Therapeutic Alliance in Family-Based Treatment of Anorexia Nervosa: In-Person Versus Telehealth.

OBJECTIVE: The therapeutic alliance is broadly linked with positive outcomes. However, nearly all research in this area involves in-person therapy, whereas teletherapy has grown increasing common since the COVID-19 pandemic. There is now a pressing need to establish whether the nature and importance of the therapeutic alliance is impacted by teletherapy. This study examined therapeutic alliance in families of youth with anorexia nervosa who were participating in a randomized controlled trial that transitioned from in-person to telehealth visits during the COVID-19 pandemic. METHOD: We analysed data from 53 adolescents and their parents (20 began in-person, 33 began with telehealth). Both parents, youth and therapist completed the Working Alliance Inventory-Short Revised after 4 weeks of treatment. RESULTS: We found no significant differences across telehealth and in-person treatment for paternal or therapist reported data. However, both adolescents and mothers reported higher bond and goal-related alliance for in-person sessions compared to telehealth. CONCLUSIONS: Findings regarding alliance across telehealth and in-person sessions were mixed, with some preference among mothers and youth for in-person treatment. Future studies should determine whether possible adaptations can improve working alliance during family-based treatment for anorexia nervosa via telehealth.

The importance of improving cognitive flexibility in adolescents with anorexia nervosa: The case for cognitive remediation therapy.

OBJECTIVE: Inefficiencies in executive functioning (EF), more specifically cognitive flexibility and an overly detailed processing style, are frequently observed in individuals with Anorexia Nervosa (AN) and have been identified as potential targets in treatment. Cognitive Remediation Therapy (CRT) is an adjunctive treatment approach specifically designed to have a positive impact on EF. Mainly evaluated in adults, CRT has been criticized for its perceived ineffectiveness in promoting weight restoration or directly reducing eating disorder symptoms. METHOD: We argue that we need to refocus our conceptual framework for using CRT as an adjunctive treatment and specifically explore its potential benefit in adolescents. RESULTS: Adolescence is a critical window for EF development during which CRT has the potential to have the most impact. While it may not specifically ameliorate eating disorder symptoms and directly improve weight gain, CRT may mitigate the impact of malnutrition on adolescent brain development, reduce attrition rates in treatment, and improve cognitive flexibility and (indirectly) other maintaining factors, thereby improving global functioning. DISCUSSION: More research needs to be done to understand the development of EF in adolescents with AN and how best to employ CRT as an adjunctive treatment to support development and target maintaining factors. The current article broadly reviews findings on executive functioning inefficiencies in adolescents with AN and discusses the purpose and role of CRT in treating AN. Finally, we highlight key critiques of using CRT and pose questions for future research. PUBLIC SIGNIFICANCE: Treatments targeting executive functioning in adolescents with AN are limited. We need to better understand how CRT can benefit adolescents in treatment. Increasing treatment options, including adjunctive treatments, is necessary to reduce the long-term impact of AN.

The buffet challenge: a behavioral assessment of eating behavior in adolescents with an eating disorder.

OBJECTIVE: Eating disorders are characterized by disturbances in nutritional intake and abnormal mealtime behaviors. Laboratory eating paradigms offer a unique opportunity to accurately measure dietary intake and eating behaviors, however, these studies have predominantly occurred in adults. This paper describes the development and preliminary psychometric examination of the Buffet Challenge, a laboratory-based meal task for youths with an eating disorder. METHOD: We recruited and assessed 56 participants as part of a randomized controlled trial of Family-Based Treatment for adolescents with anorexia nervosa. Adolescents completed the Buffet Challenge at baseline, midway through treatment (~ week 16 of a 6 months course), and end of treatment. Participants and their parents also reported eating disorder symptomatology and treatment related variables of interest were recorded. RESULTS: All adolescents were willing to complete the Buffet Challenge at all time points, although one refused to give up their cellphone, and there were no significant adverse events recorded. Preliminary results are presented. CONCLUSIONS: Our initial pilot of this task in adolescents with anorexia nervosa demonstrates its acceptability, although investigation of our hypotheses was hindered by significant missing data due to COVID-related research shutdowns. Future studies should replicate procedures in a larger sample to ensure analyses are adequately powered.

The impact of social media use on body image and disordered eating behaviors: Content matters more than duration of exposure.

Social media use is rapidly expanding in terms of frequency, duration, and the diversity of platforms available. Given evidence for associations between social media use, body image disturbances, and disordered eating it is important to identify potentially harmful aspects of social media use that could serve as intervention targets. This study surveyed two demographically diverse undergraduate student cohorts in 2015 and 2022 to compare patterns in social media use, body image, and disordered eating behaviors between samples, including as a function of the COVID-19 pandemic, and to test the hypothesized moderating role of specific content consumed in the association between social media use and maladaptive outcomes. Participants in 2022 reported greater body image disturbances, more frequent vomiting and laxative use, and more time spent on a greater number of social media accounts, with significantly greater use of image-based platforms such as Snapchat, TikTok, and YouTube. Moderated regression analyses suggest that type of content consumed, but not the amount of time spent on social media or diversity of platforms utilized, is associated with body image disturbances and disordered eating behaviors after controlling for gender and body mass index. Specifically, exposure to weight loss content was associated with lower body appreciation, greater fears of negative appearance evaluation, and more frequent binge eating. Contrary to initial hypotheses, exposure to body positivity/neutrality content did not have protective effects. Findings suggest that interventions targeting negative consequences of social media use should focus on addressing content consumed, rather than time spent on social media platforms.

Modifying an Open Science Online Grocery for parents of youth with anorexia nervosa: A proof-of-concept study.

OBJECTIVE: For youth with anorexia nervosa (AN), remission requires high caloric goals to achieve weight restoration, consumption of a wide variety of calorically dense foods, and reintroduction of eliminated foods. Family-based treatment (FBT), the gold-standard treatment for youth with AN, empowers parents to renourish their child and restore them to health; yet, parents often report struggling with shifting meal planning and grocery shopping behaviors to focus on nutritional rehabilitation and weight restoration. METHODS: This proof-of-concept study aimed to modify a simulated grocery store (Open Science Online Grocery [OSOG]) for parents of youth with AN and explore the acceptability and feasibility of its use as part of standard care. Study staff collaborated with six parent research partners to modify the OSOG prior to piloting it with participants. Participants were 10 parents of youth undergoing a first-time hospitalization for medical stabilization of AN or atypical AN. Parents completed a battery of measures and a semistructured interview assessing the acceptability and feasibility of OSOG. RESULTS: Parents described the tool as credible and acceptable. Qualitative feedback highlighted common themes of caregiver burden, nutrition education, and acceptability of the tool. DISCUSSION: Results point to the need for more work in supporting parents in Phase I of FBT. PUBLIC SIGNIFICANCE: Families are instrumental in supporting youth to recover from anorexia nervosa. During treatment, parents are charged with selecting and serving their adolescent's meals, often requiring them to change grocery shopping and food preparation habits to meet their child's high caloric needs. Parents reported feeling overwhelmed by this task and noted struggling with learning different approaches to nourish their adolescent during an already stressful time. Collaboratively with parents, we modified a tool to support parents in shifting thier shopping habits, which they reported as being a helpful springboard in the early phase of treatment.

Adaptations of cognitive remediation therapy for adolescents with anorexia nervosa for delivery via telehealth.

OBJECTIVE: The COVID-19 pandemic hastened a transition to treatment delivery via telehealth. While barriers still exist, the increased uptake of telehealth has the potential to increase access to mental health treatment for all diagnoses, including eating disorders. Delivery of evidence-based treatment as well as adjunctive treatments, including those that are hard to find in-person, have been modified to virtual format to increase accessibility and allow for continuity of care for adolescents with anorexia nervosa. METHOD: We describe how to modify and deliver Cognitive Remediation Therapy for youth with anorexia nervosa (CRT-AN) via a telehealth platform. Preliminary and practical guidance for best practice for both group and individual delivery is established. RESULTS: With minimal modifications, CRT-AN can be delivered via telehealth for both individual and group delivery. More disengagement in group delivery was noted; however, overall application of the treatment via a remote platform was observed. DISCUSSION: As more treatment moves to a telehealth format, highlighting how an adjunctive treatment like CRT-AN can combined with other treatments in a telehealth format has the potential to increase research in its implementation and furthermore increase its dissemination. PUBLIC SIGNIFICANCE: Cognitive Remediation Therapy for Anorexia Nervosa (CRT-AN) requires significant manipulation of materials and supplementary human guidance. Suggestions for how to modify CRT-AN for remote delivery via telehealth are provided. Modifications grew out of immediate changes made during the beginning of the COVID-19 pandemic and can be used to inform changes therapists and programs can make to continue to or begin to use CRT-AN in a remote fashion.

How Does Fasting Affect Cognition? An Updated Systematic Review (2013-2020).

PURPOSE OF REVIEW: The goal of this review was to provide an update on the literature examining how voluntary, temporary abstention from eating impacts cognitive function. RECENT FINDINGS: We evaluated peer-reviewed articles published between August 2013 and January 2021 that assessed adults, included a measure of cognitive functioning with neutral stimuli, and compared individuals in a fasted state to individuals in a fed state (either within- or between-subject designs). Nineteen articles (21 studies) met inclusion criteria. Sample sizes, fasting methods, and tasks varied across studies. Review of studies indicated that fasting was associated with deficits in cognitive functioning; few studies indicated a benefit in cognitive functioning following a single voluntary fast. The heterogeneity and rarity of available studies limits the conclusions that can be drawn. Several crucial psychosocial and sociodemographic moderators remain unexplored. Recommendations for future work are discussed.

The emotion regulatory function of online social networking: Preliminary experimental evidence.

Correlational research suggests that emotion regulation deficits, which are known risk factors for substance addictions, may also play a role in the development of problem behaviors such as excessive or maladaptive use of social networking sites (SNS). This study sought to experimentally assess the hypothesized emotion regulatory function of SNS use. 139 undergraduates (53.2% female) were randomized to view brief movie clips known to reliably induce positive (37.4%), negative (29.5%), or neutral mood (33.1%) and then to browse a SNS (46.8%) or control website (53.2%). Mood and subjective urge to access SNS and the Internet were assessed before and after viewing the movie clips and browsing the websites. Participants meeting criteria for "moderate" levels of disordered SNS use self-reported significantly greater deficits in emotion regulation (p = .02, ηp2 = 0.14). Increases in positive and negative affect following the mood induction were associated with a decrease in subjective urge to access SNS (r = -0.22, p = .02, r = -0.28, p = .002, respectively). Time spent browsing SNS resulted in significantly greater increases in self-reported positive affect, compared to the control website (p = .001, ηp2 = 0.09). We replicate previous findings of greater emotion regulation deficits in individuals endorsing problematic SNS use. Increased positive and negative affect resulted in decreased urge to access SNS, suggesting that social networking may primarily serve to counter low-arousal emotions like boredom. Data provide initial experimental evidence to support the hypothesized emotion regulatory function of SNS, with SNS exposure resulting in increased positive affect. Findings suggest that interventions targeting problematic SNS use should incorporate strategies for improved emotion regulation.

The Transdiagnostic Nature of Cravings: Smoking Cessation and Food Craving in Pregnancy.

OBJECTIVES: Smoking cessation prior to pregnancy is strongly encouraged due to the adverse effects of tobacco use on the developing fetus, but appears to also increase risk of excess gestational weight gain (GWG). Smoking cessation has previously been shown to cause weight gain in non-pregnant individuals, in part due to an increase in food craving frequency. Food craving frequency in pregnancy is a known predictor of excess GWG, but has not yet been examined in relation to pre-pregnancy smoking status. This study sought to test the hypothesis that pre-pregnancy smoking cessation elevates excess GWG risk via an increase in food craving frequency. METHODS: Pregnant women (n = 82) completed measures of pre-pregnancy tobacco use and current general and specific food cravings. Gestational weight gain was calculated based on participant self-report of pre-pregnancy weight and data on weight prior to delivery culled from medical records. RESULTS: Pre-pregnancy tobacco use was associated with significantly greater food craving frequency in pregnancy (p = .05), specifically for high-fat and fast-foods (both p < .05), compared to women who did not smoke. Emotional and physiological aspects of cravings accounted for 35% of the variance in excess GWG (p < .03). CONCLUSIONS: Pre-pregnancy smoking appears predictive of food raving frequency in pregnancy and could thus contribute to excess GWG risk. Findings highlight the importance of incorporating strategies for managing cravings into behavioral interventions promoting healthy GWG for women endorsing pre-pregnancy tobacco use.

Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions.

Over the past several decades, Dialectical Behavior Therapy (DBT) has been adapted for a range of presenting problems related to emotion dysregulation. Considerable enthusiasm exists regarding the use of DBT for treating eating disorders; however, to date, there have been no reviews summarizing empirical efforts to adapt DBT for eating disorders in youth. Accordingly, in the present narrative review, we provide a comprehensive summary of existing work testing DBT for adolescent eating disorders. First, we briefly review existing work applying DBT to eating disorders in adults and general adolescent samples. We then review research focused specifically on the use of DBT for adolescent eating disorders, including both those studies applying DBT as the primary treatment and investigations of DBT as an adjunctive treatment. Overall, initial results for DBT-based approaches are promising. However, rigorous empirical work testing DBT for treating adolescent eating disorders remains limited; the majority of existing research is comprised of case series and small-scale studies. Therefore, we close with specific recommendations for future research testing this approach.

Correlates of co-occurring eating disorders and substance use disorders: a case for dialectical behavior therapy.

Given the high rates of comorbidity between eating disorders (EDs) and substance use disorders (SUDs), it is important to develop effective treatment approaches for individuals with both an ED and SUD (ED-SUD). To date, there is limited information guiding the concurrent treatment of these disorders. To build on existing research, the present study compared adult patients with ED-SUD (n = 36) to patients with ED-only (n = 62) in terms of demographics, psychiatric comorbidity, and self-reported eating disorder and related psychopathology. Results indicated that ED-SUD patients had a higher number of psychiatric comorbidities, were more likely to be prescribed mood stabilizers, and were more sensitive to reward. They also reported greater difficulty with emotion regulation, including more difficulty engaging in goal-directed activity, higher impulsivity, and more limited access to emotion regulation strategies. These differences highlight the importance of targeting emotion dysregulation for ED-SUD, and provide evidence for the importance of integrated, transdiagnostic treatment to simultaneously address the SUD, ED, and other psychiatric comorbidities. Implications for tailoring treatment are discussed with a focus on Dialectical Behavior Therapy (DBT).

Food craving frequency mediates the relationship between emotional eating and excess weight gain in pregnancy.

An estimated 50% of pregnancies in the U.S. are associated with maternal weight gain that exceeds Institute of Medicine recommendations. The numerous adverse consequences of obesity in gestation, delivery and the postpartum have been widely documented. The role of excess gestational weight gain (GWG) as a predictor of lifetime obesity risk in mothers and their children is also increasingly recognized. Cravings and negative affect are commonly cited triggers of overconsumption in pregnant women. We sought to examine the role of food craving frequency as a mediator in the relation between emotional eating and excess GWG. In this cross-sectional study, pregnant women (n = 113) completed the Dutch Eating Behavior Questionnaire, a measure of "restrained," "emotional," and "external" eating styles, along with the Food Craving Inventory, which quantifies cravings for "high fat foods," "fast food fats," "carbohydrates/starches," and "sweets." Participants also reported on pre-pregnancy weight and height, and GWG at the time of survey completion. Data supported the hypothesized mediation model, with frequency of "high fat foods" cravings fully mediating the relationship between "emotional" eating and excess GWG (Sobel test z = 2.40, p = .016). This study addresses the striking dearth of research examining potentially modifiable psychosocial predictors of excess GWG. Future longitudinal research should examine if salient affective states trigger food cravings, thus placing pregnant women at increased risk of excess weight gain. Findings have implications for treatment interventions targeting excess GWG, suggesting a need to teach skills to help patients better manage low moods and cravings.

Dietary Restraint Partially Mediates the Relationship between Impulsivity and Binge Eating Only in Lean Individuals: The Importance of Accounting for Body Mass in Studies of Restraint.

Binge eating is characteristic of eating and weight-related disorders such as binge eating disorder, bulimia nervosa, and obesity. In light of data suggest impulsivity is associated with overeating specifically in restrained eaters, this study sought to elucidate the exact nature of the associations between these variables, hypothesizing that the relationship between impulsivity and binge eating is mediated by restrained eating. We further hypothesized that the role of dietary restraint as a mediator would be moderated by body mass index (BMI). Study participants (n = 506, 50.6% female) were categorized based on self-reported BMI as under- and normal-weight (BMI < 25, 65.8%, n = 333) or overweight and obese (BMI ≥ 25, 34.2%, n = 173) and completed the "restrained eating" subscale of the Dutch Eating Behavior Questionnaire, the "impulse control difficulties" subscale of the Difficulties with Emotion Regulation Scale, and the Binge Eating Scale. Findings provide initial evidence for the hypothesized moderated mediation model, with dietary restraint partially mediating the relationship between impulsivity and binge eating severity only in lean respondents. In respondents with overweight or obesity, impulsivity was significantly correlated with binge eating severity, but not with dietary restraint. Findings inform our conceptualization of dietary restraint as a possible risk factor for binge eating and highlight the importance of accounting for body mass in research on the impact of dietary restraint on eating behaviors.

Food cravings in pregnancy: Preliminary evidence for a role in excess gestational weight gain.

Currently, more than 50% of American women gain an excessive amount of weight during pregnancy as per guidelines established by the Institute of Medicine and American Congress of Obstetrics and Gynecology. This excess gestational weight gain (GWG) is associated with health complications in both mothers and children. This study sought to examine the hypothesized causal role of cravings in excess GWG. Pregnant women were recruited from a local hospital (n = 40) and via posts on pregnancy-related websites (n = 43). Weight (current and pregravid) and height data were collected to calculate body mass index (BMI) and recommended versus excess GWG. Participants completed the Food Craving Inventory (FCI), which quantifies "frequency" of cravings for specific foods and the likelihood of "giving in" to these cravings. Overweight/obesity prior to pregnancy was reported by 40.5%-57.9% of participants. At the time of survey completion, 19.5% of online and 31.6% of hospital respondents had gained more than the recommended amount of weight for their stage of gestation. All women had experienced and given in to at least one craving, with cravings for "sweets" and "fast foods" being most common. Craving "frequency" accounted for a substantial portion of variance in excess GWG (25.0% in the online sample and 32.0% in respondents recruited at the hospital). Frequency of "giving in" to cravings accounted for 35.0% of the variance in excess GWG in the online sample only. Findings suggest that both craving frequency and consumption of craved foods may increase risk of excess GWG, providing support for the development of interventions targeting cravings in pregnancy as potentially modifiable determinants of energy intake.

Pickles and ice cream! Food cravings in pregnancy: hypotheses, preliminary evidence, and directions for future research.

Women in the United States experience an increase in food cravings at two specific times during their life, (1) perimenstrually and (2) prenatally. The prevalence of excess gestational weight gain (GWG) is a growing concern due to its association with adverse health outcomes in both mothers and children. To the extent that prenatal food cravings may be a determinant of energy intake in pregnancy, a better understanding of craving etiology could be crucial in addressing the issue of excessive GWG. This paper reviews the available literature to corroborate and/or dispute some of the most commonly accepted hypotheses regarding the causes of food cravings during pregnancy, including a role of (1) hormonal changes, (2) nutritional deficits, (3) pharmacologically active ingredients in the desired foods, and (4) cultural and psychosocial factors. An existing model of perimenstrual chocolate craving etiology serves to structure the discussion of these hypotheses. The main hypotheses discussed receive little support, with the notable exception of a postulated role of cultural and psychosocial factors. The presence of cravings during pregnancy is a common phenomenon across different cultures, but the types of foods desired and the adverse impact of cravings on health may be culture-specific. Various psychosocial factors appear to correlate with excess GWG, including the presence of restrained eating. Findings strongly suggest that more research be conducted in this area. We propose that future investigations fall into one of the four following categories: (1) validation of food craving and eating-related measures specifically in pregnant populations, (2) use of ecological momentary assessment to obtain real time data on cravings during pregnancy, (3) implementation of longitudinal studies to address causality between eating disorder symptoms, food cravings, and GWG, and (4) development of interventions to ensure proper prenatal nutrition and prevent excess GWG.

Chocolate craving and disordered eating. Beyond the gender divide?

Chocolate craving in women has previously been linked to disordered eating behaviors. A relatively higher prevalence of eating disorder pathology may account for the fact that chocolate craving is significantly more common in women in North America, compared to many other countries. While support for a causal role of disordered eating in the etiology of craving in women is growing, little is known about the extent to which food cravings are associated with disordered eating behaviors in men. This study was designed to systematically assess the impact of gender and chocolate craving on measures of attitudes to chocolate, responsiveness to food cues in the environment, body shape dissatisfaction, dietary restraint, and eating disorder and general pathology. Undergraduate men and women (n = 645, 37.2% male) were invited to complete self-report questionnaires assessing demographics, height and weight, food cravings, dietary attitudes and behaviors, along with eating disorder and general pathology. Data suggest that the relationship between chocolate craving and disordered eating behaviors in men is the opposite of what has previously been observed in women: compared to non-cravers, male chocolate cravers reported significantly more guilt related to craving, but were significantly less likely to diet and reported lower levels of dietary restraint, less frequent weight fluctuations, and fewer symptoms of eating disorders. Findings indicate that a positive relationship between disordered eating behaviors and chocolate craving may be unique to women (and potentially women in North America). Findings have important implications for our understanding of cultural and psychosocial factors involved in the etiology of food cravings.

A systematic review of the effects of experimental fasting on cognition.

Numerous investigations have been conducted on the impact of short-term fasting on cognition in healthy individuals. Some studies have suggested that fasting is associated with executive function deficits; however, findings have been inconsistent. The lack of consensus regarding the impact of short-term fasting in healthy controls has impeded investigation of the impact of starvation or malnutrition in clinical groups, such as anorexia nervosa (AN). One method of disentangling these effects is to examine acute episodes of starvation experimentally. The present review systematically investigated the impact of short-term fasting on cognition. Studies investigating attentional bias to food-related stimuli were excluded so as to focus on general cognition. Ten articles were included in the review. The combined results are equivocal: several studies report no observable differences as a result of fasting and others show specific deficits on tasks designed to test psychomotor speed, executive function, and mental rotation. This inconsistent profile of fasting in healthy individuals demonstrates the complexity of the role of short-term fasting in cognition; the variety of tasks used, composition of the sample, and type and duration of fasting across studies may also have contributed to the inconsistent profile. Additional focused studies on neuropsychological profiles of healthy individuals are warranted in order to better develop an understanding of the role of hunger in cognition.