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1.  The Role of Motivation in Family-Based Guided Self-Help Treatment for Pediatric Obesity 
Childhood Obesity  2014;10(5):392-399.
Background: Identifying factors associated with effective treatment for childhood obesity is important to improving weight loss outcomes. The current study investigated whether child or parent motivation throughout the course of treatment predicted reductions in BMI.
Methods: Fifty 8- to 12-year-old children with overweight and obesity (BMI percentiles 85–98%) and their parents participated in a guided self-help weight loss program, which included 12 brief sessions across 5 months. Parents and interventionists reported on child and parent motivation level at each session. Multilevel slopes-as-outcome models were used to examine growth trajectories for both child and parent BMI across sessions.
Results: Greater interventionist-rated child motivation predicted greater reductions in child BMI; parent motivation did not. However, interventionist-rated parent motivation predicted greater reductions in parent BMI, and its impact on BMI became more pronounced over the course of treatment, such that sustained motivation was more important than initial motivation. Children who were older, Latino, or who had lower initial BMIs had slower reductions in BMI.
Conclusions: This study suggests that motivation may be an important predictor of reduced BMI in child obesity treatment, with sustained motivation being more important than initial motivation. In particular, interventionist-rated, but not parent-rated, motivation is a robust predictor of child and parent BMI outcomes. Future research may evaluate whether motivational interventions can enhance outcome, with particular attention to improving outcomes for Latino children.
PMCID: PMC4195249  PMID: 25181608
2.  Dimensions of emotion dysregulation in bulimia nervosa 
The goal of this study was to examine associations between dimensions of emotion dysregulation and eating disorder (ED) symptoms in bulimia nervosa (BN). This investigation used baseline data from a BN treatment study that included 80 adults (90% women) with full or subthreshold BN. Participants completed the Difficulties in Emotion Regulation Scale (DERS) and the Eating Disorders Examination (EDE) interview. The EDE global score was significantly correlated with the DERS total score, as well as several DERS subscales: Nonacceptance, Impulse, and Strategies. Further, the DERS Goals subscale was found to be uniquely associated with frequency of purging and driven exercise, although none of the subscales were associated with frequency of objective binge eating. Findings indicate that emotion dysregulation is associated with ED symptoms in BN, suggesting the utility of interventions that address emotion regulation skills deficits in the treatment of the disorder.
PMCID: PMC4554700  PMID: 24619484
emotion regulation; affect regulation; emotion; bulimia nervosa
3.  A perfect storm: examining the synergistic effects of negative and positive emotional instability on promoting weight loss activities in anorexia nervosa 
Frontiers in Psychology  2015;6:1260.
Growing evidence indicates that both positive and negative emotion potentially influence the development and maintenance of anorexia nervosa, through both positive and negative reinforcement of weight loss activities. Such reactive emotional experience may be characterized by frequent and intense fluctuations in emotion, a construct known as “emotional instability.” The purpose of this study was to investigate the association between positive emotional instability and weight loss activities in anorexia nervosa, and to investigate the synergistic effects of positive and negative emotional instability on promoting weight loss activities. Using ecological momentary assessment methods, 118 participants with anorexia nervosa reported their emotional experiences and behaviors at least six times daily over 2 weeks using a portable digital device. Using generalized linear modeling, results indicated that high levels of both positive and negative emotional instability, and the interaction between the two, were associated with more frequent weight-loss activities, beyond anorexia subtype and mean levels of emotional intensity. These findings indicate that when women with anorexia exhibit both high levels of both positive and negative emotional instability they are more prone to a variety of weight loss activities. The importance of addressing the role of both positive and negative emotion in anorexia treatment is discussed.
PMCID: PMC4553383  PMID: 26379588
anorexia nervosa; positive emotion; emotional instability; purging; weighing
4.  Behavioral, emotional, and situational context of purging episodes in anorexia nervosa 
The current study examined behavioral, emotional, and situational factors involved in purging among women with anorexia nervosa (AN).
Women with AN (n=118) completed a two-week ecological momentary assessment protocol involving daily reports of eating disorder behaviors, mood, and stressful events. Generalized estimating equations examined the likelihood and context of purging following eating episodes involving both overeating and loss of control (binge eating; BE); loss of control only (LOC); overeating only (OE); and neither loss of control nor overeating (non-pathological eating; NE).
Relative to NE, purging was more likely to occur following BE, LOC, and OE (Wald chi-square=18.05; p<.001). BE was more strongly associated with subsequent purging than LOC but not OE; the latter two did not differ from one another. Negative affect predicted purging following NE (Wald chi-square=7.71; p=.005).
Binge eating involving large amounts of food was the strongest predictor of purging in AN, which challenges the notion that loss of control is the most salient aspect of experiencing distress in bulimia nervosa and binge eating disorder. Parallel to findings from the binge eating literature, negative affect strongly predicted purging following non-pathological eating. Further research should clarify the function and triggers of purging in AN.
PMCID: PMC4535345  PMID: 25643935
Binge eating; loss of control; overeating; purging; compensatory behaviors; ecological momentary assessment; anorexia nervosa
5.  Ecological momentary assessment of eating episodes in obese adults 
Psychosomatic medicine  2014;76(9):747-752.
The context of eating episodes in obesity is poorly understood. This study examined emotional, physiological, and environmental correlates of pathological and non-pathological eating episodes in a heterogeneous sample of obese adults.
Community-based participants [n=50; 84% female (n=42); M body mass index=40.3±8.5; M age=43.0±11.9] with (n=5; 10%) and without binge eating disorder (BED; n=45; 90%) recorded all eating episodes and their associated emotional, physiological, and environmental factors via ecological momentary assessment for two weeks. Generalized estimating equations examined relations between these variables and eating episodes characterized by both self-identified loss of control while eating and overeating (binge eating; BE), loss of control only (LOC), overeating only (OE), and neither loss of control nor overeating (non-pathological eating; NE).
Episodes involving loss of control (BE and LOC) were associated with the highest levels of pre- and post-episode negative affect (Wald chi-square range=15.67–24.39; ps≤.001), while those involving overeating (BE and OE) were associated with the lowest levels of pre- and post-episode hunger (Wald chi-square range=18.14–39.75; ps<.001). LOC episodes were followed by the highest level of post-episode cravings (Wald chi-square=25.87; p<.001) and were most likely to occur when participants were alone (Wald chi-square=13.20; p=.004).
Binge and loss of control eating were more consistently associated with emotional and physiological cues than overeating and non-pathological eating, while most environmental variables did not differ among eating episode types. Results support distinctions among the different objective and subjective constructs characterizing aberrant eating, and should be used to inform interventions for obesity and related eating pathology.
PMCID: PMC4530605  PMID: 25373891
Obesity; binge eating; loss of control; overeating; ecological momentary assessment
6.  Proposed Diagnostic Criteria for Night Eating Syndrome 
To propose criteria for diagnosis of the night eating syndrome (NES).
An international research meeting was held in April 2008, and consensus criteria for NES diagnosis were determined.
The core criterion is an abnormally increased food intake in the evening and nighttime, manifested by (1) consumption of at least 25% of intake after the evening meal, and/or (2) nocturnal awakenings with ingestions at least twice per week. Awareness of the eating episodes is required, as is distress or impairment in functioning. Three of five modifiers must also be endorsed. These criteria must be met for a minimum duration of 3 months.
These criteria help standardize the definition of NES. Additional aspects of the nosology of NES yet to be fully elaborated include its relationship to other eating and sleep disorders. Assessment and analytic tools are needed to assess these new criteria more accurately.
PMCID: PMC4531092  PMID: 19378289
7.  The Role of Leptin, Melanocortin, and Neurotrophin System Genes on Body Weight in Anorexia Nervosa and Bulimia Nervosa 
Although low weight is a key factor contributing to the high mortality in anorexia nervosa (AN), it is unclear how AN patients sustain low weight compared with bulimia nervosa (BN) patients with similar psychopathology. Studies of genes involved in appetite and weight regulation in eating disorders have yielded variable findings in part due to small sample size and clinical heterogeneity. This study: (1) assessed the role of leptin, melanocortin, and neurotrophin genetic variants in conferring risk for AN and BN and (2) explored the involvement of these genes in body mass index (BMI) variations within AN and BN.
Our sample consisted of 745 individuals with AN without a history of BN, 245 with BN without a history of AN, and 321 controls. We genotyped 20 markers with known or putative function among genes selected from leptin, melanocortin, and neurotrophin systems.
There were no significant differences in allele frequencies among individuals with AN, BN, and controls. AGRP rs13338499 polymorphism was associated with lowest illness-related BMI in those with AN (p=0.0013), and NTRK2 rs1042571 was associated with highest BMI in those with BN (p=0.0018).
To our knowledge, this is the first study to address the issue of clinical heterogeneity in eating disorder genetics and to explore the role of known or putatively functional markers in genes regulating appetite and weight in individuals with AN and BN. If replicated, our results may serve as an important first step toward gaining a better understanding of weight regulation in eating disorders.
PMCID: PMC4191922  PMID: 24831852
anorexia nervosa; bulimia nervosa; candidate gene association; body weight; melanocortins; neurotrophins
9.  Daily Patterns of Anxiety in Anorexia Nervosa: Associations with Eating Disorder Behaviors in the Natural Environment 
Journal of abnormal psychology  2013;122(3):672-683.
The role of anxiety has been emphasized in etiological/maintenance models of anorexia nervosa. This study identified daily patterns of anxiety in anorexia nervosa and examined the likelihood of the occurrence of eating disorder behaviors in each trajectory, the daily temporal distribution of eating disorder behaviors in each trajectory, and the extent to which the tendency to exhibit particular anxiety trajectories was associated with baseline diagnostic and trait-level personality variables. Women with full or subthreshold anorexia nervosa (N = 118) completed a two-week ecological momentary assessment (EMA) protocol during which they reported on a variety of behavioral and affective variables, including anxiety and eating disorder behaviors. Using latent growth mixture modeling to classify EMA days (N = 1526) based on anxiety ratings, seven distinct daily anxiety trajectories were identified. Overall differences between trajectories were found for rates of binge eating, self-induced vomiting, body checking, skipping meals, and dietary restriction. Further, distinct daily temporal distributions of eating disorder behaviors were found across the trajectories, with peaks in the probability of behaviors frequently coinciding with high levels of anxiety. Finally, traits of personality pathology (affective lability, self-harm, social avoidance, and oppositionality) and the presence of a co-occurring mood disorder were both found to be associated with the tendency to experience particular daily anxiety trajectories (e.g., Stable High anxiety). Findings support the presence of within-person variability in daily anxiety patterns in anorexia nervosa and also provide evidence for an association between these anxiety patterns and eating disorder behaviors.
PMCID: PMC4515356  PMID: 23647124
eating disorder; anxiety; ecological momentary assessment; latent growth mixture modeling; personality
10.  Therapeutic Factors Affecting the Cognitive Behavioral Treatment of Bulimia Nervosa via Telemedicine versus Face-to-Face Delivery 
Recently, Mitchell and colleagues (2008) conducted a randomized controlled trial of an empirically supported treatment for bulimia nervosa (BN) delivered face-to-face (FTF-CBT) or via telemedicine (TV-CBT). Results suggested that the TV-CBT and FTF-CBT were generally equivalent in effectiveness. The objective of the current study was to examine ratings of therapeutic alliance factors in TV-CBT and FTF-CBT.
Data obtained from 116 adults who met criteria for BN or eating disorder—not otherwise specified (EDNOS) with binge eating or purging weekly and 6 doctoral-level psychologists who delivered the therapy were used in the analyses.
Therapists generally endorsed greater differences between the treatment delivery methods than patients. Patients tended to make significantly higher ratings of therapeutic factors than therapists.
TV-CBT is an acceptable method for the delivery of BN treatment compared to FTF-CBT, and TV-CBT is more easily accepted as a treatment delivery method by patients than therapists.
PMCID: PMC4496947  PMID: 22072405
11.  Parent Predictors of Child Weight Change in Family Based Behavioral Obesity Treatment 
Obesity (Silver Spring, Md.)  2012;20(7):1539-1543.
Family based behavioral treatment for overweight and obese children includes parenting skills targeting the modification of child eating and activity change. The purpose of this study was to examine parenting skills and parent weight change as predictors of child weight change in a sample of 80 parent/child dyads who were enrolled in a family based behavioral weight loss program for childhood obesity. Eighty overweight and obese children and their parents who enrolled in treatment in two sites were included in the study. Variables included those related to parent modeling (parent BMI), home food environment, parenting (parent and child report), and demographics. Results suggested that parent BMI change was a significant predictor of child weight, in that a reduction of 1 BMI unit in the parent was associated with a 0.255 reduction in child BMI. None of the other variables were significant in the final model. This study is consistent with other research showing that parent weight change is a key contributor to child weight change in behavioral treatment for childhood obesity. Researchers and clinicians should focus on encouraging parents to lose weight to assist their overweight and obese child in weight management.
PMCID: PMC4456177  PMID: 22421896
12.  Latent profile analysis of eating episodes in anorexia nervosa 
Despite being characterized primarily by disturbances in eating behavior, relatively little is known about specific eating behaviors in anorexia nervosa (AN) and how they relate to different emotional, behavioral, and environmental features.
Women with AN (n=118) completed a 2-week ecological momentary assessment (EMA) protocol during which they reported on daily eating- and mood-related patterns. Latent profile analysis was used to identify classes of eating episodes based on the presence or absence of the following indicators: loss of control; overeating; eating by oneself; food avoidance; and dietary restraint.
The best-fitting model supported a 5-class solution: avoidant eating; solitary eating; binge eating; restrictive eating; and loss of control eating. The loss of control and binge eating classes were characterized by high levels of concurrent negative affect and a greater likelihood of engaging in compensatory behaviors. The restrictive eating class was associated with the greatest number of concurrently-reported stressful events, while the avoidant and solitary eating episode classes were characterized by relatively few accompanying stressful events. Body checking was least likely to occur in conjunction with restrictive eating behaviors.
Results support the presence of discrete types of eating episodes in AN that are associated with varying degrees of negative affect, stress, and behavioral features of eating disorders. Loss of control and dietary restriction may serve distinct functional purposes in AN, as highlighted by their differing associations with negative affect and stress. Clinical interventions for AN may benefit from targeting functional aspects of eating behavior among those with the disorder.
PMCID: PMC4011391  PMID: 24630466
Anorexia nervosa; eating behavior; ecological momentary assessment; negative affect; binge eating; dietary restriction
13.  Nutritional Adequacy of Dietary Intake in Women with Anorexia Nervosa 
Nutrients  2015;7(5):3652-3665.
Understanding nutrient intake of anorexia nervosa (AN) patients is essential for the treatment. Therefore, estimates of total energy and nutrient consumption were made in a group of young women (19 to 30 years) with restricting and binge purge subtypes of AN participating in an ecological momentary assessment study. Participants completed three nonconsecutive 24-hour diet recalls. Mean nutrient intakes were stratified by subtype and by quartiles of energy intake and compared to the age specific Dietary Reference Intake (DRI) levels, as well as to the reported intakes from the What We Eat In America (WWEIA) dietary survey 2011–2012. Reported intake was determined for energy, macronutrients, and micronutrients. The mean body mass index (BMI) for all participants was 17.2 ± 0.1 kg/m2. Reported nutrient intake was insufficient for participants in quartiles 1–3 of both AN subtypes when compared to the DRIs. Intake reported by participants in quartile 4 of both subgroups met requirements for most nutrients and even met or exceeded estimated energy needs. Counseling of AN patients should be directed to total food consumption to improve energy intake and to reduce individual nutritional gaps.
PMCID: PMC4446771  PMID: 25988761
anorexia nervosa; dietary intake; WWEIA; NHANES 2011–2012
14.  Eating disorder not otherwise specified presentation in the US population 
To examine prevalence and clinical correlates of eating disorder not otherwise specified (EDNOS) in the U.S. population.
Two cross-sectional surveys of adults and adolescents used the WHO CIDI to assess DSM-IV criteria for anorexia nervosa (AN), bulimia nervosa (BN), and EDNOS.
Lifetime prevalence of EDNOS was 4.78% in adolescents and 4.64% in adults. The majority of adolescents and adults with an eating disorder presented with EDNOS. Three-quarters of participants with EDNOS met criteria for comorbid disorders, while one-quarter endorsed suicidality. Severity correlates were equally prevalent in EDNOS and AN whereas comparisons between EDNOS and BN varied by specific correlate and sample. Adolescents with subthreshold AN (SAN) endorsed more anxiety than AN (p<0.05), and adolescents and adults with SAN endorsed more suicidal plans than AN (p’s<0.05).
Findings increase our understanding of the clinical relevance of EDNOS. Eating disorder diagnostic nomenclature requires modification to capture the full spectrum.
PMCID: PMC4408273  PMID: 22407912
Anorexia Nervosa; Bulimia Nervosa; EDNOS; EDNOS-subtypes; classification; DSM
15.  Are food restriction and pressure-to-eat parenting practices associated with adolescent disordered eating behaviors? 
To examine associations between parental pressure-to-eat and food restriction and adolescent disordered eating behaviors, within a sample of parent-adolescent pairs.
Adolescents (N=2231) and their parents (N=3431) participated in two, coordinated, population-based studies designed to examine factors associated with weight and weight-related behaviors in adolescents.
Overall, higher levels of pressure-to-eat or food restriction was significantly and positively associated with use of disordered eating behaviors among boys. For every one unit increase [Scale Range: 1-(low control) to 4 – (high control)] in mothers’ food restriction, boys were twice as likely to engage in extreme weight control behaviors (p≤0.01). Examination of the association between food-related parenting practices and disordered eating behaviors among girls revealed fewer significant associations. However, analyses did reveal that for every one unit increase in mothers’ food restriction, girls were 1.33 times more likely to engage in extreme weight control behaviors (p=0.04).
Study findings provide evidence of an association between controlling food-related parenting practices and adolescent disordered eating behaviors, particularly in boys. Future longitudinal research is needed to establish directionality of observed associations.
PMCID: PMC3963280  PMID: 24105668
16.  Affect and eating behavior in obese adults with and without elevated depression symptoms 
Although there is a modest relation between obesity and depression, mechanisms that contribute to this co-occurrence are unclear. This study examined mood and eating behavior among obese adults with and without elevated depression symptoms.
Obese adults (N=50) were subtyped according to a Beck Depression Inventory (BDI) cutoff of 14, indicating “probable depression.” Participants with (BDI≥14; n=15) and without elevated depression symptoms (BDI<14; n=35) were compared on affect- and eating-related variables measured via questionnaire and ecological momentary assessment (EMA) using ANCOVA and mixed model regression.
After adjusting for group differences in body mass index (BMI; p=.03), participants with elevated depression symptoms reported greater emotional eating via self-report questionnaire [F(1,50)=4.3; p=.04], as well as more frequent binge eating (Wald chi-square=13.8; p<.001) and higher daily negative affect (Wald chi-square=7.7; p=.005) on EMA recordings. Emotional eating mediated the relationship between depression status and BMI (indirect effect estimate=3.79; 95% CI=1.02–7.46).
Emotional eating and binge eating were more commonly reported by obese adults with elevated depression symptoms compared to those without, and may occur against a general backdrop of overall low mood. Intervention and prevention programs for obesity and/or depression should address disordered eating to prevent or minimize adverse health consequences.
PMCID: PMC3980849  PMID: 24014067
Obesity; depression; emotional eating; binge eating; ecological momentary assessment
17.  Stress and Eating Disorder Behavior in Anorexia Nervosa as a Function of Menstrual Cycle Status 
Fluctuations in ovarian hormones during the menstrual cycle and psychosocial stress contribute to eating disorder (ED) behavior.
Using ecological momentary assessment techniques, this study examined relationships between stress and binge eating, self-induced vomiting, and dietary restriction based on menstrual cycle status in anorexia nervosa (AN). 109 females with full and subthreshold AN (17–45 years old) recorded ED behavior and stress ratings over two weeks. Using hierarchical linear modeling, individuals with eumenorrhea and those with amenorrhea or oligomenorrhea were compared.
Following episodes of meal skipping, momentary stress decreased in individuals with normal menstrual cycles and increased in those with irregular menstrual cycles.
Results suggest that changes in stress severity in response to food restriction may differ based on ovarian hormonal status and may be a mechanism by which AN is maintained in individuals without menstrual disturbance.
PMCID: PMC3946633  PMID: 24222529
18.  Hard Exercise, Affect Lability, and Personality Among Individuals with Bulimia Nervosa 
Eating behaviors  2013;14(4):10.1016/j.eatbeh.2013.07.004.
The current study explores the personality traits of compulsivity (e.g., sense of orderliness and duty to perform tasks completely) and restricted expression (e.g., emotion expression difficulties) as potential moderators of the relation between affect lability and frequency of hard exercise episodes in a sample of individuals with bulimic pathology. Participants were 204 adult females recruited in five Midwestern cities who met criteria for threshold or subthreshold bulimia nervosa (BN). Compulsivity was found to significantly moderate the relation between affect lability and number of hard exercise episodes over the past 28 days, such that among those with high compulsivity, level of affect lability was associated with the number of hard exercise episodes; whereas, among those with low compulsivity, affect lability was not associated with the number of hard exercise episodes. The same pattern of findings emerged for restricted expression; however, this finding approached, but did not reach statistical significance. As such, it appears that affect lability is differentially related to hard exercise among individuals with BN depending upon the level of compulsivity and, to a more limited extent, restricted expression. These results suggest that, for individuals with BN with either compulsivity or restricted expression, focusing treatment on increasing flexibility and/or verbal expression of emotions may help them in the context of intense, fluctuating affect.
PMCID: PMC3832258  PMID: 24183126
exercise; emotion regulation; bulimia nervosa; affect lability; compulsivity; emotion expression
19.  Examining Duration of Binge Eating Episodes in Binge Eating Disorder 
The primary goal of this paper is to examine and clarify characteristics of binge eating in individuals with binge eating disorder (BED), particularly the duration of binge eating episodes, as well as potential differences between individuals with shorter compared to longer binge eating episodes.
Two studies exploring binge eating characteristics in BED were conducted. Study 1 examined differences in clinical variables among individuals (N = 139) with BED who reported a short (< 2 hours) versus long (≥ 2 hours) average binge duration. Study 2 utilized an ecological momentary assessment (EMA) design to examine the duration and temporal pattern of binge eating episodes in the natural environment in a separate sample of nine women with BED.
Participants in Study 1 who were classified as having long duration binge eating episodes displayed greater symptoms of depression and lower self-esteem, but did not differ on other measures of eating disorder symptoms, compared to those with short duration binge eating episodes. In Study 2, the average binge episode duration was approximately 42 minutes, and binge eating episodes were most common during the early afternoon and evening hours, as well as more common on weekdays versus weekends.
Past research on binge episode characteristics, particularly duration, has been limited to studies of binge eating episodes in BN. This study contributes to the existing literature on characteristics of binge eating in BED.
PMCID: PMC3889648  PMID: 23881639
20.  Restrictive Eating Behaviors are a Non-Weight-Based Marker of Severity in Anorexia Nervosa 
The purpose of this study was to compare the type and frequency of restrictive eating behaviors across the two subtypes of anorexia nervosa (AN; restricting [ANr] and binge eating/purging [ANbp]) using ecological momentary assessment (EMA) and to determine whether subtype differences in restrictive eating behaviors were attributable to severity of the disorder or the frequency of binge eating.
Participants (N = 118) were women at least 18 years of age with full (n = 59) or sub-threshold (n = 59) AN who participated in a two week (EMA) protocol.
General estimating equations revealed that individuals with ANbp generally reported more frequent restrictive eating behaviors than individuals with ANr. These differences were mostly accounted for by greater severity of eating psychopathology, indicating that the presence and frequency of restrictive eating behaviors in AN may be non-weight-based markers of severity. Binge eating frequency did not account for these findings.
The present findings are especially interesting in light of the weight-based severity rating in the DSM-5.
PMCID: PMC4001723  PMID: 23868197
Anorexia nervosa; subtypes; dietary restriction; severity
21.  Picking and nibbling: Frequency and associated clinical features in bulimia nervosa, anorexia nervosa and binge eating disorder 
Picking and nibbling (P&N) is a newly studied eating behavior characterized by eating in an unplanned and repetitious manner in between meals and snacks. This behavior seems to be related to poorer weight loss outcomes after bariatric surgery for weight loss in severely obese patients, but clarification is still required regarding its value in other clinical samples.
The purpose of this study was to investigate the frequency of P&N across different eating disorder samples, as well as to examine its association with psychopathological eating disorder features.
Our sample included treatment-seeking adult participants, recruited for five different clinical trials: 259 binge eating disorder (BED); 264 bulimia nervosa (BN) and 137 anorexia nervosa (AN). Participants were assessed using the Eating Disorders Examination interview before entering the clinical trials.
P&N was reported by 44% of the BED; 57.6% of the BN and 34.3% of the AN participants. No association was found between P&N and BMI, the presence of compensatory behaviors, binge eating or any of the EDE subscales.
This study suggests that P&N behavior is highly prevalent across eating disorder diagnoses. Our findings suggest that P&N is not associated with psychopathology symptoms or other eating disordered behaviors.
PMCID: PMC4009470  PMID: 23922133
Picking and nibbling; eating behaviors;  eating disordered behaviors
22.  Bipolar disorder with comorbid binge eating history: A genome-wide association study implicates APOB 
Journal of affective disorders  2014;165:151-158.
Bipolar disorder (BD) is a highly heritable disease. While genome-wide association (GWA) studies have identified several genetic risk factors for BD, few of these studies have investigated the genetic etiology of specific disease subtypes. In particular, BD is positively associated with eating dysregulation traits such as binge eating behavior (BE), yet the genetic risk factors underlying BD with comorbid BE have not been investigated.
Utilizing data from the Genetic Association Information Network study of BD, which included 729,454 single nucleotide polymorphisms (SNPs) genotyped in 1001 European American bipolar cases and 1034 controls, we performed GWA analyses of bipolar subtypes defined by the presence or absence of BE history, and performed a case-only analysis comparing BD subjects with and without BE history. Association signals were refined using imputation, and network analysis was performed with Ingenuity Pathway Analysis software. Based on these results, candidate SNPs were selected for replication in an independent sample of 855 cases and 857 controls.
Top ranking SNPs in the discovery set included rs6006893 in PRR5, rs17045162 in ANK2, rs13233490 near PER4, rs4665788 and rs10198175 downstream of APOB, rs2367911 in CACNA2D1, and rs7249968 near ZNF536. Rs10198175 in APOB also demonstrated evidence of association in the replication sample and a meta-analysis of the two samples.
Without information of BE history in controls, it is not possible to determine whether the observed association with APOB reflects a risk factor for BE behavior in general or a risk factor for a subtype of BD with BE. Further longitudinal and functional studies are needed to determine the causal pathways underlying the observed associations.
This study identified new potential BD-susceptibility genes, highlighting the advantages of phenotypic sub-classification in genetic research and clinical practice.
PMCID: PMC4224146  PMID: 24882193
Bipolar disorder; Binge eating; Phenotypic subtypes; Network analysis; Genome-wide association study (GWAS); APOB
23.  Associations between Retrospective versus Ecological Momentary Assessment Measures of Emotion and Eating Disorder Symptoms in Anorexia Nervosa 
Journal of psychiatric research  2013;47(10):1514-1520.
This study examined the unique associations between eating disorder symptoms and two emotion-related constructs (affective lability and anxiousness) assessed via distinct methodologies in anorexia nervosa (AN). Women (N=116) with full or subthreshold AN completed baseline emotion and eating disorder assessments, followed by two weeks of ecological momentary assessment (EMA). Hierarchical regressions were used to examine unique contributions of baseline and EMA measures of affective lability and anxiousness in accounting for variance in baseline eating disorder symptoms and EMA dietary restriction, controlling for age, body mass index, depression, and AN diagnostic subtype. Only EMA affective lability was uniquely associated with baseline eating disorder symptoms and EMA dietary restriction. Anxiousness was uniquely associated with baseline eating disorder symptoms regardless of assessment method; neither of the anxiousness measures was uniquely associated with EMA dietary restriction. Affective lability and anxiousness account for variance in global eating disorder symptomatology; AN treatments targeting these emotion-related constructs may prove useful.
PMCID: PMC3805055  PMID: 23880601
eating disorders; ecological momentary assessment; emotion; affective lability; anxiety; assessment
24.  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
25.  Relationship between maternal parenting and eating self-efficacy in overweight children when stressed 
Eating and weight disorders : EWD  2013;18(3):283-288.
Emotional eating is associated with negative eating habits and obesity. Parents may be able to decrease the risk of emotional eating in children by promoting greater self-efficacy to engage in healthy eating behaviors. Our goal was to determine the relationship between certain parenting behaviors and eating self-efficacy (ESE) to consume healthy foods during times of emotional stress in a population of overweight/obese children.
Eighty children (60% female; mean BMI percentile = 98.4%; 79.2% White) completed a survey that assessed their ESE when stressed, feeling down, or bored. Children also reported on mothers’ parenting behaviors coded along three factors: acceptance-based parenting (AC), psychological control (PC), and firm control (FC). Correlations and multiple linear regression models were used for analysis.
AC was positively correlated with ESE when stressed. PC and FC were inversely correlated with ESE when feeling down. In the multivariate regression, only FC was significantly inversely associated with ESE when feeling down.
Results suggest that overweight children who perceive their mothers to exhibit firm control have lower ESE to make healthy choices when feeling sad. These results suggest that pediatric obesity programs should place a stronger focus on decreasing firm control behaviors among parents in order to help children engage in healthier eating behaviors.
PMCID: PMC3775574  PMID: 23868554
Parenting style; parenting behaviors; childhood obesity; self-efficacy; eating behaviors; emotional eating

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