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1.  Using ancestry-informative markers to identify fine structure across 15 populations of European origin 
European Journal of Human Genetics  2014;22(10):1190-1200.
The Wellcome Trust Case Control Consortium 3 anorexia nervosa genome-wide association scan includes 2907 cases from 15 different populations of European origin genotyped on the Illumina 670K chip. We compared methods for identifying population stratification, and suggest list of markers that may help to counter this problem. It is usual to identify population structure in such studies using only common variants with minor allele frequency (MAF) >5% we find that this may result in highly informative SNPs being discarded, and suggest that instead all SNPs with MAF >1% may be used. We established informative axes of variation identified via principal component analysis and highlight important features of the genetic structure of diverse European-descent populations, some studied for the first time at this scale. Finally, we investigated the substructure within each of these 15 populations and identified SNPs that help capture hidden stratification. This work can provide information regarding the designing and interpretation of association results in the International Consortia.
PMCID: PMC4169539  PMID: 24549058
population stratification; AIMs; principal component analysis
2.  Characteristics of Women with Body Size Satisfaction at Midlife: Results of the Gender and Body Image Study (GABI) 
Journal of women & aging  2013;25(4):10.1080/08952841.2013.816215.
This study characterizes the profile of women (N = 1,789) ages 50 and over who report body size satisfaction on a figure rating scale. Satisfied women (12.2%) had a lower body mass index and reported fewer eating disorder symptoms, dieting behaviors, and weight and appearance dissatisfaction. Interestingly, satisfied women exercised more than dissatisfied women and weight and shape still played a primary role in their self-evaluation. Weight monitoring and appearance altering behaviors did not differ between groups. Body satisfaction was associated with better overall functioning. This end point appears to represent effortful body satisfaction rather than passive contentment.
PMCID: PMC3816007  PMID: 24116991
body satisfaction; body image; aging; eating disorders; silhouette; women
3.  Body Dissatisfaction in Women Across the Lifespan: Results of the UNC-SELF and Gender and Body Image (GABI) Studies 
To explore age differences in current and preferred silhouette and body dissatisfaction (current -preferred silhouette discrepancy) in women aged 25-89 years using figural stimuli (range: 1-very small to 9-very large). Data were abstracted from two online convenience samples (N = 5,868). t-tests with permutation-adjusted p-values examined linear associations between mean silhouette scores (current, preferred, discrepancy score) and age with/without stratification by body mass index (BMI). Modal current silhouette was 5; modal preferred silhouette was 4; mean discrepancy score was 1.8. There was no significant association between current silhouette and age, but a positive linear association between preferred silhouette and age remained after stratification by BMI. A significant inverse linear association of silhouette discrepancy score and age was found only prior to stratification by BMI. Body dissatisfaction exists in women across the adult life span and is influenced by BMI.
PMCID: PMC3745223  PMID: 22949165
body dissatisfaction; body image; eating disorders; silhouette; women
4.  The Significance of Repetitive Hair-Pulling Behaviors in Eating Disorders 
Journal of clinical psychology  2011;67(4):391-403.
We studied the relation between intrusive and repetitive hair-pulling, the defining feature of trichotillomania, and compulsive and impulsive features in 1453 individuals with anorexia nervosa and bulimia nervosa. We conducted a series of regression models examining the relative influence of compulsive features associated with obsessive compulsive disorder; compulsive features associated with eating disorders; trait features related to harm avoidance, perfectionism and novelty seeking; and self harm. A final model with a reduced sample (n=928) examined the additional contribution of impulsive attributes. One out of 20 individuals endorsed hair-pulling. Evidence of a positive association with endorsement of compulsive behavior of the obsessive compulsive spectrum emerged. Hair-pulling may be more consonant with ritualistic compulsions than impulsive urges in those with eating disorders.
PMCID: PMC3664303  PMID: 21365638
eating disorders; trichotillomania; hair-pulling; anorexia nervosa; bulimia nervosa; impulsivity; compulsivity
5.  Association Study of 182 Candidate Genes in Anorexia Nervosa 
We performed association studies with 5,151 SNPs that were judged as likely candidate genetic variations conferring susceptibility to anorexia nervosa (AN) based on location under reported linkage peaks, previous results in the literature (182 candidate genes), brain expression, biological plausibility, and estrogen responsivity. We employed a case–control design that tested each SNP individually as well as haplotypes derived from these SNPs in 1,085 case individuals with AN diagnoses and 677 control individuals. We also performed separate association analyses using three increasingly restrictive case definitions for AN: all individuals with any subtype of AN (All AN: n = 1,085); individuals with AN with no binge eating behavior (AN with No Binge Eating: n = 687); and individuals with the restricting subtype of AN (Restricting AN: n = 421). After accounting for multiple comparisons, there were no statistically significant associations for any individual SNP or haplotype block with any definition of illness. These results underscore the importance of large samples to yield appropriate power to detect genotypic differences in individuals with AN and also motivate complementary approaches involving Genome-Wide Association (GWA) studies, Copy Number Variation (CNV) analyses, sequencing-based rare variant discovery assays, and pathway-based analysis in order to make up for deficiencies in traditional candidate gene approaches to AN.
PMCID: PMC2963154  PMID: 20468064
single nucleotide polymorphisms; probands; anorexia nervosa; bulimia nervosa
6.  Environmental and genetic risk factors for eating disorders: What the clinician needs to know 
Patients and families are often aware of research on genetic factors influencing eating disorders. Accurate interpretations of research on environmental and genetic risk factors can be empowering to patients and families; however, misinterpretations could prove detrimental. The clinician who is not versed in genetic research may feel ill-prepared to discuss the nuances of genetic research with patients and families. In this paper the authors discuss what is known about genetic and environmental risk factors with an emphasis on gene-environment interplay in order to increase clinicians’ comfort level with discussing these complex issues with their patients.
PMCID: PMC2719561  PMID: 19014858
Anorexia nervosa; bulimia nervosa; binge eating disorder; genetic; environment; risk
7.  Binge eating and menstrual dysfunction 
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.
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.
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.
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.
PMCID: PMC3909535  PMID: 24360136
menstruation; amenorrhea; oligomenorrhea; binge eating; binge eating disorder
8.  Primary Amenorrhea in Anorexia Nervosa: Impact on Characteristic Masculine and Feminine Traits 
Animal studies indicate gonadal hormones at puberty have an effect on the development of masculine and feminine traits. However, it is unknown whether similar processes occur in humans. We examined whether women with anorexia nervosa (AN), who often experience primary amenorrhea, exhibit attenuated feminization in their psychological characteristics in adulthood due to the decrease/absence of gonadal hormones at puberty. Women with AN were compared on a number of psychological characteristics using General Linear Models based on the presence/absence of primary amenorrhea. Although women with primary amenorrhea exhibited lower anxiety scores than those without primary amenorrhea, in general, results did not provide evidence of attenuated feminization in women with AN with primary amenorrhea. Future research should utilize novel techniques and direct hormone measurement to explore the effects of pubertal gonadal hormones on masculine and feminine traits.
PMCID: PMC4266542  PMID: 24123541
Organizational effects; sex differences; amenorrhea; pubertal timing; anorexia nervosa
9.  Behavioral and Psychophysiological Responsiveness During Child Feeding in Mothers with Histories of Eating Disorders: A Pilot Study 
The aim of this pilot project was to describe maternal responsiveness during child feeding in mothers with eating disorder histories through the combined use of observational, self-report, and physiologic methods. For this non-randomized cohort pilot study, 25 mothers with histories of eating disorders and 25 mothers with no history of an eating disorder with children ages 6–36 months were selected such that the groups were similar based on child age group (within 6 months) and child sex. Maternal behavioral responsiveness to child cues was assessed by video-recording and behavioral coding of both a free-play and feeding episode. Physiologic engagement was assessed through measurement of respiratory sinus arrhythmia (RSA) reactivity during free-play and feeding episodes. No differences were detected in observed behavioral responsiveness during feeding or free-play in mothers with eating disorder histories compared with controls. Mothers with eating disorder histories did report more parenting stress, increased anxiety, and exhibited a blunted physiologic stress response (less RSA reactivity) during both feeding and free-play interactions with their children. These results support future larger-scale investigations of RSA reactivity in mothers with eating disorders.
PMCID: PMC3913224  PMID: 24511180
eating disorders; mothers; feeding behavior; maternal responsiveness; RSA reactivity; infant feeding
10.  Binge Eating, Body Mass Index, and Gastrointestinal Symptoms 
Journal of psychosomatic research  2013;75(5):10.1016/j.jpsychores.2013.08.009.
Symptoms of both gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are frequently reported by individuals who binge eat. Higher body mass index (BMI) has also been associated with these disorders and with binge eating (BE). However, it is unknown whether BE influences GERD/IBS and how BMI might affect these associations. Thus, we examined the potential associations among BE, GERD, IBS, and BMI.
Participants were from the Swedish Twin study of Adults: Genes and Environment (STAGE) and provided information on disordered eating behavior, BMI, gastrointestinal (GI) disorders, and commonly comorbid psychiatric and somatic illnesses. Key features of GERD and IBS were identified to create modified definitions of both disorders that were used as primary outcome variables. Logistic regression models were applied to determine the association between BE and each GERD/IBS both independently and in the context of BMI and other commonly comorbid psychiatric and somatic morbidities.
Prevalence estimates for GERD and IBS were higher among women than men (all p-values < .001). Only the association between BE and IBS was significant in both men and women after adjustment for BMI and the psychiatric/somatic morbidities.
BE appears to be an important consideration in the presence of IBS symptoms in both men and women, even when considering the impact of BMI and other commonly comorbid conditions. This association underscores the importance of routine assessment of BE in patients presenting with IBS to effectively manage the concurrent presentation of these problems.
PMCID: PMC3817501  PMID: 24182635
Binge eating; body mass index; gastroesophageal reflux disease; irritable bowel syndrome
11.  Remission, continuation, and incidence of eating disorders during early pregnancy: A validation study on a population-based birth cohort 
Psychological medicine  2012;43(8):1723-1734.
The objective of this study was to validate previously published rates of remission, continuation, and incidence of broadly defined eating disorders during pregnancy. The previous rate modeling was done by our group (Bulik et al. 2007) and yielded participants halfway into recruitment of the planned 100,000 pregnancies in the Norwegian Mother and Child (MoBa) Cohort at the Norwegian Institute of Public Health. This study aimed to internally validate the findings with the completed cohort.
77267 pregnant women enrolled at 17 weeks gestation between 2001 and 2009 were included. Participants were split into a “training” sample (n=41243) based on participants in the MoBa version 2 dataset of the original study and a “validation” sample (n=36024) comprising individuals in the MoBa version 5 dataset that were not in the original study (Bulik et al. 2007). Internal validation of all original rate models involved fitting a calibration model to compare model parameters between the “training” and “validation” samples as well as bootstrap estimates of bias in the entire version 5 dataset.
Remission, continuation, and incidence estimates from the “training” sample remained stable when evaluated via a split sample validation procedure. Pre-pregnancy prevalence estimates in the “validation” sample were 0.1% for anorexia nervosa, 1.0% for bulimia nervosa (BN), 3.3% for binge eating disorder (BED), and 0.1% for purging disorder (EDNOS-P). In early pregnancy, estimates were 0.2% for BN, 4.8% for BED, and <0.01% for EDNOS-P. Consistent with the original study, incident BN and EDNOS-P during pregnancy were rare. For BED, the adjusted incidence rate in the “validation” sample was 1.17 per 1000 person-weeks. The highest rates were for full or partial remission for BN and EDNOS-P, and continuation for BED.
This study provides evidence of validity of previously estimated rates of remission, continuation, and incidence of eating disorders during pregnancy. Eating disorders during pregnancy were relatively common, occurring in nearly 1 in every 20 women, although almost all were cases of BED. Pregnancy was a window of remission from BN but a window of vulnerability for onset and continuation of BED. Training to detect the signs and symptoms of eating disorders by obstetricians/gynecologists and interventions to enhance pregnancy and neonatal outcomes warrant attention.
PMCID: PMC4206832  PMID: 23164164
Eating disorders; epidemiology; incidence; pregnancy; prospective; remission; The Norwegian Mother and Child Cohort Study
12.  Race/Ethnicity, Education, and Treatment Parameters as Moderators and Predictors of Outcome in Binge Eating Disorder 
Binge eating disorder (BED) is prevalent among individuals from minority racial/ethnic groups and among individuals with lower levels of education, yet the efficacy of psychosocial treatments for these groups has not been examined in adequately powered analyses. This study investigated the relative variance in treatment retention and post-treatment symptom levels accounted for by demographic, clinical, and treatment variables as moderators and predictors of outcome.
Data were aggregated from eleven randomized, controlled trials of psychosocial treatments for BED conducted at treatment sites across the United States. Participants were N = 1,073 individuals meeting criteria for BED including n = 946 Caucasian, n = 79 African American, and n = 48 Hispanic/Latino participants. Approximately 86% had some higher education; 85% were female. Multi-level regression analyses examined moderators and predictors of treatment retention, Eating Disorder Examination (EDE) global score, frequency of objective bulimic episodes (OBEs), and OBE remission.
Moderator analyses of race/ethnicity and education were non-significant. Predictor analyses revealed African Americans were more likely to drop out of treatment than Caucasians, and lower level of education predicted greater post-treatment OBEs. African Americans showed a small but significantly greater reduction in EDE global score relative to Caucasians. Self-help treatment administered in a group showed negative outcomes relative to other treatment types, and longer treatment was associated with better outcome.
Observed lower treatment retention among African Americans and lesser treatment effects for individuals with lower levels of educational attainment are serious issues requiring attention. Reduced benefit was observed for shorter treatment length and self-help administered in groups.
PMCID: PMC4175452  PMID: 23647283
binge eating disorder; race; ethnicity; socioeconomic status; treatment outcome
13.  Genetic variants associated with disordered eating 
While the genetic contribution to the development of anorexia nervosa (AN) has long been recognized, there has been little progress relative to other psychiatric disorders in identifying specific susceptibility genes. Here we have carried out a GWAS on an unselected community sample of female twins surveyed for eating disorders.
We conducted genome wide association analyses in 2564 female twins for four different phenotypes derived from self-report data relating to lifetime presence of 15 types of disordered eating: anorexia nervosa spectrum, bulimia nervosa spectrum, purging via substances, and a binary measure of no disordered eating behaviors versus 3 or more. To complement the variant level results we also conducted gene-based association tests using VEGAS.
While no variants reached genome-wide significance at the level of p<10−8, six regions were suggestive (p<5×10−7). The current results implicate the following genes: CLEC5A; LOC136242, TSHZ1 and SYTL5 for the anorexia nervosa spectrum phenotype, NT5C1B for the bulimia nervosa spectrum phenotype, and ATP8A2 for the disordered eating behaviors phenotype.
As with other medical and psychiatric phenotypes, much larger samples and meta-analyses will ultimately be needed to identify genes and pathways contributing to predisposition to eating disorders.
PMCID: PMC3775874  PMID: 23568457
14.  Factors Associated With Recovery from Anorexia Nervosa 
Journal of psychiatric research  2013;47(7):972-979.
Previous studies of prognostic factors of anorexia nervosa (AN) course and recovery have followed clinical populations after treatment discharge. This retrospective study examined the association between prognostic factors—eating disorder features, personality traits, and psychiatric comorbidity—and likelihood of recovery in a large sample of women with AN participating in a multi-site genetic study. The study included 680 women with AN. Recovery was defined as the offset of AN symptoms if the participant experienced at least one year without any eating disorder symptoms of low weight, dieting, binge eating, and inappropriate compensatory behaviors. Participants completed a structured interview about eating disorders features, psychiatric comorbidity, and self-report measures of personality. Survival analysis was applied to model time to recovery from AN. Cox regression models were used to fit associations between predictors and the probability of recovery. In the final model, likelihood of recovery was significantly predicted by the following prognostic factors: vomiting, impulsivity, and trait anxiety. Self-induced vomiting and greater trait anxiety were negative prognostic factors and predicted lower likelihood of recovery. Greater impulsivity was a positive prognostic factor and predicted greater likelihood of recovery. There was a significant interaction between impulsivity and time; the association between impulsivity and likelihood of recovery decreased as duration of AN increased. The anxiolytic function of some AN behaviors may impede recovery for individuals with greater trait anxiety.
PMCID: PMC3682792  PMID: 23535032
Eating disorders; anorexia nervosa; recovery; prognostic factors; personality; comorbidity
15.  Exploratory study of the role of family in the treatment of eating disorders among Puerto Ricans 
In Latino culture, the family is a major source of social support. We explored the needs and the role of the Puerto Rican eating disorders patient’s family in the treatment process by conducting a focus group with five close relatives of youth with eating disorders. Qualitative analyses indicated the need to integrate the family into treatment and to provide management guidelines to assist with the resolution of situations that emerge frequently during recovery. These results underscored the importance of developing and incorporating psychosocial interventions that include family support and guidance for relatives of Puerto Rican youth patients with eating disorders.
PMCID: PMC4067703  PMID: 24971160
eating disorders; caregiving; family; focus group; Puerto Ricans
16.  Subjective Experience of Sensation in Anorexia Nervosa 
Behaviour research and therapy  2013;51(6):256-265.
The nature of disturbance in body experience in anorexia nervosa (AN) remains poorly operationalized despite its prognostic significance. We examined the relationship of subjective reports of sensitivity to and behavioral avoidance of sensory experience (e.g., to touch, motion) to body image disturbance and temperament in adult women currently diagnosed with AN (n=20), women with a prior history of AN who were weight restored (n=15), and healthy controls with no eating disorder history (n=24). Levels of sensitivity to sensation and attempts to avoid sensory experience were significantly higher in both clinical groups relative to healthy controls. Sensory sensitivity was associated with body image disturbance (r(56) = .51, p < .0001), indicating that body image disturbance increased with increased global sensitivity to sensation. Sensory sensitivity was also negatively and significantly correlated with lowest BMI (r2 = −.32, p < .001), but not current BMI (r2 = .03, p = .18), and to the temperament feature of harm avoidance in both clinical groups. We discuss how intervention strategies that address sensitization and habituation to somatic experience via conditioning exercises may provide a new manner in which to address body image disturbance in AN.
PMCID: PMC3955712  PMID: 23523866
anorexia nervosa; eating disorders; body image disturbance; kinesthesia; vestibular
17.  The Changing “Weightscape” of Bulimia Nervosa 
The American journal of psychiatry  2012;169(10):1031-1036.
Ms. Z, a 35-year-old African-American single woman with a body mass index (BMI) of 37.8 kg/m2 (height 5 feet, 5.5 inches, weight 238 lb.), presents for an evaluation for bulimia nervosa. She was referred to the eating disorders program by her primary care physician who knew about her eating disorder, but was primarily concerned about her weight and blood pressure. Ms. Z has an advanced degree and is employed full time. She has struggled with her eating, weight, and body image since childhood and began binge eating regularly (1–2× week) at age 15. Fasting and self-induced vomiting began in her early twenties, when she achieved her lowest adult BMI of 21.6 kg (weight 130 lb. at age 23). She gained 100 pounds in the past 7 years and currently binges and purges 1–2 times a day. A typical binge consists of a box of cookies, a pint of ice cream, 7 oz. of cheese, two bowls of cereal with 2 cups of milk, and 4 pickles. Ms. Z has seen five therapists to address her eating behaviors and weight concerns and participated in numerous commercial weight loss programs. She states binge eating has always served a self-soothing purpose for her.
Ms. Z has a demanding university-related job that absorbs most of her time. She has few friends and has not been in a romantic relationship for the past five years believing that no one would be interested in a woman of her size. She also claimed that food is more reliable than any man because “it’s always there when you need it and you don’t have to take care of it or stoke its ego.” She spends evenings at home working until she is completely exhausted, heads to the kitchen for an all-out binge, vomits everything up, and then cries herself to sleep. She has never smoked and does not drink alcohol. Current medications prescribed by her primary care physician include Fluoxetine (20 mg), Norvasc (5 mg), and Clonazepam (prn).
What are Ms. Z’s treatment goals? What are her primary care physician’s? Is her medication for bulimia nervosa adequate? How well would cognitive-behavioral therapy for bulimia nervosa address her personal treatment goals? Her physician’s? What challenges might a therapist face having Ms. Z in group therapy for bulimia?
PMCID: PMC4038540  PMID: 23032383
18.  Correlates of Weight Instability across the Lifespan in a Population-Based Sample 
Research from overweight/obese clinical samples links weight instability to poor health. This study investigated whether negative health outcomes were associated with weight instability in a population-based sample.
One thousand five hundred ten women and 1,111 men from the Mid-Atlantic Twin Registry completed questionnaires assessing demographics, body size in childhood, adolescence, and adulthood, health satisfaction, and disordered eating. Noneating disorder psychiatric diagnoses were assessed via clinical interviews.
Weight instability was related to lower health satisfaction and self-esteem, and higher body dissatisfaction, dieting, and binge eating for both sexes. Weight unstable women were more likely to meet criteria for lifetime major depressive disorder, generalized anxiety disorder, and eating disorders. Weight stable women were more likely to abuse alcohol; however, two of these associations [e.g. weight instability and generalized anxiety disorder (GAD) and weight stability and alcohol abuse] became non-significant once lifetime binge eating was accounted for, indicating that these forms of psychopathology are more strongly related to binge eating than weight instability itself. No associations between weight stability and psychiatric diagnoses were found in men.
Weight instability is related to mental and physical health concerns for both sexes. It was also specifically associated with depression and eating pathology in women.
PMCID: PMC4030469  PMID: 20957706
weight instability; binge eating; silhouette measures
19.  LIBER8 Design and Methods: An Integrative Intervention for Loss of Control Eating among African American and White Adolescent Girls 
Contemporary clinical trials  2012;34(1):174-185.
Loss of control (LOC) eating affects a significant number of adolescents of all racial and ethnic backgrounds and is associated with numerous psychosocial problems, including depression, anxiety, low self-esteem, body dissatisfaction, and weight concerns. However, empirically validated, culturally sensitive treatments for adolescents with these disordered eating behaviors are not available. This pilot project involved designing a developmentally and culturally appropriate treatment for LOC eating for adolescent girls. We intend to conduct multiple focus groups with adolescent girls who engage in LOC eating, and their primary caregivers. Data from these groups will inform the subsequent creation of a manualized treatment protocol. We will then evaluate the efficacy of this intervention (LIBER8—Linking Individuals Being Emotionally Real) to reduce LOC eating. This intervention will integrate components of dialectical behavior therapy, such as mindfulness and distress tolerance skills training, and cognitive-behavioral therapy. We will also integrate text-messaging, a key adolescent communication strategy, as a means of self-monitoring. Participants meeting study criteria will be offered participation in this 12-week randomized controlled trial comparing LIBER8 to a weight management control condition (2BFit). We hypothesize that this intervention will serve to reduce LOC eating, as well as improve psychosocial functioning as evidenced by decreased depression, anxiety, eating disorder cognitions, emotional eating, impulsivity, and improved quality of life. The feasibility and acceptability of this intervention will be extensively evaluated with the explicit intent of informing a subsequent larger randomized controlled trial.
PMCID: PMC4025958  PMID: 23142669
binge eating disorder; loss of control; adolescents; African American; treatment; randomized clinical trial
20.  NURTURE: Development and Pilot Testing of a Novel Parenting Intervention for Mothers with Histories of an Eating Disorder 
To describe the treatment development and pilot testing of a group parenting intervention, NURTURE (Networking, Uniting, and Reaching out To Upgrade Relationships and Eating), for mothers with histories of eating disorders.
Based on focus group findings, extant research, and expert opinion, NURTURE was designed to be delivered weekly over 16 (1.5 hour) sessions via an interactive web conferencing forum. It comprises four modules: 1) laying the foundation, 2) general parenting skills, 3) eating and feeding, and 4) breaking the cycle of risk. Pilot testing was conducted with three groups of 3–6 mothers (N = 13) who had children ages 0–3 years to determine feasibility (e.g., retention), acceptability (e.g., feedback questionnaire responses), and preliminary efficacy. Maternal satisfaction with NURTURE and changes in mother-child feeding relationship measures, maternal feeding style, maternal self-efficacy, and maternal psychopathology (eating disorder, depression, and anxiety symptoms) across three time points (baseline, post-treatment, 6-month follow-up) were examined. All outcomes were exploratory.
The intervention was well tolerated with a 100% retention rate. Feedback from mothers was generally positive and indicated that the groups provided an engaging, supportive experience to participants. We observed changes suggestive of improvement in self-reported maternal self-efficacy and competence with parenting. There were no notable changes in measures of maternal feeding style or psychopathology.
NURTURE is a feasible, acceptable, and potentially valuable intervention for mothers with eating disorder histories. Results of this pilot will inform a larger randomized-controlled intervention to determine efficacy and impact on child outcomes.
PMCID: PMC4009482  PMID: 23983082
21.  Course and predictors of maternal eating disorders in the postpartum period 
To investigate course and predictors of eating disorders in the postpartum period.
A total of 77,807 women, participating in the Norwegian Mother and Child Cohort Study (MoBa), completed questionnaires during pregnancy including items covering DSM-IV criteria for pre-pregnancy anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS-P), and binge eating disorder (BED). Additional questionnaires were completed at 18 and 36 months postpartum.
Proportions of women remitting at 18 months and 36 months postpartum were 50% and 59% for AN, 39% and 30% for BN, 46% and 57% for EDNOS-P, and 45% and 42% for BED, respectively. However, disordered eating persisted in a substantial proportion of women meeting criteria for either full or subthreshold eating disorders. BN during pregnancy increased the risk for continuation of BN. BMI and psychological distress were significantly associated with course of BED.
This is the first large-scale population-based study on course of eating disorders in the postpartum period. The results indicated that disordered eating persists in a substantial proportion of women with pre-pregnancy eating disorders. Health care professionals working with women in this phase of life need to pay specific attention to eating disorder symptoms and behaviors.
PMCID: PMC3622173  PMID: 23307499
eating disorder; anorexia nervosa; bulimia nervosa; binge eating disorder; postpartum; pregnancy; weight retention; depression; course; the Norwegian mother and child cohort study; MoBa
22.  Promoviendo una Alimentación Saludable (PAS) Design and Methods: Engaging Latino Families in Eating Disorder Treatment 
Contemporary clinical trials  2013;35(1):52-61.
The use of culturally sensitive intervention could improve mental health care for the eating disorders treatment in the Latino population. The aim of this report is to describe the rationale, design, and methods of the ongoing study entitled “Engaging Latino families in eating disorders treatment.” The primary aim of the study is to compare (a) the combined effect of individual cognitive behavioral therapy for bulimia nervosa (CBT-BN) that has been previously adapted for the Latino population plus Family Enhanced (FE) modules, with (b) the standard adapted individual CBT-BN in a proof-of-principle study with 40 Latina adults with eating disorders and one relative or significant other per patient. We hypothesize that 1) the feasibility, acceptability, and adherence of participants in CBT-BN+ FE will be superior to individual CBT-BN only; 2) relatives in CBT-BN+ FE will report greater treatment satisfaction, greater reduction in family conflict, and greater decreases in caregiver burden than relatives in the individual CBT-BN only condition; and 3) patients who participate in CBT-BN+ FE will show trends towards greater decreases in ED symptoms compared with patients in CBT-BN only; although power will be limited to detect this difference. However, we predict that they will show greater retention in treatment, greater treatment satisfaction, and greater decreases in family conflict than patients in CBT-BN only. The completion of this investigation will yield important information regarding the acceptability and feasibility of a culturally sensitive evidence-based treatment model for Latinos with eating disorders. (Word Count=240)
PMCID: PMC3640683  PMID: 23376815
Latinas; Eating disorders; Cultural adaptation; Family intervention; Clinical trial; Cognitive-behavioral therapy
23.  Exploring barriers and facilitators in eating disorders treatment among Latinas in the United States 
Journal of Latina/o psychology  2013;1(2):112-131.
The purpose of this study was to explore facilitators and barriers that may contribute to, or prevent, the engagement and retention of Latinos in eating disorders (EDs) treatment.
The main objective of this investigation was to explore more fully the facilitators and barriers that may contribute to or prevent the engagement and retention of Latinos/as in EDs treatment.
A qualitative design based on grounded theory was used to guide in-depth interviews with 5 Latinas (mean age 31.2 years) with history of EDs and with 5 Latino mental health providers (mean age 36.4 years).
Six main themes were found in the discussion with patients and mental health providers: immigration stress, treatment experience in the U.S., facilitators of help seeking, barriers to help seeking, treatment needs, and facilitators of treatment retention. For patients, lack of information about EDs and lack of bilingual treatment were identified as practical barriers. Other emotional factors such as stigma, fear of not being understood, family privacy and not being ready to change were identified as barriers to seeking help. Among facilitator factors that encouraged patients to seek help, the most salient were the perception of the severity of the ED and emotional distress. For treatment retention, family support was a key element among patients. For providers, offering short-term treatment and directive treatment were seen as relevant factors for treatment retention in Latinos.
A culturally sensitive intervention model for Latinas with EDs in the U.S. is discussed addressing four levels: patient; family; providers; and system.
PMCID: PMC3981100  PMID: 24729950
treatment barriers; Latinas; eating disorders; treatment facilitators; treatment retention
25.  Temporal Sequence of Comorbid Alcohol Use Disorder and Anorexia Nervosa 
Addictive behaviors  2012;38(3):1704-1709.
Women with eating disorders have a significantly higher prevalence of substance use disorders than the general population. The goal of the current study was to assess the temporal pattern of comorbid anorexia nervosa (AN) and alcohol use disorder (AUD) and the impact this ordering has on symptomatology and associated features. Women were placed into one of three groups based on the presence or absence of comorbid AUD and the order of AN and AUD onset in those with both disorders: (1) AN Only, (2) AN First, and (3) AUD First. The groups were compared on psychological symptoms and personality characteristics often associated with AN, AUD, or both using general linear models. Twenty-one percent of women (n = 161) with AN reported a history of AUD with 115 reporting AN onset first and 35 reporting AUD onset first. Women with binge-eating and/or purging type AN were significantly more likely to have AUD. In general, differences were found only between women with AN Only and women with AN and AUD regardless of order of emergence. Women with AN and AUD had higher impulsivity scores and higher prevalence of depression and borderline personality disorder than women with AN Only. Women with AN First scored higher on traits commonly associated with AN, whereas women with comorbid AN and AUD displayed elevations in traits more commonly associated with AUD. Results do not indicate a distinct pattern of symptomatology in comorbid AN and AUD based on the temporal sequence of the disorders.
PMCID: PMC3558554  PMID: 23254222
anorexia nervosa; alcohol use disorder; comorbidity; age of onset

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