evidenced lower self-esteem than CON-Low, and greater behavioral problems than CON-Mod and CON-Low, but did not differ from LOC-Low in these domains. With the exception of LOC-Low and CON-Mod, all groups differed on global eating-disorder severity, with LOC-Mod scoring the highest. Overvaluation of shape and weight appears to be of questionable importance in defining subtypes of youth with LOC eating. However, as overvaluation and LOC eating each independently predicts eating-disorder onset, their confluence may confer even further risk for eating-disorder development. Longitudinal studies should address this possibility. Developmentally appropriate discussion about body image disturbance may be indicated in interventions targeting pediatric LOC eating and/or obesity.

The significance of repetitive hair-pulling behaviors in eating disorders

We studied the relation between intrusive and repetitive hair pulling, the defining feature of trichotillomania, and compulsive and impulsive features in 1,453 individuals with anorexia nervosa and bulimia nervosa. We conducted a series of regression models examining the relative influence of compulsive features associated with obsessive-compulsive disorder, compulsive features associated with eating disorders, trait features related to harm avoidance, perfectionism, and novelty seeking, and self harm. A final model with a reduced sample (n = 928) examined the additional contribution of impulsive attributes. One of 20 individuals endorsed hair pulling. Evidence of a positive association with endorsement of compulsive behavior of the obsessive-compulsive spectrum emerged. Hair pulling may be more consonant with ritualistic compulsions than impulsive urges in those with eating disorders.

Classification of eating disturbance in children and adolescents: proposed changes for the DSM-V

Childhood and adolescence are critical periods of neural development and physical growth. The malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified may have more severe and potentially more protracted consequences during youth than during other age periods. The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.

Eating disorders

This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

Classification of child and adolescent eating disturbances. Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA)

OBJECTIVE

: The purpose of this article is to summarize major conceptual and clinical variables related to age-appropriate and developmentally appropriate classification of eating problems and disorders in children and adolescents.

METHOD

A review of current classifications and related literature in child development is provided. Problems with current classification schemes are identified and discussed.

RESULTS

Current classifications are inadequate to address the clinical and research needs of children and adolescents with eating disturbances and disorders.

CONCLUSION

A range of possible changes in classification strategies for eating disorders in children and adolescents are described.

Changes in depressive symptoms and glycemic control in diabetes mellitus

OBJECTIVE

To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes.

METHODS

Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels.

RESULTS

Mean and standard deviation baseline BDI and HbA1c levels were 17.9 +/- 5.8 and 7.6 +/- 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group.

CONCLUSION

Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes.