Patient perspectives of weight stigma across the cancer continuum: A scoping review.

BACKGROUND: Weight stigma has been defined as the social devaluation and denigration of individuals because of their weight. The purpose of this scoping systematic review was to assess and understand patient experiences with weight stigma in the cancer care setting. METHODS: We conducted a systematic scoping review of studies examining shame, prejudice, bias, and stigma in relation to weight and cancer-related care using five databases: PubMed, CINAHL Plus Full Text (ProQuest), Cochrane Library, PsycINFO (EBSCO), and Scopus. Articles were uploaded into Covidence for de-duplication and screening. Included studies were peer reviewed, reported adult patient experiences in cancer-related care, and were published in English between October 2012 and February 2023. Study characteristics and key findings were abstracted and qualitatively synthesized. RESULTS: Publications meeting inclusion criteria yielded five studies (n = 113 participants). Most focused on the experiences of women (n = 4) and cancers which predominantly impact women (i.e., breast, cervical, endometrial; n = 4). All stages of the cancer continuum were included with studies examining screening (n = 2), treatment (n = 1), and post-treatment survivorship (n = 2). Weight discrimination was discussed in four studies and weight-biased stereotypes were discussed in three studies. Experiences of weight bias internalization were reported in four studies. One study described an instance of implicit weight bias. CONCLUSIONS: Limited studies examine patient experiences of weight stigma in cancer care; however, current evidence suggests that patients do experience weight stigma in cancer-related care. This review highlights critical gaps and a need for more research on the prevalence and impact of weight stigma in cancer screening and care.

Mechanisms of improved body composition among perimenopausal women practicing Meditative Movement: a proposed biobehavioral model.

OBJECTIVES: Weight gain and unfavorable body composition are prevalent among midlife/older women throughout menopause. These shifts may negatively impact health, well-being, and longevity. Efforts to attenuate weight and body composition changes are traditionally driven by manipulation of diet and/or exercise; however, sustained results are limited, possibly because the full spectrum of biobehavioral systems is not addressed by diet and exercise alone. We propose a biobehavioral model detailing mechanisms of body composition decline among perimenopausal women and the associated components of Meditative Movement (ie, tai chi, qigong, yoga) that address each of these factors. METHODS: Based on our previous work and extensive review of the literature, we developed a multifactorial and multidimensional biobehavioral model including factors that most directly relate to body composition among perimenopausal women: 1) psychological (ie, stress and mood, mindfulness and self-compassion, body awareness), 2) behavioral (ie, sleep, physical activity, eating behaviors), and 3) physiological (ie, cortisol, estrogen). Relationships between each factor, Meditative Movement practice components, and predicted effects on body composition were explored in detail. RESULTS: Our model describes select psychological, behavioral, and physiological factors, and potential mechanistic pathways of Meditative Movement practice driving improved changes in body composition and weight outcomes for perimenopausal women. CONCLUSIONS: The proposed model details a novel, evidence-supported means to reduce the risk of deleterious shifts in body composition throughout perimenopause and menopause thereafter. We suggest that these changes may occur directly and/or indirectly through psychological, behavioral, and physiological mechanisms that facilitate the desired changes in body composition.

Examination of the two-step water load test as a measure of gastric interoception and associations with eating and weight/shape concerns in a nonclinical sample.

OBJECTIVE: The current study extended research examining the validity of the two-step Water Load Test (WLT-II), an objective, laboratory-based measure of gastric interoception, by investigating the validity of the WLT-II in a nonclinical sample and testing its contribution to the prediction of eating and weight/shape concerns. METHODS: Participants (n = 129, 73.6% cisgender female, M = 20.13 years old) completed the WLT-II Questionnaire and two-step WLT-II, as well as self-report measures of eating and weight/shape concerns (Eating Disorder Examination Questionnaire; EDE-Q) and interoception (Multidimensional Assessment of Interoceptive Awareness-2; Intuitive Eating Scale-2 Reliance on Hunger and Satiety), in the lab at a large southeastern university. Data analysis included repeated measures ANOVA, correlations, and a series of hierarchical linear regressions. RESULTS: Participants reported considerably more discomfort after the "maximum fullness" trial compared to the "satiation" trial. The WLT-II's objective measure of gastric interoception (sat_%) was not significantly correlated with the self-report measures of interoception and did not predict EDE-Q Dietary Restraint, Eating Shame, or Weight/Shape Concerns. Unexpectedly, greater gastric sensitivity was associated with less EDE-Q Preoccupation/Restriction. Exploratory analyses suggested a possible nonlinear association. DISCUSSION: These results support the validity of the WLT-II in its ability to create, measure, and distinguish between the states of satiation and maximum fullness. However, results also suggest additional work is needed to better understand what the WLT-II's sat_% measure is capturing, as well as investigate potential nonlinear associations of the WLT-II with disordered eating. PUBLIC SIGNIFICANCE: Interoception, or the processing of internal body signals, shows important links to disordered eating. Despite the clear relevance of gastric interoception to disordered eating-such as the ability to detect satiety signals-existing research has relied on general, self-report measures of interoception. This study examined the utility of a laboratory-based measure of gastric interoception. Results suggested mixed support for its validity and utility for predicting eating and weight/shape concerns in a nonclinical population.

Characterizing emotional eating: Ecological momentary assessment with person-specific modeling.

Emotional eating is a topic of clinical importance, with links to weight regulation and wellness. However, issues of concept clarity and measurement can interfere with efforts to understand and intervene on emotional eating. One explanation for prior difficulties in defining emotional eating may be that this construct is not uniform across individuals. The current study critically examined emotional eating by combining ecological momentary assessment (EMA) with an idiographic analytic approach. The study examined the heterogeneity in the emotions and dysregulated eating behaviors often thought to underlie emotional eating, by establishing and comparing latent factor profiles across individuals. Ten community adults with overweight or obesity completed a 21-day EMA protocol, with 5 daily prompts to report on relevant emotions and eating behaviors. P-technique factor analysis was used to examine the data. Results suggested variability across individuals in the number of factors that emerged, the items that loaded on each factor, and the strength of loadings. Dysregulated eating was not found to covary with affective states strongly enough to produce a distinct "emotional eating" factor for any individual, nor did the correlations between factors suggest strong relationships between emotions and dysregulated eating for most participants, even in this sample with 90% of participants self-identifying as "emotional eaters." Findings are consistent with a growing body of literature questioning the validity of the "emotional eating" construct as currently defined and measured, and supports conceptualizing emotional eating as a locally heterogenous construct that varies between people. Combining EMA with an intra-individual modeling technique appears to be a promising approach for understanding emotional eating. Additional work with larger samples is needed to capture the full range in individual profiles.

Boredom proneness, interoception, and emotional eating.

Emotional eating is associated with weight gain and difficulty losing weight during weight loss interventions. Theoretical and empirical work suggest boredom may be an important predictor of problematic eating behaviors. Yet, little work has examined the role of boredom in emotional eating. Further, individual differences in the ability to recognize internal cues (i.e., interoception) may alter the impact of boredom on emotional eating. This study hypothesized that boredom proneness would predict unique variance in emotional eating after accounting for negative and positive affect, and that the association between boredom proneness and emotional eating would be stronger among those with poorer interoceptive ability compared to those with better interoceptive ability. Hypotheses were tested in two large samples using multiple linear regression. Participants aged 18-65 were recruited from MTurk (n = 365; 59.2% female) and an undergraduate research pool (n = 461; 52.9% female). Participants completed self-report measures: Boredom Proneness Scale; Dutch Eating Behavior Questionnaire- Emotional Eating; Multidimensional Assessment of Interoceptive Awareness-2; Intuitive Eating Scale-2- Reliance on Hunger and Satiety Cues; and Positive and Negative Affect Schedule. Boredom proneness was a significant predictor of emotional eating in both samples, even accounting for the broad dimensions of negative and positive affect (ps < .001). Interoception did not moderate the association between boredom proneness and emotional eating in either sample (ps > .05), but was an independent predictor of emotional eating (ps < .001). Boredom proneness and interoceptive ability may warrant attention as targets in the prevention and treatment of emotional eating. Future work should continue exploring different emotion categories and different facets of interoception in emotional eating, as well as examine novel mechanisms that could inform intervention efforts.

General versus hunger/satiety-specific interoceptive sensibility in predicting disordered eating.

Dysfunctional interoceptive processing of hunger and satiety cues is particularly relevant to disordered eating behaviors. However, researchers often rely on general measures of interoceptive sensibility (IS1; self-reported experience of internal bodily cues) which conflate interoceptive processes across biological systems (e.g., gastric, cardiac) when assessing the role of interoception in disordered eating. Participants (N = 213; 50% female, age M = 20.77 years) were recruited from a large southeastern university for this online study and completed the Intuitive Eating Scale-2 (hunger/satiety-specific), the Multidimensional Assessment of Interoceptive Awareness-2 (general), and the Eating Disorder Inventory Interoceptive Awareness Subscale (general) as measures of IS. The Eating Pathology Symptoms Inventory was used to assess disordered eating attitudes and behaviors. Controlling for sex and body mass index, hunger/satiety-specific IS was associated with binge eating, purging, and cognitive restraint over and above general IS measures and emerged as the dominant predictor of each. Hunger/satiety-specific IS did not predict restricting behavior. Dysfunctional processing of hunger and satiety cues may be a particularly important risk factor to target in screenings and interventions for disordered eating. Findings highlight the importance of careful selection of IS measures in research and targeting hunger/satiety-specific IS in clinical interventions for disordered eating.

Invariance of the Eating Disorder Inventory-Drive for Thinness subscale across university and community samples.

The Eating Disorder Inventory-Drive for Thinness (EDI-DT) subscale is commonly used in research and as an eating disorder screening measure, but extant evidence is scant regarding its psychometric properties. University and community samples often are treated as interchangeable in terms of research conclusions. Given established demographic differences between these two populations, the present study tested measurement invariance of the EDI-DT across these two sample types. Two large samples of university students (n = 537; 50% female, 67% White; n = 584; 52% female, 67% White) and community participants (n = 535; 57% female, 81% White; n = 533; 63% female, 82% White) completed the EDI-DT online. Multiple group confirmatory factor analyses tested configural, metric, scalar, and strict invariance by sample type. The EDI-DT subscale was not invariant across university and community samples. Post-hoc-regularized multiple nonlinear factor analyses suggested potential item bias associated with sample type, age, and body mass index on six of the seven items. Item bias, however, appeared to be associated with minimal clinical impact. Collectively, results suggest that the EDI-DT may be functionally invariant and appropriate for use with broad populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A comparison of food and alcohol disturbance (FAD) in sorority and non-sorority women.

Objective: College students who are members of groups in which appearance and alcohol norms are highly salient may be at particular risk for engaging in food and alcohol disturbance (FAD) behaviors. This study compared demographically-matched sorority- and non-sorority members on FAD and associated behaviors. Participants: College women who self-identified as being in a sorority (n = 95) were matched with non-sorority peers (n = 95) on age, body mass index (BMI), ethnicity, and race. Methods: Participants completed an online survey assessing alcohol use, eating disorder symptoms, appearance-related peer pressure, FAD behaviors, and demographic information. Mann-Whitney U tests and generalized linear models tested hypotheses. Results: Sorority members reported more alcohol use and FAD behaviors; however, after controlling for year in school, alcohol use, and eating disorder symptoms, Greek status no longer predicted FAD behaviors. Conclusions: Differences in FAD behaviors across sorority- and non-sorority women were due to differences in alcohol consumption.

Eating Disorder Symptomatology Among Adolescents Presenting for Bariatric Surgery Candidacy: Examining Differences by Sex and Racial Minority Status.

BACKGROUND: Research on adolescent bariatric surgery candidates is limited by insufficient inclusion of ethnic minorities and males, and lack of consideration of the full spectrum of disordered eating behaviors (i.e., restriction, compensatory behaviors [e.g., purging], overeating/binge eating behaviors). OBJECTIVES: The current study investigated differences in the full range of disordered eating behaviors across sex and ethnicity among adolescents seeking bariatric surgery. SETTING: Teaching hospital, United States. METHODS: Data were collected using retrospective chart review of 79 adolescent bariatric surgery candidates (59% female, 46.8% Hispanic, MBMI = 50.2, SDBMI = 10.0, Mage = 17.3, SDage = 2.02) who had completed the self-reported Eating Disorder Diagnostic Scale for DSM-5 at intake. RESULTS: Approximately 33% of study participants met self-reported criteria for an eating disorder, with 35% endorsing binge eating behaviors and 50% endorsing compensatory behaviors. Few differences in behavior frequencies were observed across sex or racial/ethnic status. CONCLUSIONS: Findings underscore the importance of assessing the full spectrum of disordered eating behaviors among adolescent bariatric surgery candidates.

Patient Motivations and Goals for Bariatric Surgery: A Mixed Methods Study.

BACKGROUND: Existing research has primarily focused on weight as the outcome of interest for bariatric surgery; however, patients frequently report other lifestyle and interpersonal surgery motivations and goals. Understanding the spectrum of bariatric surgery goals and motivations has important implications for enhancing patient-centered care and surgery outcomes. OBJECTIVES: The current study characterized the nature of bariatric patient motivations and goals for surgery, described the extent to which motivations matched goals, and examined whether men and women differed in the specific motivations/goals described. SETTING: Teaching hospital, United States METHODS: Data were obtained via retrospective chart review of bariatric patient responses to the clinic's standard open-ended questions about motivations and goals for bariatric surgery. A mixed method approach was used, including content analysis, to identify themes and χ2/t test analyses to test gender differences. RESULTS: Surgery motivations and outcome goals were reflected by 8 overarching and overlapping themes. The most common motivations were related to general health and quality of life. The most common goals were to improve health/longevity and mobility. Over a quarter of patients showed no overlap between motivations and goals. Few gender differences were observed. CONCLUSION: Findings underscore the importance of goals beyond weight loss, as well as the utility of helping patients shape their goals in accordance with goal-setting theories.

Food and alcohol disturbance by athlete status: the roles of drive for thinness, drive for muscularity, and sex.

OBJECTIVE: This study investigated the association between self-identified athlete status and Food and Alcohol Disturbance (FAD) behaviors, and whether this association was moderated by drives for thinness or muscularity, and sex. PARTICIPANTS: 575 individuals (77.6% female, 40.0% identifying as athletes) recruited from a large southeastern university. METHODS: Participants completed online measures of athletic identity, drives for muscularity and thinness, FAD behaviors, and demographic variables. RESULTS: Compared to non-athletes, male athletes with higher drive for muscularity endorsed more alcohol effects behaviors; female athletes endorsed the inverse relationship. Higher drive for thinness was associated with more diet and exercise behaviors among all participants, and extreme weight control behaviors among athletes. CONCLUSIONS: Athlete status moderated the associations between drives for thinness/muscularity and FAD Alcohol Effects and Extreme Weight Control Behaviors. Regardless of athlete status, college students with higher drive for thinness are at risk for engaging in more FAD Diet & Exercise behaviors.

Support for a two-dimensional model of food craving using self-report questionnaire and cue-reactivity methodologies.

OBJECTIVE: Evidence supports the transdiagnostic importance of food cravings across the spectrum of disordered eating behaviors. The ambivalence model of craving (AMC), originally applied to substance use craving, highlights the need to consider not just the motivational state of "approach," but also that of "avoidance." The aims of this project were to (a) extend the existing literature by providing additional psychometric support for the food approach and avoidance questionnaire (FAAQ), (b) extend research supporting the validity of applying the AMC to disordered eating by incorporating a cue-reactivity paradigm, and (c) examine the unique contributions of the FAAQ and in-the-moment cue-elicited craving to the prediction of disordered eating. METHOD: Participants (N = 223; 52.0% female, age M = 20.51 years) were recruited from a large southeastern university. Participants completed a food cue-reactivity paradigm and measures of food craving and disordered eating in a lab setting. RESULTS: The factor structure and construct validity of the FAAQ was supported and both general states of food craving (i.e., FAAQ) and cue-elicited food craving were incrementally associated with the spectrum of disordered eating behaviors. As anticipated, both FAAQ and in-the-moment cue-elicited approach were primarily associated with overeating behaviors, whereas FAAQ and cue-elicited avoidance were primarily associated with restrictive eating behaviors. DISCUSSION: Findings highlight the importance of including an avoidance dimension of food craving and have important implications for disordered eating prevention and intervention work.

A test of the stress-buffering hypothesis of social support among bariatric surgery patients.

BACKGROUND: The buffering effect of social support against a range of stress-related health outcomes has been well-documented; however, no previous work has examined the applicability of this model to bariatric surgery outcomes. OBJECTIVES: The present study sought to address whether social support interacts with stress in predicting postsurgical outcomes, as well as whether these associations may vary by sex. SETTING: Teaching hospital, United States. METHODS: Data were collected using retrospective chart review (n = 548). Stress, patient sex, and social support were explored as predictors of curvilinear weight loss trajectories during the first year after surgery using growth curve modeling. RESULTS: Attendance at follow-up appointments was poor, with 250 patients at 6 months and 187 at 12 months. On average, these patients lost 27% of their total weight between baseline and the 12-month follow-up. Overall, weight-related emotional support appeared to be most relevant to weight loss/maintenance in this population; cohabitating with a spouse or significant other and attendance at support group meetings did not predict weight loss or show any significant interactions with stress. CONCLUSIONS: The present study found only partial support for the stress-buffering model of social support among bariatric surgery patients. Such findings have important implications for assessment and follow-up care after bariatric surgery, as well as for future research in this area.

The role of drive for thinness in the association between weight status misperception and disordered eating.

Weight status misperception is related to disordered eating outcomes, but little research has explored the differential impacts of misperception directionality, nor factors that explain these relationships. Self-Discrepancy Theory applied to body image gives a framework to how weight status over-perception may prompt a drive for thinness, which in turn may be important in the development of disordered eating cognitions and behaviors. AIMS: To that end, the current study tested whether drive for thinness may account for the association between direction of weight status misperception and disordered eating behaviors. METHODS: Young adults (N = 522) completed measures identifying weight status perception (accurate, under-, and over-perception), drive for thinness, and disordered eating attitudes and behaviors (appearance satisfaction, restrained, uncontrolled, and emotional eating). Indirect effect models with drive for thinness entered as the intervening variable were estimated for each outcome. RESULTS: Drive for thinness accounted for the associations between weight status misperception and all outcomes. In general, compared to either accurate or under-perception, over-perception of weight status was associated with more disordered eating attitudes and behaviors via higher drive for thinness. CONCLUSIONS: Consistent with Self-Discrepancy Theory, drive for thinness emerged as a possible mechanism of the association between weight status misperception and disordered eating outcomes. Findings suggest potential utility in targeting drive for thinness, as opposed to accuracy of weight status perception, for prevention of disordered eating attitudes and behaviors, including those that may contribute to weight gain.

Applying a multidimensional model of craving to disordered eating behaviors: Development of the Food Approach and Avoidance Questionnaire.

Despite revisions to the DSM-5, current diagnostic criteria poorly capture the phenomena of eating disorders. The construct of food craving may help to explain the range of disordered eating and compensatory behaviors, but current measures do not fully capture the construct. Borrowing from the substance use literature and emphasizing both approach and avoidance craving inclinations, the ambivalence model of craving (AMC) provides a useful framework for predicting broad patterns of disordered eating behaviors. This study sought to develop and preliminarily validate a multidimensional AMC-based measure of food craving. Items for the Food Approach and Avoidance Questionnaire were generated and development and validation data were collected via online survey from community-based adults and university students (N = 1,070). Exploratory factor and item response theory analyses were used for measure development. Linear regressions were used to examine convergent and discriminant validity. Exploratory sensitivity analyses included logistic regressions and receiver operating characteristic curves. As hypothesized, a 2-factor measure was supported. No sex differences emerged in item functioning. The approach factor was associated with greater trait food craving, more uncontrolled eating, and greater likelihood of meeting self-reported diagnostic criteria for bulimia nervosa and binge eating disorder. The avoidance factor was associated with higher levels of restrained eating, drive for thinness, and an increased likelihood of meeting self-reported diagnostic criteria for anorexia nervosa and bulimia nervosa. Preliminary data support a new multidimensional measure of approach and avoidance food craving with potential for a transdiagnostic conceptualization of disordered eating and compensatory behaviors. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Development and Psychometric Evaluation of a Brief Approach and Avoidance of Alcohol Questionnaire.

BACKGROUND: The Approach and Avoidance of Alcohol Questionnaire (AAAQ) was developed as a measure of craving to assess both desires to consume and desires to avoid consuming alcohol. Although the measure has been used in a variety of populations to predict future alcohol use behavior, the factor structures observed vary based on sample type (e.g., clinical vs. college samples) and may be overly long for use in repeated measures designs. The current article describes the development of a brief version of the AAAQ for use in clinical populations. METHODS: Using existing data sets of individuals in treatment for alcohol use disorder, exploratory analyses (e.g., exploratory factor analysis and item response theory) were conducted using an inpatient sample (N = 298) at a substance abuse treatment facility. Confirmatory analyses (e.g., confirmatory factor analysis and multiple regression) were conducted using an inpatient detoxification sample (N = 175) and a longitudinal outpatient treatment sample (N = 53). RESULTS: The brief AAAQ had comparable internal consistency, explained a similar amount of variance in alcohol consumption and related problems, and exhibited superior model fit as compared to the original measure. CONCLUSIONS: These findings indicate that the brief AAAQ is an effective tool to assess alcohol craving in clinical populations in treatment settings.

Body mass index as a moderator of the association between weight status misperception and disordered eating behaviors.

Weight status under-perception is protective against disordered eating behaviors and weight gain; however, it is unclear whether under-perception may confer protection across all weight classes. This work explored body mass index as a moderator of the association between weight status perception accuracy and disordered eating behaviors among adults with overweight or obesity. A total of 572 adults (58.7% female; age M = 39.50, SD = 11.57) with overweight or obesity (body mass index M = 31.50, SD = 6.24) completed a series of online questionnaires assessing uncontrolled, emotional, and restrained eating, eating disorder symptoms, weight status perception, and demographics. Controlling for race/ethnicity, age, and sex, linear and negative binomial regressions were used to test hypotheses. Compared to accurate weight status perception, under-perception was associated with less uncontrolled (p = .003) and restrained eating (p = .002). Under-perception was particularly protective against emotional eating (p = .022) and eating disorder symptoms (p = .017) for individuals of overweight or Class I obesity. In general, weight status under-perception was associated with fewer disordered eating behaviors. The protective effects of under-perception of weight status may be maximized for individuals of overweight or Class I obesity statuses.

The role of craving in emotional and uncontrolled eating.

This study presents a novel application of the cognitive processing model of alcohol craving (CPMA) from the addictions field to the role of food craving in the well-established restrained eating-overeating relationship associated with binge eating disorder (BED). A community sample (N = 1058, ages 18-66) completed an online survey assessing four core domains: restrained eating, trait food craving, uncontrolled eating, and emotional eating. In accordance with the CPMA, food craving emerged as a significant indirect effect of the association between restrained eating and both uncontrolled and emotional eating. Gender did not significantly moderate any direct or indirect associations, suggesting that gender may not change the pattern of association between restrained eating and different facets of overeating. Results suggest that treatments targeting binge eating behaviors may benefit from 1) explicitly addressing the activation of food craving rather than concentrating on reducing restrained eating and 2) recognizing that food craving may be an important gender-neutral target with the potential to reduce binge and overeating behaviors. Future research should extend these preliminary findings by examining the application of the CPMA to eating behaviors while jointly investigating antecedents and contextual factors.