Tiffany M. Stewart

Cognitive-Behavioral Theories of Eating Disorders:

This article presents an integrated cognitive-behavioral theory of eating disorders that is based on hypotheses developed over the past 30 years. The theory is evaluated using a selected review of the eating disorder literature pertaining to cognitive biases, negative emotional reactions, binge eating, compensatory behaviors, and risk factors for eating disorders. In general, hypotheses derived from cognitive-behavioral theories have been supported by a variety of research studies. The implications of these findings for treatment and prevention of eating disorders are discussed. This review of the literature serves as a conceptual base for some of the other articles that are included in this special issue of Behavior Modification. The article concludes with an introduction to six articles that discuss issues related to psychiatric classification, assessment, treatment, and prevention of eating disorders.

Wise Mind Project: A School-based Environmental Approach for Preventing Weight Gain in Children

Objective: The Wise Mind pilot study compared the efficacy of an environmental approach for prevention of inappropriate weight gain in children with an active control condition that used an environmental approach for modifying expectancies related to the use of alcohol, tobacco, and drugs.

Light on body image treatment: acceptance through mindfulness.

The treatment of body image has to be multifaceted and should be directed toward the treatment of the whole individual—body, mind, and spirit—with an ultimate culmination of acceptance and compassion for the self. This article presents information on a mindful approach to the treatment of body image as it pertains to concerns with body size and shape. This approach fosters the idea that the treatment process should be one of observation, nonjudgment, neutrality, and acceptance. To this end, this article will depict the conceptualization of body image treatment from a mindful perspective, in which mindfulness serves as the foundation on which the multiple facets of treatment are built. The core components of body image treatment (i.e., cognitive, perceptual, behavioral, and emotional), in the context of mindfulness, are discussed as they relate to the treatment of body image disturbance. This article may be viewed as a theoretical overview of a new treatment concept for body image disturbance.

Effect of an Environmental School-Based Obesity Prevention Program on Changes in Body Fat and Body Weight: A Randomized Trial

This study tested the efficacy of two school‐based programs for prevention of body weight/fat gain in comparison to a control group, in all participants and in overweight children. The Louisiana (LA) Health study utilized a longitudinal, cluster randomized three‐arm controlled design, with 28 months of follow‐up. Children (N = 2,060; mean age = 10.5 years, SD = 1.2) from rural communities in grades 4–6 participated in the study. Seventeen school clusters (mean = 123 children/cluster) were randomly assigned to one of three prevention arms: (i) primary prevention (PP), an environmental modification (EM) program, (ii) primary + secondary prevention (PP+SP), the environmental program with an added classroom and internet education component, or (iii) control (C). Primary outcomes were changes in percent body fat and BMI z scores. Secondary outcomes were changes in behaviors related to energy balance. Comparisons of PP, PP+SP, and C on changes in body fat and BMI z scores found no differences. PP and PP+SP study arms were combined to create an EM arm. Relative to C, EM decreased body fat for boys (−1.7 ± 0.38% vs. −0.14 ± 0.69%) and attenuated fat gain for girls (2.9 ± 0.22% vs. 3.93 ± 0.37%), but standardized effect sizes were relatively small (<0.30). In conclusion, this school‐based EM programs had modest beneficial effects on changes in percent body fat. Addition of a classroom/internet program to the environmental program did not enhance weight/fat gain prevention, but did impact physical activity and social support in overweight children.

Rigid vs. flexible dieting: association with eating disorder symptoms in nonobese women.

The correlates of rigid and flexible dieting were examined in a sample of 188 nonobese women recruited from the community and from a university. The primary aim of the study was to test the hypothesis that women who utilize rigid versus flexible dieting strategies to prevent weight gain report more eating disorder symptoms and higher body mass index (BMI) in comparison to women who utilize flexible dieting strategies. The study sample included women who were underweight (29%), normal weight (52%), and overweight (19%). None of the women were obese, as defined by BMI>30. Participants were administered a questionnaire that measures Rigid Control and Flexible Control of eating. Body weight and height were measured and measures of eating disorder symptoms and mood disturbances were administered. Our results indicated that BMI was significantly correlated with rigid dieting and flexible dieting. BMI was controlled statistically in other analyses. The study found that individuals who engage in rigid dieting strategies reported symptoms of an eating disorder, mood disturbances, and excessive concern with body size/shape. In contrast, flexible dieting strategies were not highly associated with BMI, eating disorder symptoms, mood disturbances, or concerns with body size. Since this was a cross sectional study, causality of eating disorder symptoms could not be addressed. These findings replicate and extend the findings of earlier studies. These findings suggest that rigid dieting strategies, but not flexible dieting strategies, are associated with eating disorder symptoms and higher BMI in nonobese women.

Louisiana (LA) Health: Design and methods for a childhood obesity prevention program in rural schools ☆

There is a worldwide epidemic of obesity with far-reaching consequences for the health of our nation. Prevention of obesity, especially in children, has been deemed by public health policy makers to be one of the most important objectives for our country. This prevention project, called Louisiana (LA) Health, will test whether modification of environmental and behavioral factors can prevent inappropriate weight gain in children from rural parishes of Louisiana who are enrolled in the fourth to sixth grades during Year 1. The primary aim of the LA Health project is to test the efficacy of two school-based approaches for obesity prevention: primary prevention alone and a combination of primary and secondary prevention which will be compared to a no-intervention control group using a cluster randomization research design, with 17 school clusters randomly assigned to the three treatment arms. The study will span 3 years and will provide critical tests of strategies that: 1) modify the childs environment as a primary prevention strategy and 2) provide health behavior modification via classroom instruction and internet counseling as a secondary prevention strategy. The study will also recruit a similar sample of students to measure changes in body weight relative to height, gender, and age over the same three-year period.

Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy Phase 2 (CALERIE Phase 2) screening and recruitment: Methods and results

The Comprehensive Assessment of the Long-term Effects of Reducing Intake of Energy Phase 2 (CALERIE) study is a systematic investigation of sustained 25% calorie restriction (CR) in non-obese humans. CALERIE is a multicenter (3 clinical sites, one coordinating center), parallel group, randomized controlled trial. Participants were recruited, screened, and randomized to the CR or control group with a 2:1 allocation. Inclusion criteria included ages 21-50 years for men and 21-47 years for women, and a body mass index (BMI) of 22.0 ≤ BMI < 28.0 kg/m(2). Exclusion criteria included abnormal laboratory markers, significant medical conditions, psychiatric/behavioral problems, and an inability to adhere to the rigors of the evaluation/intervention schedule. A multi-stage screening process (telephone screen and 3 in-clinic visits) was applied to identify eligible participants. Recruitment was effective and enrollment targets were met on time. 10,856 individuals contacted the clinical sites, of whom 9787 (90%) failed one or more eligibility criteria. Of the 1069 volunteers who started the in-clinic screening, 831 (78%) were either ineligible or dropped. 238 volunteers were enrolled (i.e., initiated the baseline evaluations), 220 were randomized, and 218 started the assigned intervention (2% from the first screening step). This study offered lessons for future multi-center trials engaging non-disease populations. Recruitment strategies must be tailored to specific sites. A multi-disciplinary screening process should be applied to address medical, physical, and psychological/behavioral suitability of participants. Finally, a multi-step screening process with simple criteria first, followed by more elaborate procedures has the potential to reduce the use of study resources.

Children in School Cafeterias Select Foods Containing More Saturated Fat and Energy than the Institute of Medicine Recommendations

In this study, we examined if childrens food selection met the School Meals Initiative (SMI) standards and the recently released Institute of Medicine (IOM) recommendations. Mean food selection, plate waste, and food intake were also examined. Food intake of 2049 4th-6th grade students was measured objectively at lunch over 3 d with digital photography in 33 schools. The percent of children whose food selection met the SMI standards and IOM recommendations for energy (kJ), fat and saturated fat, calcium, iron, and vitamin A and C were calculated. The SMI standards provide lower limits for most nutrients; the IOM provides a range of values, including an upper limit for energy. Seventy-seven percent of childrens energy selection met the SMI lower limit, but only 16% of children met the IOMs recommended range and 74% of children exceeded the upper limit. More than 70% of children exceeded the SMI and IOMs saturated fat recommendations. Children selected (mean +/- SD) 3168 +/- 621 kJ, discarded 882 +/- 581 kJ, and consumed 2286 +/- 716 kJ. Children were less likely to discard fat than carbohydrate, resulting in proportionally more fat being consumed. Most children met SMI and IOM recommendations for protein, calcium, iron, and vitamin A. With few exceptions, energy selection was similar among groups of children, but plate waste differed (P < 0.001), resulting in greater energy intake among boys compared with girls, Caucasians compared with African Americans, and heavier compared with lighter children. Childrens selection was high in saturated fat and, based on IOM criteria, included excess energy.

Effect of Calorie Restriction on Mood, Quality of Life, Sleep, and Sexual Function in Healthy Nonobese Adults: The CALERIE 2 Randomized Clinical Trial

IMPORTANCE Calorie restriction (CR) increases longevity in many species and reduces risk factors for chronic diseases. In humans, CR may improve health span, yet concerns remain about potential negative effects of CR. OBJECTIVE To test the effect of CR on mood, quality of life (QOL), sleep, and sexual function in healthy nonobese adults. DESIGN, SETTING, AND PARTICIPANTS A multisite randomized clinical trial (Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy Phase 2 [CALERIE 2]) was conducted at 3 academic research institutions. Adult men and women (N = 220) with body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 22.0 to 28.0 were randomized to 2 years of 25% CR or an ad libitum (AL) control group in a 2:1 ratio favoring CR. Data were collected at baseline, 12 months, and 24 months and examined using intent-to-treat analysis. The study was conducted from January 22, 2007, to March 6, 2012. Data analysis was performed from July 18, 2012, to October 27, 2015. INTERVENTIONS Two years of 25% CR or AL. MAIN OUTCOMES AND MEASURES Self-report questionnaires were administered to measure mood (Beck Depression Inventory-II [BDI-II], score range 0-63, higher scores indicating worse mood, and Profile of Mood States [POMS], with a total mood disturbance score range of -32 to 200 and higher scores indicating higher levels of the constructs measured), QOL (Rand 36-Item Short Form, score range 0-100, higher scores reflecting better QOL, and Perceived Stress Scale, score range 0-40, higher scores indicating higher levels of stress), sleep (Pittsburgh Sleep Quality Index [PSQI], total score range 0-21, higher scores reflecting worse sleep quality), and sexual function (Derogatis Interview for Sexual Function-Self-report, total score range 24-188, higher scores indicating better sexual functioning). RESULTS In all, 218 participants (152 women [69.7%]; mean [SD] age, 37.9 (7.2) years; mean [SD] BMI, 25.1 [1.6]) were included in the analyses. The CR and AL groups lost a mean (SE) of 7.6 (0.3) kg and 0.4 (0.5) kg, respectively, at month 24 (P < .001). Compared with the AL group, the CR group had significantly improved mood (BDI-II: between-group difference [BGD], -0.76; 95% CI, -1.41 to -0.11; effect size [ES], -0.35), reduced tension (POMS: BGD, -0.79; 95% CI, -1.38 to -0.19; ES, -0.39), and improved general health (BGD, 6.45; 95% CI, 3.93 to 8.98; ES, 0.75) and sexual drive and relationship (BGD, 1.06; 95% CI, 0.11 to 2.01; ES, 0.35) at month 24 as well as improved sleep duration at month 12 (BGD, -0.26; 95% CI, -0.49 to -0.02; ES, -0.32) (all P < .05). Greater percent weight loss in the CR group at month 24 was associated with increased vigor (Spearman correlation coefficient, ρ = -0.30) and less mood disturbance (ρ = 0.27) measured with the POMS, improved general health (ρ = -0.27) measured with the SF-36, and better sleep quality per the PSQI total score (ρ = 0.28) (all P < .01). CONCLUSIONS AND RELEVANCE In nonobese adults, CR had some positive effects and no negative effects on health-related QOL. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00427193.

Military Services Fitness Database: Development of a Computerized Physical Fitness and Weight Management Database for the U.S. Army

The Department of Defense (DoD) has mandated development of a system to collect and manage data on the weight, percent body fat (%BF), and fitness of all military personnel. This project aimed to (1) develop a computerized weight and fitness database to track individuals and Army units over time allowing cross-sectional and longitudinal evaluations and (2) test the computerized system for feasibility and integrity of data collection over several years of usage. The computer application, the Military Services Fitness Database (MSFD), was designed for (1) storage and tracking of data related to height, weight, %BF for the Army Weight Control Program (AWCP) and Army Physical Fitness Test (APFT) scores and (2) generation of reports using these data. A 2.5-year pilot test of the MSFD indicated that it monitors population and individual trends of changing body weight, %BF, and fitness in a military population.