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Conditioning processes and cue exposure in the modification of excessive eating.

Excessive eating is one of the principal characteristics of bulimia. Eating more than intended is also a prominent feature both of obese people who are trying to lose weight and normal weight women who are attempting to restrict their food intake. Overeating tends to be triggered by a specific set of cues, which commonly involve either mood disturbances or exposure to "forbidden" food, but may include other environmental cues. It is argued that conditioning processes are relevant both to the establishment of meal patterns in normal subjects and in the maintenance of excessive eating. Treatment procedures have typically followed the general approach of "Self Management" which emphasises reducing exposure to the cues associated with eating. An alternative approach derives from the idea that the association between eating responses (or urges to eat) and external cues may be learned, and therefore should in principle be ameanable to extinction through systematic unreinforced exposure. In this article the possible mechanisms of cue-induced overeating are discussed and the potential utility of cue exposure techniques for the management of excessive eating evaluated.

Arousal↗

"Just three more bites": an observational analysis of parents' socialization of children's eating at mealtime.

The objective of this study was to describe comprehensively the structure and process of the childhood mealtime environment. A socioeconomically diverse sample of 142 families of kindergarteners (52% females) was observed at dinnertime using a focused-narrative observational system. Eighty-five percent of parents tried to get children to eat more, 83% of children ate more than they might otherwise have, with 38% eating moderately to substantially more. Boys were prompted to eat as often as girls and children were prompted to eat as many times in single- as in two-parent households. Children were very rarely restricted in their mealtime intake. High-SES parents used reasoning, praise, and food rewards significantly more often than low-SES families. Mothers used different strategies than fathers: fathers used pressure tactics with boys and mothers praised girls for eating. Future research should examine the meanings children ascribe to their parents' communications about food intake and how perceived parental messages influence the development of long-term dietary patterns. Interpreted alongside the evidence for children's energy self-regulation and the risk of disruption of these innate processes, it may be that parents are inadvertently socializing their children to eat past their internal hunger/satiety cues. These data reinforce current recommendations that parents should provide nutritious foods and children, not parents, should decide what and how much of these foods they eat.

Adult↗

Loss of control over eating in obese youngsters.

OBJECTIVE: To investigate loss of control over eating in a sample of obese youngsters seeking treatment. METHOD: Obese youngsters (aged 10-16) were categorized into those having experienced loss of control (LC) and those who had not (NoLC) using the child version of the Eating Disorder Examination. Furthermore, the LC group was subdivided into an objective binge eating (OBE) and a subjective binge eating (SBE) group. The groups were compared on psychological measures. RESULTS: LC subjects (17.9%) showed more concern about eating, weight and shape. They also reported more emotional and external eating behaviors and more depression. Youngsters who report SBE show resemblances to both NoLC and OBE subjects. DISCUSSION: LC subjects are characterized by more eating-related psychopathology and higher levels of depression. Especially obese youngsters with OBE turned out to be a pathological group.

Adolescent↗

Sexual abuse and eating disorder symptoms: the mediator role of bodily dissatisfaction.

OBJECTIVE: The relationship between sexual abuse and eating disorders remains controversial; the role of intervening variables has often been neglected in past research. This study aimed at investigating the role of bodily dissatisfaction as a mediator effect on the impact of sexual abuse and the reporting of eating disorder symptoms. METHOD: In a community sample of 126 young women aged 18 to 30 years, we investigated the links between sexual abuse and eating disorders by means of self-compiled measures, including the Eating Attitudes Test, the Bulimic Investigatory Test of Edinburgh, the Body Attitudes Test (BAT), and the revised Hopkins Symptom Checklist (SCL-90-R). RESULTS: Those who reported sexual abuse in childhood scored higher at the Eating Attitudes Test, the Bulimic Investigatory Test of Edinburgh, and the BAT, compared with those who denied sexual abuse or experienced sexual abuse at an age after puberty. The experience of bodily dissatisfaction, as measured by the BAT, acted as an intervening variable (mediator) between sexual abuse in childhood and eating disorder symptoms. CONCLUSION: Although caution is required when reading the conclusions that could be drawn from self-reported measures, sexual abuse before puberty could be considered as a risk factor for the development of eating disorder symptoms, inducing revulsion about the body in ways that may intermix with concerns about body shape, size, and weight.

Adolescent↗

Neuroticism and introversion: a risky combination for disordered eating among a non-clinical sample of undergraduate women.

Recent evidence suggests that people who score low on measures of sociability may be at risk for certain types of psychopathology, including mood and anxiety disorders. In an attempt to extend these findings to other forms of psychopathology, we examined levels of neuroticism and extraversion in relation to eating problems in a non-clinical sample of undergraduate women. The Eysenck Personality Questionnaire (EPQ), Eating Disorders Inventory (EDI), and the Eating Attitudes Test (EAT-26) were completed by 196 first-year undergraduate females. We found that high neuroticism was related to high scores on both of the EDI subscales (Bulimia and Drive for Thinness) as well as high scores on the EAT-26 measure, replicating previous work. In addition, neuroticism served as a moderator such that lower extraversion (i.e., introversion) was related to greater disordered eating, but only for those women who scored high on neuroticism. Thus, a combination of neuroticism and introversion may be a risk-factor for symptoms of eating disorders in a non-clinical sample of university women.

Adult↗

Maladaptive core beliefs and eating disorder symptoms.

This study compared maladaptive core beliefs of eating-disordered groups (full and subthreshold syndrome) and healthy controls and investigated the association between eating disorder symptoms and core beliefs. Participants were compared on self-report measures of core beliefs (YSQ) and eating disorder psychopathology (BITE). Anorexia nervosa (AN; both subtypes) and bulimia nervosa (BN) patients had significantly more core beliefs than healthy controls. Binge eating disorder (BED) patients had intermediate scores between AN and BN on the one hand and healthy controls on the other hand. No correlation was found between core beliefs and frequency of binge eating. Frequency of vomiting, laxative misuse and fasting was positively associated with all domains of core beliefs. Patients with eating disorders have some core beliefs which are not directly related to eating, weight or shape. Frequency of purging and fasting behaviors is associated with more severe maladaptive core beliefs. Our data demonstrate the importance of identifying purging and fasting as significant clinical markers.

Achievement↗

Healthful eating: perceptions, motivations, barriers, and promoters in low-income Minnesota communities.

Self-administered surveys of low-income subjects (n=796)recruited at food programs, grocery stores, and other public places in four Minnesota study communities were designed to examine definitions of healthful food and to identify motivations, barriers, and promoters of healthful eating. Fruits and vegetables were most often given as definitions of healthful eating, regardless of income, race, or sex. Subjects said they eat healthfully primarily for health, weight, and family concerns. Almost half of subjects indicated that time was a barrier to healthful eating, and more than one-third cited money concerns. Half of the top promoters of healthful eating included federal or local food assistance programs. Family was the most common promoter. Identification of perceptions, barriers, and promoters of healthful eating for low-income and minority populations may be useful for tailored intervention planning. Specifically, family-based interventions and food assistance programs may be more successful in promoting healthful eating for selected segments of the population.

Adult↗

Anorexia nervosa in male adolescents: body image, eating attitudes and psychological traits.

PURPOSE: To evaluate body image and its relationship with psychological and behavioral traits associated with anorexia nervosa in male patients. METHODS: Thirty male adolescents with anorexia nervosa (AN) were compared with 421 male adolescents from the general population. Body image was evaluated with the Subjective Body Dimensions Apparatus. Eating attitudes were evaluated by the Eating Attitudes Test in its 26-item version (EAT-26). In 19 AN patients and 200 boys from the comparison group, the Eating Disorders Inventory (EDI) was also administered. RESULTS: AN patients had higher mean scores in the EAT-26 and the Body Dissatisfaction scale on the EDI, but not on the other EDI scales. Both groups overestimated all parts of their bodies but AN patients presented a greater overestimation of shoulders (p = .007), hips (p = .01) and thighs (p = .019). Correlations in the anorexic group were high and negative between body overestimation and body mass index and also high but positive between overestimation and the EAT and the Drive for Thinness scale on the EDI. Overestimation did not correlate significantly with other EDI scales. CONCLUSIONS: Male patients with anorexia nervosa overestimate some parts of their bodies more often than controls; this overestimation is related to body mass index, abnormal eating attitudes and drive for thinness, but not to other psychological traits evaluated by the EDI.

Adolescent↗

Helping patients with advanced cancer live with concerns about eating: a challenge for palliative care professionals.

This paper reports findings of an exploratory study of the eating habits of people with advanced cancer living in the south of England in 2003. The purpose of the study was to develop an understanding of why eating can be experienced as troubling and examine the potential for helping people live with the changes in eating habits that often accompany advanced cancer. Semistructured interviews were conducted with 30 patients, 23 lay caregivers, and 14 specialist nurses. The data were analyzed thematically. It was found that patients experienced eating-related concerns when the reality of eating differed from the expectations of eating. Patient response to concern ranged from acceptance to self-action. A subgroup of participants believed that they could have been helped by support for taking self-action. Eating-related concerns present nurses and other health care professionals with the challenge of supporting differing patient preferences for living with the symptom, which can include the expectation of support for self-action.

Adult↗

Relationship between bipolar illness and binge-eating disorders.

In this study we describe the frequency of eating disorders (EDs) in a group of bipolar (BP) patients. We evaluated a sample of 51 outpatients, diagnosed as having BP I disorder on the basis of the Structured Clinical Interview for DSM-IV (SCID). Each of these subjects was administered the Binge Eating Disorder Clinical Interview (BEDCI) to determine the presence of binge eating disorder (BED) or bulimia nervosa (BN). Of the 51 BP patients, 14 (9 BED, 5 BN) met criteria for an ED. Most patients developed binge eating coincident with the first episode of BP disorder or after the onset of it. This was true for those who developed BED as well as BN, and involved both manic and depressive phases. All BN patients were women (5/5), and family history of binge eating was present in 80% of BN subjects, but only in 22.2% of BED and 29.7% of non-ED BP patients. We found a high frequency of concordance between BP illness and binge eating problems in our sample of BP patients. Given the temporal sequence of the mood disorder, which generally preceded the ED, we suggest a model in which the ED evolves due to modulation of emotions with food, as well as use of medications to treat BP disorder that disrupt hunger and satiety mechanisms. Given differences in gender distribution and family history, cultural and familial influences may also be significant in the minority of BP binge-eating patients who develop BN.

Adult↗

Self-reported eating behaviors of extremely obese persons seeking bariatric surgery: a factor analytic approach.

OBJECTIVE: To summarize the self-reported eating behaviors of persons seeking bariatric surgery and to provide reliability data for a clinical instrument that assesses those eating behaviors. RESEARCH METHODS AND PROCEDURES: Adults (552) with extreme obesity (mean +/- standard deviation BMI = 52.4 +/- 10.1 kg/m2) completed the Weight and Lifestyle Inventory (WALI) before undergoing bariatric surgery. The WALI is a self-report instrument that includes 24 items that assess the eating behaviors to which respondents attribute their excess weight. These items were entered into a principal components analysis with promax rotation. Relationships of factor scores to demographic and psychosocial variables were examined. Test-retest reliability data were obtained from a smaller sample (n = 58) of less obese participants (BMI = 34.4 +/- 4.0 kg/m2) who completed the WALI twice within 2 weeks, before beginning a non-surgical weight loss program. RESULTS: The principal components analysis yielded five factors with acceptable internal consistency and test-retest reliability. These included: eating in response to negative affect, eating in response to positive affect and social cues, general overeating and impaired appetite regulation, overeating at early meals, and snacking. Each factor was related to symptoms of binge eating disorder, and every factor except the second one was associated with depressive symptoms. Factor scores were unrelated or weakly associated with demographic characteristics. DISCUSSION: The eating behaviors of persons seeking bariatric surgery can be assessed reliably and parsimoniously with the WALI. The predictive utility of the factors obtained in this study remains to be examined.

Adult↗

Eating disorders: current nutrition therapy and perceived needs in dietetics education and research.

OBJECTIVE: Research was conducted to obtain a profile of nutrition therapy currently in practice for patients with anorexia nervosa, bulimia nervosa, and anorexia/bulimia (mixed diagnosis) and to identify the areas of dietetics education and research regarding eating disorders that need more attention. DESIGN: A cross-sectional correlational survey was conducted by mailing a questionnaire composed of open- and closed-ended questions to US dietitians who work with patients who have eating disorders. SAMPLE: Of 199 dietitians selected from a list of 495 representing all geographic areas of the United States, 117 responded. The list was obtained from a national referral network for eating disorders. STATISTICAL ANALYSIS: chi 2 Analysis was completed on all closed-ended answers. Pearson's correlation coefficient with a value of P < .05 was considered significant. RESULTS: Nutrition therapy administered varied among dietitians treating inpatients, outpatients, and both. Three community groups were identified as most important to reach for prevention of eating disorders: junior high school students, coaches, and parents. Crucial areas of research were perceived by 94 dietitians to be comparative effectiveness of techniques of medical nutrition therapy (n = 55) and of techniques of prevention (n = 26) and increased understanding of etiology in relation to identification of high-risk groups and prevention (n = 21). Dietitians desired further information on multiple topics related to eating disorders. APPLICATION: Medical nutrition therapy for eating disorders is a specialization that requires education and training beyond the minimum required for dietetic registration. Some of the techniques required are unique to this specialization due, in part, to the psychological nature of the disorders. All dietitians, however, must be able to recognize and refer patients with eating disorders; these skills must be included in basic undergraduate programs and internships. This study supports the need for more research concerning the outcomes of nutrition therapy and the effectiveness of prevention programs.

Anorexia Nervosa↗

The effect of eating out on quality of diet in premenopausal women.

OBJECTIVE: To compare the intake of women who report varying levels of frequency of consuming food at commercial facilities outside the home. DESIGN: A 1-week descriptive study of dietary intake in women. Subjects completed daily diet records that included information regarding the source of the food eaten at each meal or snack. The sample was divided on the basis of the number of meals each subject reported obtaining from a commercial establishment outside the home. Of the 129 subjects, 56% (n = 72) reported eating out 5 times or less during the week of recording (Low Eating Out group) and the remainder (n = 57) reported eating out between 6 and 13 times (High Eating Out group) SUBJECTS/SETTING: One hundred twenty-nine premenopausal women were recruited via community advertising for an investigation of health habits. This study was conducted in a midsouthern US city. STATISTICAL ANALYSES PERFORMED: Results were analyzed using independent sample t tests and chi 2 tests. RESULTS: Mean intake was compared for the groups. The High Eating Out group was found to be consuming significantly more total energy (2,057 kcal vs 1,769 kcal; P = .002), fat (79.5 g vs 60.6 g; P < .001), and sodium (3,299 mg vs 2,903 mg; P = .043) and marginally more carbohydrate (261.5 g vs 234.6 g; P = .055) and protein (71.5 g vs 65.4 g; P = .066). Total fiber or calcium intake did not differ between the groups. CONCLUSIONS: Our study demonstrates that women who report eating out a greater number of times per week report more total energy intake as well as higher fat and sodium intakes. However, the High Eating Out group did not consume significantly more fiber or calcium in the extra energy consumed.

Adult↗

A descriptive analysis of factors contributing to binge eating.

This study was designed to examine temporally proximal and remote antecedents as well as immediate and delayed consequences of binge eating behavior. Participants included 16 undergraduate females who reported engaging in binge eating at least two times per week and experiencing a sense of lack of control during binge eating episodes on the Questionnaire of Eating and Weight Patterns. Results indicated that the most frequent proximal antecedents to binge eating were negative emotions such as feeling depressed, angry, empty, hopeless, worried, or dissatisfied. The most frequent consequences of binge eating included relief from negative feelings and thoughts and decrease in hunger or craving. The results of this study suggest that the function of binge eating can be identified through assessment of antecedents and consequences with real time recording and retrospective reports. Treatment implications are discussed.

Adult↗

Heritability of binge-eating and broadly defined bulimia nervosa.

BACKGROUND: Using diagnostic information obtained at two different times, we incorporated error of measurement into structural equation twin models to evaluate the contribution of additive genetic, common environmental, and individual-specific environmental factors to the liability to binge-eating and broadly defined bulimia nervosa (BN). We also evaluated the validity of the equal environment assumption (EEA) with reference to these two phenotypes. METHODS: We interviewed 1897 female twins (including both members of 854 twin pairs) from a population-based register about their lifetime history of binge-eating and of broadly defined BN twice, approximately 5 years apart. RESULTS: The reliabilities of a lifetime history of binge-eating (kappa = .34) and of broadly defined BN (kappa = .28) were low. Based on single interviews, the heritability of binge-eating was estimated to be 50% and broad BN 60%, with the remaining variance attributable to individual-specific environment. Common environmental influences had no effect on liability to either trait. By combining information from two interview waves and thereby incorporating error of measurement into a structural equation model, the estimated heritability of the latent vulnerability to binge-eating (82%) and broadly defined BN (83%) increased substantially. Although there were no violations of the EEA detected for binge-eating, cosocialization influenced twin concordance for broadly defined BN. CONCLUSIONS: Lifetime histories of binge-eating and broadly defined BN appear to be highly heritable conditions of low reliability.

Adolescent↗

Habitual binge/purge behavior influences circulating ghrelin levels in eating disorders.

Previous studies have reported that fasting plasma ghrelin concentrations play an important role in the pathophysiology of eating disorders. The purpose of this study was to examine the relationship between plasma ghrelin levels and frequency of abnormal eating behaviors, nutritional parameters in eating disorders. Fasting blood samples were obtained in 40 female anorexia nervosa (AN) patients, 21 restricting type (AN-R) and 19 binge-eating/purging type (AN-BP), in 31 bulimia nervosa (BN) patients, 18 purging type (BN-P) and 13 non-purging type (BN-NP), in 15 female healthy volunteers (control) before the initiation of active treatment. The fasting plasma ghrelin concentrations in all subjects were negatively correlated with nutritional parameters such as body mass index, percent body fat and serum cholinesterase concentration. The mean plasma ghrelin level in BN-P was higher than that in both BN-NP and controls despite similar nutritional parameters. The plasma ghrelin levels in both AN-R and AN-BP did not differ from BN-P despite difference of nutritional parameters. For both AN-BP and BN-P patients with habitual binge/purge behavior, there were significant correlations among plasma ghrelin values, frequencies of binge/purge cycles and serum amylase values. In BN-NP, there were no significant correlations among plasma ghrelin values, frequencies of binge-eating episodes and serum amylase values. These results suggest that habitual binge/purge behavior may have some influence on circulating plasma ghrelin levels in both BN-P and AN-BP. Habitual binge/purge cycles with vomiting as opposed to binge-eating episodes without vomiting may have a greater influence on fasting plasma ghrelin concentration in eating disorders.

Adolescent↗

The specificity of restrained versus unrestrained eaters' responses to food cues: general desire to eat, or craving for the cued food?

Previous research has shown that exposure to food cues increases eating, especially in restrained eaters. The present study attempted to determine whether this elevated consumption reflects a general desire to eat in response to food cues, or specific desire/craving for the cued food. Restrained and unrestrained eaters were exposed to the smell of either pizza, cookies, or no smell for 10 minutes, were asked to write their thoughts (corresponding to the smell cue) about pizza, cookies or in general, and were then presented with either pizza or cookies to 'taste and rate'. Results indicated that restrained eaters are more responsive than are unrestrained eaters to pre-eating exposure to smell and thought cues, eating significantly more after such cues. An interaction with food type, however, indicated that restrained eaters ate more only when the food presented to eat was the same as the prior food cues. Self-reported desire to eat, liking, and craving for a particular food increased somewhat for restrained eaters after exposure to the smell and thought of that food. Restrained eaters' intake of a food that differed from the pre-eating food cues did not differ from their intake following no prior exposure to food cues. Restrained eaters thus showed a highly specific response to exposure to food cues.

Adolescent↗

Contributions of obesity, gender, hunger, food preference, and body size to bite size, bite speed, and rate of eating.

College students ate two high preference or two low preference doughnuts under high or low hunger conditions. Subjects were led to believe that we were interested in preference ratings made after eating the doughnuts. The number of bites and the total snack time were covertly recorded. Having weighed the doughnuts previously, we calculated the bite size (amount per bite), bite speed (time per bite), and eating rate (amount per second). Eating rate increased as obesity, body size, hunger, and preference increased; men ate at a faster rate than women. Larger bites accounted for the increased rate of the obese, the high preference subjects, and those having a larger body size. The hungry subjects increased their eating rate by taking faster bites. Men ate faster than women by taking both larger but slower bites. Thus eating rate is under multiple control. The data also suggest that the effects of obesity and, in part, gender on these eating responses may be more parsimoniously explained as body size effects. Modification of these within-session eating responses in order to regulate food intake will be successful only when the relationships among these measures are understood.

Adolescent↗