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1.  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
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  Predicting group cognitive-behavioral therapy outcome of binge eating disorder using empirical classification 
Behaviour research and therapy  2013;51(9):10.1016/j.brat.2013.05.001.
The purpose of this study was to use empirical classification based on Latent Profile Analysis to identify subgroups of binge eating disorder (BED) and to evaluate the extent to which these subgroups were predictive of treatment outcome in group cognitive–behavioral therapy (CBT). The Eating Disorder Examination (EDE), Structured Clinical Interview for DSM-IV, and Inventory of Depressive Symptomatology-Self-Report were administered to 259 participants at baseline in a 15-session CBT trial (190 of whom received active treatment). The best fitting model included three profiles: dietary restraint only (DRO; n = 96; 51%); low dietary restraint (LDR; n = 52; 27%); and dietary restraint plus psychopathology (DRP; n = 42; 22%). Regression analyses revealed that after controlling for baseline score and treatment condition, EDE Global scores were lower for the DRO compared to the LDR profile at one year follow-up (p = .047). Class assignment was not predictive of EDE binge eating frequency or abstinence at end of treatment or follow-up. These results suggest that meaningful empirical classes based on eating disorder symptoms, psychopathology, dietary restraint, and BMI can be identified in BED and that these classes may be useful in predicting long-term group CBT outcome.
PMCID: PMC3813468  PMID: 23820157
Binge eating; Cognitive–behavioral therapy; Empirical classification; Prognosis
10.  Personality-Based Subtypes of Anorexia Nervosa: Examining Validity and Utility Using Baseline Clinical Variables and Ecological Momentary Assessment 
Behaviour research and therapy  2013;51(8):512-517.
This study sought to empirically derive and validate clinically relevant personality-based subtypes of anorexia nervosa (AN).
Women (N=116) with full or subthreshold AN completed baseline measures of personality, clinical variables, and eating disorder (ED) symptoms, followed by two weeks of ecological momentary assessment (EMA). A latent profile analysis was conducted to identify personality subtypes, which were compared on baseline clinical variables and EMA variables.
The best-fitting model supported three subtypes: underregulated, overregulated, and low psychopathology. The underregulated subtype (characterized by high stimulus seeking, self-harm, and oppositionality) displayed greater baseline ED symptoms, as well as lower positive affect and greater negative affect, self-discrepancy, and binge eating in the natural environment. The overregulated subtype (characterized by high compulsivity and low stimulus seeking) was more likely to have a lifetime obsessive-compulsive disorder diagnosis and exhibited greater perfectionism; levels of negative affect, positive affect, and self-discrepancy in this group were intermediate between the other subtypes. The low psychopathology subtype (characterized by normative personality) displayed the lowest levels of baseline ED symptoms, co-occurring disorders, and ED behaviors measured via EMA.
Findings support the validity of these personality-based subtypes, suggesting the potential utility of addressing within-diagnosis heterogeneity in the treatment of AN.
PMCID: PMC3721308  PMID: 23792181
eating disorders; personality; ecological momentary assessment; affect; empirical classification; latent profile analysis
11.  The Role of Affect in the Maintenance of Anorexia Nervosa: Evidence from a Naturalistic Assessment of Momentary Behaviors and Emotion 
Journal of abnormal psychology  2013;122(3):709-719.
The current study examines the relationship of affect and eating disorder behavior in anorexia nervosa (AN) using ecological momentary assessment. Participants were 118 adult females recruited at three sites from eating disorder treatment centers and community advertisements. All participants met full DSM-IV criteria or sub-threshold criteria for AN. Participants were provided handheld computers and asked to report positive affect, negative affect, loss of control (LOC) eating, purging, exercise, drinking fluids to curb appetite, and weighing one's self multiple times per day as well as dietary restriction once daily over a two-week interval. Mixed-effects models were used to examine the extent to which affective states predict dietary restriction. Additionally, we used two analytic approaches to compare affect prior to and after other eating disorder behaviors. We found that higher daily ratings of negative affect were associated with a greater likelihood of dietary restriction on subsequent days. When examining the single rating immediately before and after behaviors, we found that negative affect increased significantly following LOC eating, purging, the combination of LOC and eating/purging, and weighing of one's self. Using this same analytic approach we also found negative affect to decrease significantly following the consumption of fluids to curb appetite and exercise. When examining the covariation of AN behaviors and negative affect assessed multiple times in the hours and minutes before the behaviors, we found negative affect significantly increased prior to LOC eating, purging, the combination of LOC eating/and purging, and weighing behavior. Negative affect also significantly decreased following the occurrence of these behaviors. These findings are consistent with the idea that that negative affect is potentially a critical maintenance mechanism of some AN symptoms, but that the analytic approach used to examine affect and behavior may have significant implications on the interpretation of findings.
PMCID: PMC3997111  PMID: 24016011
anorexia nervosa; ecological momentary assessment (EMA); negative affect; positive affect; restriction
12.  A Naturalistic Examination of Body Checking and Dietary Restriction in Women with Anorexia Nervosa 
Behaviour research and therapy  2013;51(8):507-511.
Body checking has been conceptualized as a behavioral manifestation of the core overvaluation of eating, shape, and weight concerns underlying eating disorder psychopathology. Cognitive-behavioral theories suggest that body checking behaviors may function to maintain dietary restriction. The current study examined the association between body checking frequency and dietary restriction among women with anorexia nervosa (AN) in the natural environment. Women (N = 118) with full or partial AN completed baseline clinical interviews and a two-week ecological momentary assessment protocol, during which they reported on body checking behaviors (i.e., checking whether one’s thighs touch; checking joints/bones for fat) and dietary restriction (i.e., 8 waking hours without eating; consuming less than 1200 calories per day). Average daily body checking frequency was positively associated with baseline eating disorder symptoms and body mass index. Daily body checking frequency was associated with both forms of dietary restriction on the same day, as well as the following day. Results support the theorized association between body checking and overvaluation of shape and weight, and suggest that targeting such behaviors in treatment may have utility in reducing dietary restriction.
PMCID: PMC3733328  PMID: 23792180
anorexia nervosa; body checking; dietary restriction; ecological momentary assessment
13.  Parent-Only Treatment for Childhood Obesity: A Randomized Controlled Trial 
Obesity (Silver Spring, Md.)  2010;19(3):574-580.
Parent-only (PO) treatments for childhood obesity are feasible, more cost-effective and potentially easier to disseminate. The objective of this study was to determine whether a PO treatment is not inferior to a parent + child (PC) treatment for childhood obesity. Eighty parent–child dyads with an 8–12 year old overweight or obese child (>85th BMI-P) were recruited and randomized into PO or PC treatment for childhood obesity. Parents or parent–child dyads attended 5-month treatment groups. Child and parent body size, child caloric intake, and child physical activity were assessed at baseline, post-treatment, and 6-months follow-up. Noninferiority testing using mixed linear models was used to compare PO treatment with PC treatment. Results showed that the PO group was not inferior to the PC group in terms of child weight loss. Results also showed that the PO group was not inferior to the PC group in terms of parent weight loss and child physical activity, but not child caloric intake. This study suggests that a PO treatment could provide similar results to PC in child weight loss and other relevant outcomes, and potentially could be more cost-effective and easier to disseminate. Although further research is needed, this study suggests that PO groups are a viable method for providing childhood obesity treatment.
PMCID: PMC4008332  PMID: 20966907
14.  Guided Self-Help for the Treatment of Pediatric Obesity 
Pediatrics  2013;131(5):e1435-e1442.
Clinic-based programs for childhood obesity are not available to a large proportion of the population. The purpose of this study was to evaluate the efficacy of a guided self-help treatment of pediatric obesity (GSH-PO) compared with a delayed treatment control and to evaluate the impact of GSH-PO 6-months posttreatment.
Fifty overweight or obese 8- to 12-year-old children and their parents were randomly assigned to immediate treatment or to delayed treatment. The GSH-PO includes 12 visits over 5 months and addresses key components included in more intensive clinic-based programs. Children and parents in the immediate treatment arm were assessed at time 1 (T1), participated in GSH-PO between T1 and T2, and completed their 6-month posttreatment assessment at T3. Children and parents in the delayed treatment arm were assessed at T1, participated in GSH-PO between T2 and T3, and completed their 6-month posttreatment assessment at T4. The main outcome measures were BMI, BMI z score, and percentage overweight (%OW).
Children in the immediate treatment GSH-PO arm decreased their BMI significantly more than did the delayed treatment arm (BMI group × time = −1.39; P < .001). Similar results were found for BMI z score and %OW. At the 6-month posttreatment assessment, changes resulting from GSH-PO were maintained for BMI z score and %OW but not BMI (BMI time effect = −0.06, not significant; BMI z score time effect = −0.10, P < .001; %OW time effect = −4.86, P < .05).
The GSH-PO showed initial efficacy in decreasing BMI for children in this study. Additional efficacy and translational studies are needed to additionally evaluate GSH-PO.
PMCID: PMC3639455  PMID: 23545372
childhood; obesity; guided self-help; treatment
15.  Food-Related Parenting Practices and Adolescent Weight Status: A Population-Based Study 
Pediatrics  2013;131(5):e1443-e1450.
To examine food-related parenting practices (pressure-to-eat and food restriction) among mothers and fathers of adolescents and associations with adolescent weight status within a large population-based sample of racially/ethnically and socioeconomically diverse parent-adolescent pairs.
Adolescents (N = 2231; 14.4 years old [SD = 2.0]) and their parents (N = 3431) participated in 2 coordinated population-based studies designed to examine factors associated with weight status and weight-related behaviors in adolescents. Adolescents completed anthropometric measurements and surveys at school. Parents (or other caregivers) completed questionnaires via mail or phone.
Findings suggest that the use of controlling food-related parenting practices, including pressure-to-eat and restriction, is common among parents of adolescents. Mean restriction levels were significantly higher among parents of overweight and obese adolescents compared with nonoverweight adolescents. However, levels of pressure-to-eat were significantly higher among nonoverweight adolescents. Results indicate that fathers are more likely than mothers to engage in pressure-to-eat behaviors and boys are more likely than girls to be on the receiving end of parental pressure-to-eat. Parental report of restriction did not differ significantly by parent or adolescent gender. No significant interactions by race/ethnicity or socioeconomic status were seen in the relationship between restriction or pressure-to-eat and adolescent weight status.
Given that there is accumulating evidence for the detrimental effects of controlling feeding practices on children’s ability to self-regulate energy intake, these findings suggest that parents should be educated and empowered through anticipatory guidance to encourage moderation rather than overconsumption and emphasize healthful food choices rather than restrictive eating patterns.
PMCID: PMC3639463  PMID: 23610202
parenting; feeding; adolescent obesity; weight status
16.  Moderators of Post-Binge Eating Negative Emotion in Eating Disorders 
Journal of psychiatric research  2012;47(3):323-328.
The purpose of this study was to test the impact of two variables on post-binge eating negative emotion in a combined sample of women with anorexia nervosa (AN; n = 47) and bulimia nervosa (BN; n = 121). Participants completed two weeks of an ecological momentary assessment protocol during which they provided multiple daily ratings of overall negative affect and guilt and reported eating disorder behaviors including binge eating and self-induced vomiting. The results indicate that both overall negative affect and guilt exhibited a statistically significantly decrease in the hour immediately following binge eating episodes. The decrease in guilt, but not overall negative affect, was moderated by eating disorder diagnosis and the tendency to engage in self-induced vomiting. Specifically, individuals with BN reported a greater reduction in guilt than those with AN, and individuals who did not typically engage in self-induced vomiting reported more decreases in guilt than those who typically engaged in self-induced vomiting. This study extends the existing literature on the relationship between negative affect and eating disorder behaviors, suggesting guilt as a potentially relevant facet of negative affect in the maintenance of binge eating. In addition, the findings indicate that two individual differences, eating disorder diagnosis and self-induced vomiting, may influence the trajectory of guilt following binge eating episodes.
PMCID: PMC3570645  PMID: 23245289
anorexia nervosa; bulimia nervosa; negative affect; guilt; ecological momentary assessment
17.  Trait-level and momentary correlates of bulimia nervosa with a history of anorexia nervosa 
Some investigators have suggested subtyping bulimia nervosa (BN) by anorexia nervosa (AN) history. We examined trait-level and momentary eating-related and psychosocial factors in BN with and without an AN history.
Interview, questionnaire, and ecological momentary assessment data of eating-related and psychological symptoms were collected from 122 women with BN, including 43 with (BN+) and 79 without an AN history (BN−).
Body mass index (kg/m2) was lower in BN+ than BN− (p=.001). Groups did not differ on trait-level anxiety, shape/weight concerns, psychiatric comorbidity, or dietary restraint; or on momentary anxiety, dietary restriction, binge eating, purging, or exercise frequency, or affective patterns surrounding binge/purge behaviors. Negative affect increased prior to exercise and decreased thereafter in BN+ but not BN−, although groups did not statistically differ.
Results do not support formally subtyping BN by AN history. Exercise in BN+ may modulate negative affect, which could have important treatment implications.
PMCID: PMC3570735  PMID: 22987478
eating disorders; bulimia nervosa; history of anorexia nervosa; subtyping; classification; exercise
18.  Eat this, not that! Parental demographic correlates of food-related parenting practices 
Appetite  2012;60(1):140-147.
To understand how parents of adolescents attempt to regulate their children’s eating behaviors, the prevalence of specific food-related parenting practices (restriction, pressure-to-eat) by sociodemographic characteristics (parent gender, race/ethnicity, education level, employment status, and household income) were examined within a population-based sample of parents (n=3709) of adolescents. Linear regression models were fit to estimate the association between parent sociodemographic characteristics and parental report of food restriction and pressure-toeat. Overall, findings suggest that use of controlling food-related parenting practices , such as pressuring children to eat and restricting children’s intake, is common among parents of adolescents, particularly among parents in racial/ethnic minority subgroups, parents with less than a high school education, and parents with a low household income. Results indicate that that social or cultural traditions, as well as parental access to economic resources, may contribute to a parent’s decision to utilize specific food-related parenting practices. Given that previous research has found that restriction and pressure-to-eat food-related parenting practices can negatively impact children’s current and future dietary intake, differences in use of these practices by sociodemographic characteristics may contribute, in part, to the disparities that exist in the prevalence of overweight and obesity among adolescents by their race/ethnicity and socioeconomic status.
PMCID: PMC3889702  PMID: 23022556
Parenting practices; feeding practices; feeding strategies; parents; adolescents; restriction; pressure-to-eat; socio-demographics; cross-sectional study
19.  DSM-IV-Defined Anorexia Nervosa Versus Subthreshold Anorexia Nervosa (EDNOS-AN) 
Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder, yet its heterogeneity begs less reliance on this broad diagnostic category. The purpose of this study was to compare women with anorexia nervosa (AN) and EDNOS, AN type (EDNOS-AN) from a multisite study on eating-related and general psychopathology measures.
One hundred eighteen participants (n = 59 with DSM-IV AN, n = 59 with EDNOS-AN) completed structured interviews, questionnaires and a physical examination at baseline. In addition, participants carried a handheld palm pilot computer for two weeks to provide ecological momentary assessment (EMA) information about mood and eating disorder behaviors.
No significant differences between AN and EDNOS-AN were found on the self-report and interview measures, or on the EMA mood assessments. The only differences to emerge were that participants with AN reported higher rates of binge eating and purging on EMA compared to those with EDNOS-AN, while EDNOS-AN reported higher rates of checking thighs and joints on EMA compared to those with AN. For the physiological parameters, AN presented with lower white blood cell counts compared to EDNOS-AN.
Findings highlight the clinical significance of EDNOS-AN, and support a closer look at the definition of AN as proposed by DSM-5.
PMCID: PMC3715616  PMID: 22847947
Anorexia nervosa; EDNOS; classification
20.  Subjective and Objective Binge Eating in Relation to Eating Disorder Symptomatology, Negative Affect, and Personality Dimensions 
The International journal of eating disorders  2012;46(1):10.1002/eat.22066.
The current study explored the clinical meaningfulness of distinguishing subjective (SBE) from objective binge eating (OBE) among individuals with threshold/subthreshold bulimia nervosa (BN). We examined relations between OBEs and SBEs and eating disorder symptoms, negative affect, and personality dimensions using both a group comparison and a continuous approach.
Participants were 204 adult females meeting criteria for threshold/subthreshold BN who completed questionnaires related to disordered eating, affect, and personality.
Group comparisons indicated that SBE and OBE groups did not significantly differ on eating disorder pathology or negative affect, but did differ on two personality dimensions (cognitive distortion and attentional impulsivity). Using the continuous approach, we found that frequencies of SBEs (not OBEs) accounted for unique variance in weight/shape concern, diuretic use frequency, depressive symptoms, anxiety, social avoidance, insecure attachment, and cognitive distortion.
SBEs in the context of BN may indicate broader areas of psychopathology.
PMCID: PMC3832259  PMID: 23109272
subjective binge eating; objective binge eating; affect; personality; bulimia nervosa
21.  Eating Disorder Symptomatology in Normal-Weight vs. Obese Individuals With Binge Eating Disorder 
Obesity (Silver Spring, Md.)  2011;19(7):10.1038/oby.2011.24.
Although normal-weight individuals comprise a substantial minority of the binge eating disorder (BED) population, little is known about their clinical presentation. This study sought to investigate the nature and severity of eating disturbances in normal-weight adults with BED. We compared 281 normal-weight (n = 86) and obese (n = 195) treatment-seeking adults with BED (mean age = 31.0; s.d. = 10.8) on a range of current and past eating disorder symptoms using ANOVA and χ2 analyses. After controlling for age and sex, normal-weight participants reported more frequent use of a range of healthy and unhealthy weight control behaviors compared to their obese peers, including eating fewer meals and snacks per day; exercising and skipping meals more frequently in the past month; and avoiding certain foods for weight control. They also endorsed more frequent attempts at dieting in the past year, and feeling more frequently distressed about their binge eating, at a trend level. There were no group differences in binge eating frequency in the past month, age at onset of binge eating, overvaluation of shape/weight, or likelihood of having used certain weight control behaviors (e.g., vomiting, laxative use) or having sought treatment for an eating disorder in the past. Based on our findings, normal-weight individuals appear to be a behaviorally distinct subset of the BED population with significantly greater usage of both healthy and unhealthy weight control behaviors compared to their obese peers. These results refute the notion that distress and impairment in BED are simply a result of comorbid obesity.
PMCID: PMC3818144  PMID: 21331066
22.  Racial/Ethnic Differences in Adults in Randomized Clinical Trials of Binge Eating Disorder 
Recent studies suggest that binge eating disorder (BED) is as prevalent among African American and Hispanic Americans as among Caucasian Americans; however, data regarding the characteristics of treatment-seeking individuals from racial and ethnic minority groups are scarce. The purpose of this study was to investigate racial/ethnic differences in demographic characteristics and eating disorder symptoms in participants enrolled in treatment trials for BED.
Data from 11 completed randomized, controlled trials were aggregated in a single database, the Clinical Trials of Binge Eating Disorder (CT-BED) database, which included 1,204 Caucasian, 120 African American, and 64 Hispanic participants assessed at baseline. Age, gender, race/ethnicity, education, body mass index (BMI), binge eating frequency, and Eating Disorder Examination (EDE) Restraint, Shape, Weight, and Eating Concern subscale scores were examined.
Mixed model analyses indicated that African American participants in BED treatment trials had higher mean BMI than Caucasian participants, and Hispanic participants had significantly greater EDE shape, weight, and eating concerns than Caucasian participants. No racial or ethnic group differences were found on the frequency of binge eating episodes. Observed racial/ethnic differences in BED symptoms were not substantially reduced after adjusting for BMI and education. Comparisons between the CT-BED database and epidemiological data suggest limitations to the generalizability of data from treatment-seeking samples to the BED community population, particularly regarding the population with lower levels of education.
Further research is needed to assess alternative demographic, psychological, and culturally specific variables to better understand the diversity of treatment-seeking individuals with BED.
PMCID: PMC3668439  PMID: 22201327
binge eating; eating disorders; treatment; health disparities; ethnicity
23.  Psychometric Evaluation of the Eating Disorder Examination and Eating Disorder Examination-Questionnaire: A Systematic Review of the Literature 
The purpose of this study was to systematically review the reliability of scores on the Eating Disorder Examination (EDE) and the Eating Disorder Examination-Questionnaire (EDE-Q) and to examine the validity of their use as measures of eating disorder symptoms.
Articles describing the psychometric properties of the EDE and EDE-Q were identified in a systematic search of major computer databases and a review of reference lists. Articles were selected based on a priori inclusion and exclusion criteria.
Fifteen studies were identified that examined the psychometrics of the EDE, whereas 10 studies were found that examined the psychometrics of the EDE-Q.
Both instruments demonstrated reliability of scores. There is evidence that scores on the EDE and EDE-Q correlate with scores on measures of similar constructs and support for using the instruments to distinguish between cases and non-cases. Additional research is needed to broaden the generalizability of the findings.
PMCID: PMC3668855  PMID: 21744375
eating disorder examination; eating disorder examination-questionnaire; reliability; validity; psychometrics
24.  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
25.  Factor Structure of the Eating Disorder Examination Interview in Patients With Binge-eating Disorder 
Obesity (Silver Spring, Md.)  2009;18(5):977-981.
Despite the widespread use of the Eating Disorder Examination (EDE) as a primary assessment instrument in studies of eating and weight disorders, little is known about the psychometric aspects of this interview measure. The primary purpose of this study was to evaluate the factor structure of the EDE interview in a large series of patients with binge-eating disorder (BED). Participants were 688 treatment-seeking patients with BED who were reliably administered the EDE interview by trained research clinicians at three research centers. Exploratory factor analysis (EFA) performed on EDE interview data from a random split-half of the study group suggested a brief 7-item 3-factor structure. Confirmatory factor analysis (CFA) performed on the second randomly selected half of the study group supported this brief 3-factor structure of the EDE interview. The three factors were interpreted as Dietary Restraint, Shape/Weight Overvaluation, and Body Dissatisfaction. In this series of patients with BED, factor analysis of the EDE interview did not replicate the original subscales but revealed an alternative factor structure. Future research must further evaluate the psychometric properties, including the factor structure, of the EDE interview in this and other eating-disordered groups. The implications of these factor analytic findings for understanding and assessing the specific psychopathology of patients with BED are discussed.
PMCID: PMC3652230  PMID: 19798064

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