Christine M. Peat

Body image and eating disorders in Older adults: A review

Researchers have shown body image to be an important part of a persons self-concept and have linked body dissatisfaction to various psychopathologies, most frequently eating disorders. However, the majority of the literature to date has focused on adolescents and college-aged samples, with little attention paid to the course of body image and eating disorders throughout the life span. The present article reviews the available literature on body image and eating disorders in older adults to understand more fully the unique presentation of body concerns and disordered eating across the life span. The authors address unique factors affecting body dissatisfaction and the development of eating disorders among older adults and offer directions for future research.

Validity and Utility of Subtyping Anorexia Nervosa

OBJECTIVE The purpose of this article is to review the available literature that addresses the predictive validity and utility of subtyping patients with anorexia nervosa (AN) into binge/purge and restrictor subtypes. METHOD Literature was reviewed including studies that compared individuals with subtype diagnoses on clinical and outcome variables as well as more recent research examining the frequency of diagnostic crossover. RESULTS Several studies found that in general the binge/purge subtype patients have more psychopathology, tend to be older, and tend to have a worse outcome. More recent studies which have examined diagnostic crossover suggest that the rate of crossover from the restrictor subtype to the binge/purge subtype is substantial. Crossover from the binge/purge to the restrictor subtype appears to occur less commonly. There is also literature documenting crossover from AN to bulimia nervosa (BN) and a small literature looking at crossover from BN to AN. DISCUSSION The results of this article suggest that although there is generally progression from restrictor AN to binge/purge AN to BN in a sizeable number of patients, other crossover patterns can be seen as well and the amount of crossover is quite large. This suggests a lack of predictive validity for subtypes.

Post-operative psychosocial predictors of outcome in bariatric surgery.

Although there are several recent reviews of the pre-operative factors that influence treatment outcome for bariatric surgery, commensurate efforts to identify and review the predictive validity of post-operative variables are lacking. This review describes the post-operative psychosocial predictors of weight loss in bariatric surgery. Results suggest empirical support for post-operative binge eating, uncontrolled eating/grazing, and presence of a depressive disorder as negative predictors of weight loss outcomes; whereas, adherence to dietary and physical activity guidelines emerged as positive predictors of weight loss. With the exception of depression, psychological comorbidities were not consistently associated with weight loss outcomes. Results highlight the need for post-operative assessment of disordered eating and depressive disorder, further research on the predictive value of post-operative psychosocial factors, and development of targeted interventions.

Non-suicidal self-injury in eating disordered patients: A test of a conceptual model

A theoretical model explaining the high co-occurrence of non-suicidal self-injury (NSSI) in eating disordered populations as resulting from childhood traumatic experiences, low self-esteem, psychopathology, dissociation, and body dissatisfaction was previously proposed but not empirically tested. The current study empirically evaluated the fit of this proposed model within a sample of 422 young adult females (mean age=21.60; S.D.=6.27) consecutively admitted to an inpatient treatment unit for eating disorders. Participants completed a packet of questionnaires within a week of admission. Structural equation modeling procedures showed the model provided a good fit to the data, accounting for 15% of the variance in NSSI. Childhood trauma appears to have an indirect relationship to NSSI that is likely to be expressed via relationships to low self-esteem, psychopathology, body dissatisfaction, and dissociation. It appears that dissociation and body dissatisfaction may be particularly salient factors to consider in both understanding and treating NSSI within an eating disordered population.

Self-Injury and Disordered Eating: Expressing Emotion Dysregulation through the Body.

Previous research has suggested that emotion dysregulation, body-related concerns, and depressive symptoms are associated with nonsuicidal self-injury (NSSI) and disordered eating (DE) separately and in combination. However, it has been difficult to ascertain to what extent these constructs contribute to NSSI and DE given the relatively small number of studies examining their co-occurrence, particularly among nonclinical samples. Based on responses to self-report questionnaires, college-aged women who completed the study were divided into three groups: NSSI only; DE only; and NSSI + DE based on clinical cutoff criteria. Results support hypotheses that emotion dysregulation is a shared vulnerability and that body-related concerns and depression exhibit unique patterns of association across the three groups. It appears that NSSI is best understood as a response to negative affective states relative to DE, which is best understood as a set of behaviors motivated by body image concerns. The presence of both NSSI and DE is primarily influenced by emotion dysregulation and the dominant difficulties linked to each behavior; depression and body dissatisfaction. These findings suggest that treatment and prevention efforts should emphasize emotion regulation skills and differentially target body concerns or depressive symptoms according to the primary behavioral dysfunction that is present.

Self-Objectification, Disordered Eating, and Depression: A Test of Mediational Pathways.

Objectification theory asserts that poor interoceptive awareness and features of anxiety, such as social anxiety, may be two potential mechanisms that place women at risk for both eating disorders and depression. Existing research supports this theory; however, few studies have examined the extent to which these two constructs may serve as mediators in the relationship between self-objectification and eating disorder symptoms and/or depression. Therefore, the current study evaluated the potential mediational roles of interoceptive awareness and social anxiety using the nonparametric bootstrapping procedure for multiple mediation. College-aged women (N = 214) completed self-report measures assessing self-objectification, disordered eating, depression, interoceptive awareness, and social anxiety. Results indicate that both interoceptive awareness and social anxiety are significant mediators in the relationship between self-objectification and eating disorder symptoms and depression. These findings lend further support to objectification theory and contribute to a greater understanding of the etiological underpinnings of eating disorders and depression in women. Practice implications of these results suggest that targeting both self-objectifying and socially anxious behaviors and cognitions may be an important component for reducing vulnerability to disordered eating.

Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis

Binge-eating disorder (BED), the most common eating disorder, affects approximately 3% of U.S. adults in their lifetime (13). It is characterized by recurrent (1 per week for 3 months), brief (2 hours), psychologically distressing binge-eating episodes during which patients sense a lack of control and consume larger amounts of food than most people would under similar circumstances. Full diagnostic criteria are available in Appendix Table 1. Binge-eating disorder is more common in women (3.5%) than men (2.0%) and in obese individuals (5% to 30%) (4, 5), especially those who are severely obese and those seeking obesity treatment (3, 6). It typically emerges in early adulthood (1, 7) but may surface in adolescence (8) and persist well beyond midlife (9). In May 2013, the American Psychiatric Association (APA) officially recognized BED as a distinct eating disorder with a lower diagnostic threshold (in terms of frequency and duration of symptoms) than formerly accepted (10). The numbers of persons presenting for evaluation, receiving a BED diagnosis, and requiring treatment are expected to increase (11, 12). Appendix Table 1. DSM-5 Diagnostic Criteria for Binge-Eating Disorder BED is associated with poorer psychological and physical well-being, including major depressive and other psychiatric disorders (13, 14), relationship distress and impaired social role functioning (1416), chronic pain (13, 14), obesity (13, 14, 17), and diabetes (1821). Binge eating and BED predispose individuals to metabolic syndrome independent of weight gain (17), type 2 diabetes (22), earlier-onset diabetes (20), and worse diabetes-related complications and outcomes owing to nonadherence to recommended dietary modifications (2325). Similarly, binge eating is implicated as a treatment-limiting factor in patients undergoing bariatric surgery, approximately 25% of whom experience loss-of-control eating (26) that interferes with adherence to postsurgical nutritional recommendations and may impede weight loss and reduce quality of life (27, 28). Treatment aims to reduce binge-eating frequency and disordered eatingrelated cognitions, improve metabolic health and weight (in patients who are obese, diabetic, or both), and regulate mood (in patients with coexisting depression or anxiety). Treatment approaches include psychological and behavioral treatments (hereafter psychological), pharmacologic treatments, and combinations of the 2 approaches. Table 1 describes common treatments for BED. Table 1. Interventions Commonly Used in Treating Patients With Binge-Eating Disorder Current guidelines from the APA (29, 30) and the National Institute for Health and Care Excellence (NICE) (31) support the use of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors, but they differ in content and timing. The APA recommends a team approach (including psychiatrists, psychologists, dietitians, and social workers) with CBT as the cornerstone and medication as adjunctive therapy. In contrast, NICE recommends a CBT-based self-help approach but also endorses medication monotherapy as sufficient treatment for some patients. Best practices for weight management are unclear, in part because of different perspectives on dieting-based approaches (32, 33) and bariatric surgery (3437) in obese individuals with BED. Moreover, little is known about the effect of patient-, provider-, and setting-level factors on treatment outcomes. Our group at the RTI InternationalUniversity of North Carolina Evidence-Based Practice Center conducted a systematic review for the Agency for Healthcare Research and Quality (AHRQ) (38) that updates and extends the scope of our 2006 AHRQ review on eating disorders (39, 40) by including studies of loss-of-control eating, examining nearly twice as many randomized, controlled trials (RCTs) of BED therapies, and applying meta-analytic techniques to measure BED treatment effectiveness. Methods Our methods, complete search strategies, and detailed evidence tables are available in the full systematic review (38). Our protocol (41) was guided by key questions reflecting previously identified evidence gaps, input from key informants and a technical expert panel, and analytic frameworks depicting treatment effectiveness and harms (Appendix Figure 1). Key questions focused on the effectiveness of psychological treatments compared with waitlist, pharmacologic treatments compared with placebo, and combination treatments compared with placebo or waitlist. Primary outcomes were behavioral (reducing binge-eating frequency and increasing abstinence from binge eating), psychological (improving levels of eating-related and general psychological outcomes), and physical (reducing weight and improving other markers of health where relevant), and also included harms from treatment. Appendix Figure 1. Analytic framework for treatment effectiveness and harms. BMI = body mass index; GERD = gastroesophageal reflux disease; KQ = key question. * Effectiveness of treatment. Differences between subgroups. Data Sources and Searches We searched EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov from inception to 18 November 2015, and MEDLINE from inception to 12 May 2016 (Supplement). We hand-searched reference lists and relevant systematic reviews. Supplement. Search Strategy for Full Report* Study Selection We used a PICOTS (populations, interventions, comparators, outcomes, timing, settings, and study designs) approach to identify studies that met our inclusion and exclusion criteria. The population of interest was adults with a diagnosis of BED based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth or Fifth Edition. Interventions included pharmacologic, psychological, and behavioral treatments, as well as complementary and alternative medicine. We limited inclusion to RCTs that measured outcomes at the end of treatment or later in 10 or more randomly assigned patients; included active intervention, placebo, or waitlist control groups as comparators; were conducted in outpatient, inpatient, or home-based settings (such as self-help); and were published in English. We included trials conducted in any country. We selected abstracts for full-text review of articles if they met predefined inclusion and exclusion criteria (Appendix Table 2). Two reviewers independently evaluated the full texts of selected articles to determine whether they should be included; disagreements were resolved by consensus discussion or with help from a third senior reviewer. Appendix Table 2. Inclusion and Exclusion Criteria* Data Abstraction and Risk-of-Bias Assessment One reviewer abstracted details regarding study design, patient population, interventions and comparators, outcomes, duration of treatment and follow-up, settings, and results. A second reviewer checked the abstracted data for accuracy. For each study, 2 independent reviewers rated the risks of selection, performance, attrition, detection, and outcome reporting bias; they summarized their assessment overall as low, medium, or high risk of bias. Statistical Analysis For our investigation of treatments, we omitted studies with high risk of bias, except for harms and sensitivity analyses of meta-analyses. We graded the strength of evidence (SOE) for each major outcome with guidance from the Evidence-Based Practice Center regarding study limitations, consistency, precision, directness of the evidence, and risk of reporting bias (42, 43). The SOE grades are high, moderate, low, or insufficient, reflecting levels of confidence that the evidence represents the true effect. A grade of insufficient means that evidence either was unavailable or did not permit estimation of the effect. In this review, we report results with SOE grades of low, moderate, or high; see the technical report for more detailed results, including those with insufficient SOE (38). For available trials using comparable treatment methods, durations, and outcomes, we performed an unadjusted random-effects meta-analysis using restricted maximum likelihood models (OpenMeta[Analyst] [Brown University Center for Evidence-Based Medicine]). Across studies, the percentage of patients achieving abstinence for each trial uses the number of all randomly assigned patients as the denominator to reflect a true intention-to-treat analysis (that is, to correct variations in results of modified intention-to-treat analyses from individual trials). We derived risk ratios (RRs) for abstinence (defined as 0 binge episodes recorded in the most recent assessment period, usually the past month) and mean differences (MDs) for binge episodes per week, binge days per week, eating-related obsessions and compulsions, body mass index (BMI), weight, and depression scores. We assessed statistical heterogeneity using the I 2 statistic. In considering psychological studies for pooled analyses, we did not combine data from studies using different modes of delivery (for example, individual and group therapy) for the same treatment. If relevant, we conducted sensitivity analyses to measure the effect on pooled results of including studies rated high risk of bias. We also conducted qualitative syntheses of trials with interventions or outcomes that we judged insufficiently similar for meta-analysis. Role of the Funding Source This research was funded by AHRQ. Agency staff participated in developing the scope of the work, refining the analytic framework and key questions, resolving issues regarding the project scope, reviewing the draft report, and distributing it for peer review. AHRQ did not engage in selecting studies, assessing risk of bias, or synthesizing or interpreting data. The authors are solely responsible for the content and the decision to submit this manuscript for publication. Results Overview of Trials We identified 34 trials with low or medium risk of bias (Appendix Figure 2 and Appendix Table 3). Of these, 9 were waitlist-

The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis

Bulimia nervosa (BN) is characterized by symptoms of binge eating and compensatory behavior, and overevaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. However, there is little research identifying which specific BN symptoms maintain BN psychopathology and how they are associated with symptoms of depression and anxiety. Network analyses represent an emerging method in psychopathology research to examine how symptoms interact and may become self-reinforcing. In the current study of adults with a Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM–IV) diagnosis of BN (N = 196), we used network analysis to identify the central symptoms of BN, as well as symptoms that may bridge the association between BN symptoms and anxiety and depression symptoms. Results showed that fear of weight gain was central to BN psychopathology, whereas binge eating, purging, and restriction were less central in the symptom network. Symptoms related to sensitivity to physical sensations (e.g., changes in appetite, feeling dizzy, and wobbly) were identified as bridge symptoms between BN, and anxiety and depressive symptoms. We discuss our findings with respect to cognitive–behavioral treatment approaches for BN. These findings suggest that treatments for BN should focus on fear of weight gain, perhaps through exposure therapies. Further, interventions focusing on exposure to physical sensations may also address BN psychopathology, as well as co-occurring anxiety and depressive symptoms.

Binge eating and menstrual dysfunction.

OBJECTIVE The relation between eating disorders and menstrual function has been widely studied, but it is unknown whether the behavior of binge eating itself is related to menstrual dysfunction. METHODS The 11,503 women included in this study were from the Swedish Twin study of Adults: Genes and Environment. The associations between menstrual dysfunction and binge eating were analyzed using logistic regression or multiple linear regression models with generalized estimation equations. RESULTS Women who reported lifetime binge eating were more likely to report either amenorrhea or oligomenorrhea than women who reported no binge eating. These results persisted when controlling for compensatory behaviors including self-induced vomiting, laxative use, and diuretic use. No differences between women with and without a history of binge eating were observed for age at menarche. CONCLUSION Even when controlling for the effect of compensatory behaviors, the behavior of binge eating is associated with menstrual dysfunction. Metabolic and endocrinological factors could underlie this association. Careful evaluation of menstrual status is warranted for women with all eating disorders, not just anorexia nervosa.

The Intestinal Microbiome in Bariatric Surgery Patients.

With nearly 39% of the worldwide adult population classified as obese, much of the globe is facing a serious public health challenge. Increasing rates of obesity, coupled with the failure of many behavioural and pharmacological interventions, have contributed to a rise in popularity of bariatric surgery as a treatment for obesity. Surgery-mediated weight loss was initially thought to be a direct result of mechanical alterations causing restriction and calorie malabsorption. However, the mounting evidence suggests that indirect factors influence the accumulation and storage of fat in patients that have undergone this procedure. Given the established impact the intestinal microbiota has on adiposity, it is likely that this complex enteric microbial community contributes to surgery-mediated weight loss and maintenance of weight loss postsurgery. In this review, we discuss the physiological and psychological traits exhibited by bariatric surgery candidates that can be influenced by the intestinal microbiota. Additionally, we detail the studies that investigated the impact of bariatric surgery on the intestinal microbiota in humans and mouse models of this procedure.