Internet-delivered eating disorders prevention program for adolescent girls with type 1 diabetes: Acceptable and feasible.

BACKGROUND: Adolescents with type 1 diabetes are at significantly increased risk for eating disorders and few interventions exist. OBJECTIVE: This study examined the feasibility, acceptability, and preliminary effects of an internet-based eating disorders prevention program adapted specifically for adolescent girls with type 1 diabetes. PARTICIPANTS AND METHODS: Thirty-five girls (16.2 ± 1.1 years) participated Body Project (T1D Style), a 4-week program consisting of four adolescent sessions focused on promoting illness acceptance, challenging sociocultural body image pressures, increasing social support, and teaching assertive communication. Caregivers participated in one session focused on fostering body image positivity and a healthy relationship with food. Pre-intervention, post-intervention, and 3-month follow-up surveys assessed disordered eating, body dissatisfaction, thin-ideal internalization, diabetes acceptance, diabetes distress, and quality of life. Cohen's d effect sizes were calculated at post-intervention and follow-up. Program acceptability was assessed at post-intervention. Manual fidelity and homework completion were monitored. RESULTS: High manual fidelity, retention, and homework completion were achieved. Quantitative and qualitative feedback from teens and caregivers suggested high acceptability. Large effects (d = 1.35-0.83) were observed for dieting, body dissatisfaction, diabetes distress, diabetes acceptance, and diabetes-related quality of life at post-intervention, with large-medium effects (d = 1.16-0.58) at follow-up. Medium-small effects (d = 0.49-0.78) at post-intervention were observed for diabetes-specific disordered eating and thin-ideal internalization, with effects maintained at follow-up. CONCLUSIONS: Results support the acceptability and feasibility of this targeted eating disorders prevention program for adolescent girls with type 1 diabetes. Future clinical trials are warranted to determine its effectiveness compared to a control condition.

Parenting and Psychological Health in Youth with Type 1 Diabetes: Systematic Review.

OBJECTIVE: Type 1 diabetes (T1D) is a demanding chronic illness that may result in poorer psychological health in youth. Fortunately, certain parenting practices may be protective against adverse outcomes. However, a systematic review of these relationships in youth with T1D is lacking. Thus, the current systematic review examined the literature on parenting and child psychological health outcomes (both internalizing and externalizing symptoms) in youth with T1D. Particular attention is paid to how demographic factors are associated with these relationships. METHODS: PRISMA guidelines for systematic reviews were followed, and a literature search (PubMed, PsycINFO, and CINAHL) was conducted for studies of youth with T1D that examined the relationship between specific parenting practices or characteristics of the parent-child relationship and youth (<19 years old) internalizing or externalizing symptoms. Forty studies met inclusion criteria. Studies were examined for risk of bias. RESULTS: Results support that family conflict, critical parenting, support, involvement, and relationship quality are associated with psychological health outcomes in youth with T1D, with some associations varying by parent gender, child age, demographic factors, and internalizing versus externalizing outcomes. CONCLUSIONS: Findings highlight the importance of bolstering supportive parenting and decreasing family conflict to improve psychological health in this population. Gaps in the literature related to the dearth of father and secondary caregiver report, lack of sample diversity and attention to the influence of demographic factors, and a limited number of studies examining anxiety were identified. Directions for future research and clinical implications are discussed.

Bidirectional Associations between Physical Activity and Sleep in Early-Elementary-Age Latino Children with Obesity.

Low-income Latino children are at high risk for obesity and associated comorbidities. Considering the health benefits of proper sleep habits and physical activity, understanding the patterns, or the relationship between these modifiable factors may help guide intervention strategies to improve overall health in this population. Thus, the purpose was to investigate bidirectional associations between physical activity and sleep among Latino children who are overweight/obese. Twenty-three children (boys, 70%; overweight, 17%; obese, 83%) (age 7.9 ± 1.4 years) wore activity monitors on their wrist for 6 consecutive days (comprising 138 total observations). Hierarchical linear modeling evaluated temporal associations between physical activity (light physical activity, LPA; moderate to vigorous activity, MVPA) and sleep (duration and efficiency). Although there was no association between MVPA and sleep (p > 0.05), daytime LPA was negatively associated with sleep duration that night (estimate ± SE = -10.77 ± 5.26; p = 0.04), and nighttime sleep efficiency was positively associated with LPA the next day (estimate ± SE = 13.29 ± 6.16; p = 0.03). In conclusion, increased LPA may decrease sleep duration that night, but increasing sleep efficiency may increase LPA the following day. Although further investigation is required, these results suggest that improving sleep efficiency may increase the level of physical activity reached among Latino children who are overweight/obese.

Relationships Among Metabolic-Risk, Body Fatness, and Muscular Fitness in Young Obese Latino Children.

Given the high prevalence of obesity in Latino children and potential health risks, the purpose of this study was to: 1) evaluate relationships among metabolic-risk, fitness, and body fatness; 2) determine sex differences in cardio-metabolic risk factors and fitness of obese children of Latino descent. Sixty children (boys, n = 39, 7.8 ± 1.5 years; girls, n = 21, 7.2 ± 1.5 years; body mass index, 97.8 ± 2.5th percentile) completed assessments of height, weight, and body fat, prior to fasted blood draws and a battery of fitness tests. Cardio-metabolic markers were analyzed, and a metabolic risk score created. Correlations and regression analyses evaluated the relationships among body fatness, metabolic-risk, and fitness. Independent samples t-tests determined sex differences (p < 0.05). Body fat related negatively to lower body power (p < 0.016), but positively to upper body power (p = 0.049). After controlling for age and sex, body fat (p < 0.001) was a positive predictor of variance in metabolic-risk scores, (R2 = 0.39, p < 0.001). Further, the association between body fat and metabolic-risk was not moderated by sex. Metabolic-risk scores and body fat were similar for both sexes, but boys performed better on muscular fitness tests, even after accounting for fat free mass (p < 0.05). Higher body fatness in obese Latino children may result in greater metabolic-risk and difficulty performing weight-bearing tasks. Therefore, culturally adapted weight management programs should employ a multifaceted approach to improve metabolic-risk and fitness.

Feasibility of a Multidisciplinary and Culturally Adapted Pediatric Weight Management Program for Latino Families: Results From the Vidas Activas y Familias Saludables Pilot Study.

OBJECTIVE: To determine the feasibility of a pediatric weight management program for low-income Latino families. METHODS: A pretest-posttest pilot study was conducted among 60 Latino children, aged 4-9, who were overweight/obese (body mass index-for-age ≥85th percentile). The 10-week group-based community program addressed diet, exercise, and behavior modification. Demand was assessed through recruitment and attendance, acceptability using postintervention surveys with participants, and limited efficacy testing of participant anthropometrics and cardiometabolic markers. RESULTS: Overall 65% of families were retained for follow-up. All families reported feeling more confident in making healthier food choices and would participate in the program again. Pre/post intervention testing found statistically significant decreases (P < .05) in body mass index for age z score, waist circumference, and % body fat. CONCLUSIONS AND IMPLICATIONS: This culturally adapted group intervention for Latino families was acceptable and shows promise for improved health status, although it needs to be replicated with a larger group and longer follow-up.

A brief peer gatekeeper suicide prevention training: Results of an open pilot trial.

OBJECTIVE: The purpose of the present study was to test a 1-hour peer suicide gatekeeper training for students from the broad college community in the context of an open pilot trial. METHOD: Two-hundred and thirty-one college students were recruited university-wide, Mage  = 20.7, 65.4% female, and completed a peer suicide prevention gatekeeping training program. Assessments were completed at pre-training and post-training as well as 3-month follow-up. RESULTS: This brief peer suicide gatekeeper training program was associated with increases in suicide prevention knowledge. It was also associated with an increase in the number of students who identified suicidal youth and made mental health referrals, as well as total number of referrals made, over the course of three months. Females reported greater improvement in suicide prevention skills and knowledge post-training than males. CONCLUSIONS: Offering peer suicide gatekeeper training to students from the general college population may hold promise in suicide prevention efforts.

Rumination and self-control interact to predict bulimic symptomatology in college students.

Recent studies suggest that a ruminative response style may contribute to the development and maintenance of Bulimia nervosa. However it is not clear what factors may contribute to the relationship between rumination and BN. One factor may be self-control, as studies suggest that BN symptomatology relates to deficits in self-control. In the present study, we hypothesized that the association between rumination and BN symptomatology would be the strongest among individuals with lower self-control relative to those with higher self-control. Participants were 353 students at a large university. Participants completed measures of self-control, rumination, and eating disorder symptomology as part of an online study. A hierarchical regression supported an interaction between rumination and self-control predicting bulimic symptomatology, controlling for BMI. Individuals with higher levels of rumination presented more bulimic symptoms if they also had lower levels of self-control, supporting our hypothesis. Based on these findings, assessing rumination in conjunction with self-control among individuals who present with eating concerns may help to direct treatment. Additionally, clinical interventions increasing self-control may also alleviate some BN symptoms in ruminators.

Financial Analysis of Behavioral Health Services in a Pediatric Endocrinology Clinic.

OBJECTIVE: This article addresses a current need in psychological practice by describing a financially feasible model that moves toward integrated care of behavioral health services in a pediatric endocrinology clinic. METHODS: Financial information (costs and revenue associated with behavioral health services) for the clinic, over an 18-month period (July 2012 to December 2013), was obtained through the hospital's financial department. The clinic meets one half day per week. RESULTS: Over the 18-month period, the behavioral health services generated a net gain of $3661.45 in the favor of the clinic. We determined that the psychologist and clinical psychology residents needed to see a total of four patients per half-day clinic for the clinic to "break-even." CONCLUSIONS: We describe one financially feasible way of integrating behavioral health services into a pediatric endocrinology clinic in the hope that this will be generalizable to other medical settings.

A Condensed Dialectical Behavior Therapy Skills Group for Binge Eating Disorder: Overcoming Winter Challenges.

Although binge eating disorder (BED) is a recent diagnostic category, research for efficacious and effective treatment is well underway. This case study describes a dialectical behavior therapy (DBT) skills group for BED implemented in an outpatient community clinic. Although based on Safer, Telch, and Chen's (2009) manual for BED and bulimia nervosa (BN), notable adaptations included shortening the group's duration from 20 to 12 weeks, adding an interpersonal effectiveness module and DBT-informed "Holiday Plan" worksheets, and providing inclement weather alternatives. Despite the added challenges associated with winter treatment of BED (e.g., holiday meals, weather-related schedule interruptions), the 3 women who completed treatment no longer met criteria for BED at termination and their feedback suggested that the treatment was highly acceptable. Group members demonstrated clinically significant reductions in disordered eating behavior and improvements in self-esteem, emotion regulation, and quality of life. Treatment gains were maintained at 1-year follow-up. Our discussion includes treatment implications and recommendations for future research.

The effects of avoidance coping and coping self-efficacy on eating disorder attitudes and behaviors: a stress-diathesis model.

The present study employed a series of stress-diathesis models to examine whether avoidance coping and poor coping self-efficacy contribute to disordered eating attitudes and behaviors in a sample of college students. The sample included one hundred fifteen undergraduate students (28.7% male; 71.3% female). Participants completed self-report measures to assess daily stressors, coping style, coping self-efficacy, and eating disorder attitudes and behaviors. As predicted, among students with an avoidance coping style, those who reported more daily stressors exhibited higher eating disorder attitudes and behaviors than those with less daily hassles. Contrary to study hypothesis, number of daily hassles did not moderate the association between coping self-efficacy and eating disorder attitudes and behaviors. However, there was a significant main effect for coping self-efficacy, suggesting that students who lack confidence in their coping abilities are more likely to have problematic eating attitudes and behaviors, regardless of their level of daily stress. Clinically, results suggest that students who enter college with an avoidance coping style and poor coping self-efficacy may be at risk for disordered eating, particularly with the onset of associated stress. Teaching students active problem-focused coping skills to deal with daily hassles associated with college life, and providing opportunities for repeated practice to bolster self-efficacy, may help prevent and/or reduce disordered eating attitudes and behaviors.

Two-year follow-up of an adolescent behavioral weight control intervention.

OBJECTIVE: This study examined the 24-month outcomes of a randomized controlled trial of a group-based behavioral weight control (BWC) program combined with either activity-based peer intervention or aerobic exercise. METHODS: At baseline, 118 obese adolescents (68% female; BMI = 31.41 ± 3.33) ages 13 to 16 years (mean = 14.33; SD = 1.02) were randomized to receive 1 of 2 weight loss interventions. Both interventions received the same 16-week group-based cognitive-behavioral treatment, combined with either aerobic exercise or peer-based adventure therapy. Eighty-nine adolescents (75% of original sample) completed the 24-month follow-up. Anthropometric and psychosocial measures were obtained at baseline, at the end of the 16-week intervention, and at 12 and 24 months following randomization. RESULTS: An intent-to-treat mixed factor analysis of variance indicated a significant effect for time on both percent over 50th percentile BMI for age and gender and standardized BMI score, with no differences by intervention group. Post hoc comparisons showed a significant decrease in percent overweight at 4 months (end of treatment), which was maintained at both 12- and 24-month follow-up visits. Significant improvements on several dimensions of self-concept were noted, with significant effects on physical appearance self-concept that were maintained through 24 months. CONCLUSIONS: Both BWC conditions were effective at maintaining reductions in adolescent obesity and improvements in physical appearance self-concept through 24-month follow-up. This study is one of the first to document long-term outcomes of BWC intervention among adolescents.

Associations between parent behavior and adolescent weight control.

OBJECTIVE: To evaluate associations between parent behaviors (i.e., parent weight change, self-monitoring of their behavior, and feeding practices and attitudes) and changes in adolescent BMI and weight following 16-weeks of behavioral weight control (BWC) intervention. METHOD: Adolescents (N = 86) 13-16 years old and 30-90% overweight (M = 60.54%, SD = 15.10%) who completed BWC intervention and their parents. Adolescents were randomized to 1 of 2 interventions involving 16 consecutive weeks of active treatment with 4 biweekly maintenance sessions. Adolescent weight and BMI were measured at baseline and 16-weeks. Feeding practices were measured at baseline. Parent self-monitoring was measured during the intervention. RESULTS: The only independently significant predictor of adolescent BMI change (p < .01) was parent BMI change. Greater parent self-monitoring (p < .01) predicted greater adolescent weight loss. Greater parent pressure to eat predicted less adolescent weight loss (p < .01). CONCLUSIONS: Findings highlight the potential importance of parent weight-related behaviors and feeding practices in the context of adolescent BWC.

Early patterns of food intake in an adolescent weight loss trial as predictors of BMI change.

PURPOSE: To determine whether baseline intake or initial changes in intake of fruits (F), vegetables (V), snack foods (SF), and reduced-calorie snack foods (RCSF) during standard behavioral weight loss treatment predict BMI reductions among overweight adolescents. Given conflicting messages between child and adult weight loss interventions, the role of RCSF in adolescent weight control was of particular interest. METHODS: Seventy-two adolescents, 13-16 years old, participating in a 16-week behavioral weight loss trial with diet records at baseline and 4 weeks were included. Height and weight were measured at 0 and 16 weeks. Frequency of intake of F, V, SF, and RCSF were obtained from 7-day food records at 0 and 4 weeks. RESULTS: Male gender, higher initial frequency of intake of V and increased frequency of intake of F and RCSF over the first 4 weeks of treatment accounted for 43% of the variance in BMI reduction at 16 weeks (p<.001). CONCLUSIONS: Early changes in eating habits, including increased frequency of intake of F and RCSF may promote greater adolescent BMI reductions.

Behavioral weight control treatment with supervised exercise or peer-enhanced adventure for overweight adolescents.

OBJECTIVE: To evaluate the efficacy of behavioral weight control intervention with a peer-enhanced activity intervention versus structured aerobic exercise in decreasing body mass index (BMI) and z-BMI in overweight adolescents. STUDY DESIGN: Participants were randomized to 1 of 2 group-based treatment conditions: (1) cognitive behavioral treatment with peer-enhanced adventure therapy or (2) cognitive behavioral weight control treatment with supervised aerobic exercise. Participants included 118 overweight adolescents, ages 13 to 16 years, and a primary caregiver. Changes in BMI, standardized BMI, percent over BMI, and waist circumference were examined. RESULTS: Analysis of variance on the basis of intent-to-treat indicated significant decreases in all weight change outcomes at the end of treatment, with significant decreases maintained at the 12-month follow-up. No differences in treatment conditions were observed. Secondary analyses indicated that adherence with attendance and completion of weekly diet records contributed significantly to reductions in BMI. CONCLUSIONS: A cognitive behavioral weight control intervention combined with supervised aerobic exercise or peer-enhanced adventure therapy is equally effective in short-term reduction of BMI and z-BMI in overweight adolescents. Adherence, as measured with session attendance and self-monitoring, is a key dimension of weight change.

Effects of Behavioral Weight Control Intervention on Binge Eating Symptoms Among Overweight Adolescents.

This study examined change in binge eating symptoms reported by moderately overweight adolescents following participation in a behavioral weight control intervention. A total of 194 adolescents across two randomized controlled trials participated. Adolescents in both study samples endorsed a mild level of binge eating symptoms at baseline. Results from both Study 1 and Study 2 indicate a significant reduction in binge eating symptoms following participation in a 16-week weight control intervention, F(1,60) = 9.43, p<.01 and F(1,98) = 20.98, p<.01, respectively. Several significant relationships between measures of self-concept and binge eating symptoms were noted, with lower self-concept scores related to higher binge eating symptoms scores at baseline. Changes in binge eating symptoms were also related to changes in physical appearance self-concept, global self-concept and physical self-worth at the end of the intervention. In conclusion, findings from this study support an emerging body of evidence suggesting that dietary restriction, as practiced through participation in a weight control intervention, leads to a reduction in binge eating symptoms among overweight adolescents.

Effect of weight, sleep duration, and comorbid sleep disorders on behavioral outcomes in children with sleep-disordered breathing.

OBJECTIVE: To assess the relative contribution of potential risk factors for adverse neurobehavioral outcomes in children referred for evaluation of sleep-disordered breathing (SDB), including weight, mean sleep duration, and comorbid sleep disorders. DESIGN: Medical record review. SETTING: Academic pediatric medical center. PARTICIPANTS: Clinical sample of 235 children aged 3 to 18 years undergoing overnight polysomnography for symptoms of SDB. OUTCOME MEASURES: History of behavioral, emotional, and academic problems and Child Behavior Checklist (CBCL) scores. RESULTS: More than half (56%) of the sample was overweight or at risk for overweight, more than one-third (36%) was classified as being short sleepers, and almost half (49%) had at least 1 additional sleep diagnosis. Forty-seven percent had a history of behavioral problems and 23% had a reported diagnosis of attention-deficit/hyperactivity disorder. There were no significant differences in CBCL scores based on any measure of SDB disease severity. Increased weight was associated with increased internalizing CBCL scores in a dose-dependent fashion (P = .003), while short sleepers were more likely to have elevated externalizing scores (P < .001). Overall, the strongest predictor of adverse behavioral outcomes was the presence of at least 1 additional sleep diagnosis (P < .001). CONCLUSIONS: The relationship between SDB and parent-reported behavioral outcomes in children is complex. In addition to SDB-related impairments, clinicians should consider the relative contributions of being overweight, insufficient sleep, and comorbid sleep disorders when assessing behavior in these children.

Predictors of attrition and weight loss in an adolescent weight control program.

OBJECTIVE: To evaluate demographic and psychosocial predictors of attrition and weight loss in a behaviorally based adolescent weight control trial. METHODS AND PROCEDURES: Adolescents (N = 76) aged 13-16 years and 20-80% overweight (M = 60.56%, s.d. = 15.17%) received standard group-based behavioral treatment as part of a randomized trial comparing different activity interventions for overweight adolescents. Anthropometric and psychosocial measures were obtained at baseline and after the 16-week intervention. RESULTS: Higher parent (P < 0.01) and adolescent BMI (P < 0.05) at baseline, as well as ethnic minority status (P < 0.05) were significantly associated with attrition in univariate analyses. Parent BMI remained the only significant predictor of attrition in multivariate analyses. BMI change for completers (N = 62) was highly variable, ranging from -6.09 to +1.62 BMI units. Male gender (P < 0.01) was a significant predictor of reduction in BMI, whereas not being from an ethnic minority group (P < 0.05) and attendance at group sessions (P = 0.05) were associated with > or = 5% absolute weight loss in multivariate analyses. Absolute weight loss during the first 4 weeks of the program was strongly associated with weight loss (pr = 0.44, P < 0.001) during the remainder of the intervention. Psychosocial variables were unrelated to attrition or treatment outcome. DISCUSSION: These findings highlight the potential importance of attending to parental BMI in efforts to retain adolescent participants in treatment, as well as the need to develop weight control interventions that are more effective for ethnic minority youth.

A pilot intervention to increase calcium intake in female collegiate athletes.

Calcium intake in adolescent and young adult female athletes often is inadequate to optimize peak bone mass, an important determinant of osteoporosis risk. The purpose of this study was to determine if calcium supplementation in eumenorrheic female collegiate athletes increases intake to recommended levels and promotes increases in bone mineral density (BMD). Forty-eight eumenorrheic female athletes from several college teams (15 soccer, 7 cross-country, 8 indoor track, and 18 basketball) were randomized at the beginning of a competitive season to receive either an oral calcium supplement (1000 mg calcium citrate/400 I.U. Vitamin D) or placebo daily throughout the training season (16 weeks). Self-reported daily pill intake was obtained every 2 weeks to assess adherence. Calcium intake was evaluated using the Rapid Assessment Method, and total body and leg BMD was measured at pre-, mid-, and postseason using dual energy x-ray absorptiometry (DEXA; Hologic QDR-2000). Pre-season calcium intake was lower than national recommendations for this age group (12), averaging 842 mg/d (SD = 719) and was lower in the placebo group compared to the supplemented group (649 +/- 268 vs. 1071 +/- 986 mg/d, respectively; p = .064). Adherence to supplementation was good, averaging 70% across the training season. Supplementation boosted total calcium intake to a mean of 1397 +/- 411 mg/d, which is consistent with recommended levels for this group (37). Supplementation did not influence BMD change during this 16-week intervention. Across teams, a small increase of 0.8% was observed in leg BMD. Change in total body BMD was modified by team, with a significant increase of 1.5% observed in basketball players. These results indicate that providing calcium supplements of 1000 mg/d is adequate to boost total intake to recommended levels during athletic training. Longer intervention trials are required to determine whether calcium supplementation has a positive effect on BMD.