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Homework assignments are considered key components of behavioral treatments for bulimia nervosa (BN), but little is known about whether homework compliance predicts BN symptom improvement. The present study is the first to examine whether session-by-session change in homework compliance predicts session-by-session changes in BN symptoms during behavioral treatment.Patients with BN-spectrum eating disorders (Significant between-persons effects of self-monitoring and behavioral homework compliance were identified, such that patients with greater compliance in the past week experienced greater reductions in binge eating and purging the following week. There were significant within-persons effects of self-monitoring compliance on binge eating and behavioral homework compliance on restrictive eating, binge eating, and purging, such that greater than one's usual compliance predicted greater improvements in BN symptoms the following week. No significant effects of written homework compliance were identified.Compliance with self-monitoring and behavioral homework predict improvements in BN symptoms during behavioral treatment. These findings reinforce the importance of self-monitoring and behavioral homework compliance as drivers of change during treatment for BN.

Bulimia nervosa (BN) is characterized by a pattern of binge eating and compensatory behaviors as well as an overemphasis on body weight and shape in self-evaluation. Although cognitive behavioral therapy (CBT) is efficacious, recent reviews suggest that only 30% of patients reach abstinence at posttreatment. One potential reason for these poor outcomes is that CBT fails to adequately reduce elevated negative affect (NA) and shape and weight concern, which have been shown to be correlated with poorer treatment outcomes in BN. Therefore, novel treatment components that focus on improving NA and shape and weight concern are needed in order to enhance outcomes. Promoting physical activity (PA) is a promising avenue through which to reduce NA and improve body image in healthy individuals, other clinical populations (e.g., individuals with depression or anxiety), and individuals with eating disorders. While prescribing PA for individuals with BN has been controversial (due to concerns that exercise maybe be used to compensate for binge episodes or become driven or compulsive), this approach may have many benefits, including promoting healthy lifetime exercise habits that reduce likelihood of relapse through the improvement of emotion regulation skills and weight regulation. Given the promise of PA for targeting key maintenance factors of BN, we developed a 12-session healthy PA promotion intervention for BN and tested initial feasibility, acceptability, and preliminary target engagement in an iterative case series design (n = 3). The treatment provided cognitive-behavioral skills designed to identify, practice, and achieve behavioral goals while asking patients to engage in up to 150 minutes of moderate-to-vigorous PA per week, which was preplanned during each session with the client’s therapist. Results suggested that the healthy PA promotion intervention was both feasible and acceptable to deliver. In addition, the intervention resulted in a clinically significant decrease in BN symptom frequency in each participant. Further, participants showed clinically significant decreases in NA and shape and weight concern. The current study demonstrates that healthy PA interventions can have beneficial effects on BN symptoms, NA, and shape and weight concern. However, due to the small sample size, conclusions must be treated with caution. Future research should investigate additional approaches for promoting healthy PA and include a larger sample in order to further test initial efficacy of this treatment approach.

Elevated glucose variability may be one mechanism that increases risk for significant psychological and physiological health conditions among individuals with binge-spectrum eating disorders (B-EDs), given the impact of eating disorder (ED) behaviors on blood glucose levels. This study aimed to characterize glucose variability among individuals with B-EDs compared with age-matched, sex-matched, and body mass index-matched controls, and investigate the association between frequency of ED behaviors and glucose variability.Participants were 52 individuals with B-EDs and 22 controls who wore continuous glucose monitors to measure blood glucose levels and completed ecological momentary assessment surveys to measure ED behaviors for 1 week. Independent samples t-tests compared individuals with B-EDs and controls and multiple linear regression models examined the association between ED behaviors and glucose variability.Individuals with B-EDs demonstrated numerically higher glucose variability than controls (t = 1.42, p = .08, d = 0.43), although this difference was not statistically significant. When controlling for covariates, frequency of ED behaviors was significantly, positively associated with glucose variability (t = 3.17, p = .003) with medium effect size (fGlucose variability among individuals with B-EDs appears to be positively associated with engagement in ED behaviors, particularly binge eating. Glucose variability may be an important mechanism by which adverse health outcomes occur at elevated rates in B-EDs and warrants future study.This study suggests that some individuals with binge ED and bulimia nervosa may experience elevated glucose variability, a physiological symptom that is linked to a number of adverse health consequences. The degree of elevation in glucose variability is positive associated with frequency of eating disorder behaviors, especially binge eating.

Purpose – The co-morbidity of binge eating and heavy drinking (BE+HD) is a serious concern due to the high prevalence rates and associated elevated severity. Clarifying the momentary factors that increase risk for binge eating and heavy drinking among BE+HD is important for expanding theoretical models of BE+HD and informing treatment recommendations. The current study used ecological momentary assessment (EMA) to compare the momentary processes maintaining binge eating between BE+HD and individuals with binge eating only (BE-only) and to identify the momentary risk factors for binge eating episodes and heavy drinking episodes among BE+HD. Methods – Participants (BE+HD: N = 14; BE-only: N = 37) were adults with clinically-significant binge eating who completed between 7 – 14 days of EMA prior to treatment. Results – The presence of food and within-day dietary restraint predicted higher odds of binge eating for both groups. Among BE+HD, the presence of alcohol and dietary restraint increased risk for subsequent binge eating and subsequent heavy drinking, and the absence of food increased risk for subsequent heavy drinking.Conclusion - These results offer preliminary support for treatment interventions for BE+HD that focus on reducing dietary restraint and teaching strategies for urge management in situations with palatable food or alcohol. Future research should study the maintenance mechanisms of BE+HD with larger, more diverse samples and using study design approaches with more experimenter control (i.e., laboratory experiments). Level of Evidence: Level IV, multiple time series without intervention

Purpose Difficulty reappraising drives to consume palatable foods may promote poorer inhibition and binge eating (BE) in adults with obesity, but neural underpinnings of food-related reappraisal are underexamined. Methods To examine neural correlates of food-related reappraisal, adults with obesity with and without BE wore a portable neuroimaging tool, functional near-infrared spectroscopy (fNIRS). fNIRS measured activity in the prefrontal cortex while participants watched videos of food and attempt to “resist” the food stimuli (i.e., “consider the negative consequences of eating the food”). Results Participants (N = 32, 62.5% female; BMI 38.6 $$\pm$$ ± 7.1; 43.5 $$\pm$$ ± 13.4 y) had a BMI > 30 kg/m2. Eighteen adults (67.0% female; BMI 38.2 $$\pm$$ ± 7.6) reported BE (≥ 12 BE-episodes in preceding 3 months). The control group comprised 14 adults who denied BE (64.0% female; BMI 39.2 $$\pm$$ ± 6.6). Among the entire sample, mixed models showed significant, small hyperactivation during crave and resist compared to watch (relax) condition bilaterally in the medial superior frontal gyrus, dorsolateral areas, and middle frontal gyrus (optodes 5, 7, 9, 10, 11, and 12) in the total sample. No statistically significant differences in neural activation were observed between the BE and control group. Moreover, there were no significant group by condition interactions on neural activation. Conclusion Among adults with obesity, BE status was not linked to differential activation in inhibitory prefrontal cortex areas during a food-related reappraisal task. Future research is needed with larger samples, adults without obesity, and inhibition paradigms with both behavioral and cognitive components. Level of evidence Level III: Evidence obtained from well-designed cohort or case–control analytic studies. Trial registration: # NCT03113669, date April 13, 2017.

BACKGROUND Binge eating (BE), characterized by eating a large amount of food accompanied by a sense of loss of control over eating, is a public health crisis. Negative affect is a well-established antecedent for BE. The affect regulation model of BE posits that elevated negative affect increases momentary risk for BE, as engaging in BE alleviates negative affect and reinforces the behavior. The eating disorder field’s capacity to identify moments of elevated negative affect, and thus BE risk, has exclusively relied on ecological momentary assessment (EMA). EMA involves the completion of surveys in real time on one’s smartphone to report behavioral, cognitive, and emotional symptoms throughout the day. Although EMA provides ecologically valid information, EMA surveys are often delivered only 5-6 times per day, involve self-report of affect intensity only, and are unable to assess affect-related physiological arousal. Wearable, psychophysiological sensors that measure markers of affect arousal including heart rate, heart rate variability, and electrodermal activity, may augment EMA surveys to improve accurate real-time prediction of BE. These sensors can objectively and continuously measure biomarkers of nervous system arousal that coincide with affect, thus allowing them to measure affective trajectories on a continuous timescale, detect changes in negative affect before the individual is consciously aware of them, and reduce user burden to improve data completeness. However, it is unknown whether sensor features can distinguish between positive and negative affect states, given that physiological arousal may occur during both negative and positive affect states. OBJECTIVE The aims of the present study are: 1) test the hypothesis that sensor features will distinguish positive and negative affect states in individuals with BE with > 60% accuracy and 2) test the hypothesis that a machine learning algorithm using sensor data and EMA-reported negative affect to predict the occurrence of BE will predict BE with greater accuracy than an algorithm using EMA-reported negative affect alone. METHODS This study will recruit 30 individuals with BE who will wear Fitbit Sense 2 wristbands to passively measure heart rate and electrodermal activity and report affect and BE on EMA surveys for four weeks. Machine learning algorithms will be developed using sensor data to distinguish instances of high positive and high negative affect (aim 1) and to predict engagement in BE (aim 2). RESULTS This project will be funded from November 2022-October 2024. Recruitment efforts will be conducted from January 2023 through March 2024. Data collection is anticipated to be completed in May 2024. CONCLUSIONS The present study will provide new insight into the relationship between negative affect and BE by integrating wearable sensor data to measure affective arousal. Findings from this study will set the stage for future development of more effective digital ecological momentary interventions for BE.

OBJECTIVE. Fear of weight gain (FOWG) is increasingly implicated in the maintenance of binge-spectrum eating disorders (EDs; e.g., bulimia nervosa (BN), binge eating disorder (BED)) through the pathway of increased dietary restriction. However, particularly in binge-spectrum EDs, research is nascent and based on retrospective self-report. To improve treatment outcomes, it is critical to better understand the momentary relations between FOWG and dietary restriction. METHOD. Sixty-seven adults with binge spectrum EDs completed a 7–14-day ecological momentary assessment protocol that included items regarding FOWG, ED behaviors, and types of dietary restriction (e.g., attempted restraint vs actual restriction) several times per day. Multilevel models were used to evaluate reciprocal associations between FOWG and dietary restriction, and to evaluate the indirect of effects of dietary restriction on the relation between FOWG and binge eating. RESULTS. While main effects were not statistically significant, ED presentation significantly moderated the association between increases in FOWG at time1 and both attempted and actual avoidance of enjoyable foods at time2 such that those with BN-spectrum EDs were more likely to avoid enjoyable foods following increased FOWG compared to those with BED-spectrum EDs. Engagement in restriction at time1 was not associated with decreased FOWG at time2. DISCUSSION. Prospective associations between FOWG and restriction suggest that individuals with BN may be more likely to restrict their eating following increased FOWG. These findings suggest FOWG may be an important target for future treatments.

PURPOSE: Maladaptive exercise (i.e., exercise that is either driven or compensatory) is thought to momentarily down-regulate elevated fear of weight gain (FOWG). However, little research has examined associations between FOWG and exercise, and no research has measured FOWG at a momentary level or considered exercise type (i.e., maladaptive vs. adaptive). Thus, we examined both within- and between-subject associations between FOWG and exercise among individuals with transdiagnostic binge eating. METHODS: We recruited treatment-seeking adults (N = 58, 82.9% female) to complete a 7–14-day ecological momentary assessment protocol which assessed levels of FOWG and exercise engagement and type. Mixed models and generalized estimating equations assessed within-subject associations, and linear regression assessed between-subject associations. RESULTS: There was no main effect of FOWG on exercise engagement at the next survey. However, unexpectedly, exercise type moderated this relationship such that the relationship between FOWG and exercise was strongest for episodes of adaptive exercise. Overall exercise frequency accounted for 10.4% of the variance in FOWG and exercise type explained an additional 1.7% of the variance in FOWG. CONCLUSION: The findings of the current study indicate that momentary levels of FOWG are associated with subsequent adaptive exercise episodes, while higher overall levels of maladaptive exercise were associated with higher levels of FOWG. Future treatments should place a greater emphasis on reducing the frequency of maladaptive exercise by providing strategies for reducing FOWG. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series analysis such as case studies.

The impact of homework completion on outcome from cognitive behavioral therapies (CBTs) for eating disorders (EDs) is unknown. We examined homework completion during two CBTs for bulimia-spectrum EDs and tested the associations among homework and treatment outcomes. After each session, therapists rated the quantity of self-monitoring completed (e.g. tracking food intake and ED symptoms), and degree of completion of the previous week's written (e.g. completing a worksheet) and behavioral (e.g. completing an at-home food exposure, regularly eating) homework on a Likert scale. On average, patients (

Purpose Loss of control eating (LOCE) is supported as a maladaptive regulation strategy for high negative affect (NA) and low positive affect (PA). Yet, little is known about the day-to-day activities outside of eating that may precipitate such changes in affect and impact risk for LOCE. The current ecological momentary assessment study sought to examine whether (1) low NA and high PA at a given survey would prospectively predict lower likelihood of a LOCE episode at the next survey, and (2) having recently engaged in various non-eating activities would be associated with changes in average NA and PA levels at the same survey. Methods Data collected from 66 participants with LOCE over 7–14 days were analyzed using generalized estimating equations. Results High NA but not low PA at a given survey prospectively predicted lower likelihood of a LOCE episode at the next survey. Having recently engaged in outdoor recreation and socializing was associated with lower than one’s usual NA and higher than one’s usual PA at the same survey, social media was associated with higher than one’s usual NA and lower than one’s usual PA, self-care was associated with higher than one’s usual PA, and napping was associated with lower than one’s usual PA. Conclusion Individuals may benefit from increasing the frequency of daily non-eating activities that reduce NA, since it appears to be a more salient predictor of LOCE than PA. Further research is needed to elucidate this LOCE maintenance model, particularly in regard to the role of PA. Level of evidence Level IV, multiple time series without intervention.

Recent studies have found increasing rates of overweight and obesity in bulimia nervosa (BN). However, the relationships between body mass index (BMI) and BN symptoms and other clinically relevant constructs are unknown. Participants (

Anhedonia is theorized as being relevant to binge eating spectrum disorders (BESDs) by palatable foods substituting the pleasure typically obtained from day-to-day activities. The current study examined whether anhedonia is associated with eating pathology at baseline and whether it predicts cognitive behavioral therapy (CBT) outcomes alone and when controlling for non-anhedonia depression symptoms. Ninety-three individuals from two randomized controlled trials completed the Eating Disorder Examination and Beck Depression Inventory-II at pre-, mid-, and post-treatment. Results showed that anhedonia was positively associated with global eating pathology at baseline, and larger pre- to mid-treatment anhedonia and non-anhedonia reductions predicted larger pre- to post-treatment global eating pathology reductions, though the anhedonia association was no longer significant when controlling for non-anhedonia depression. Anhedonia appears to be related to global eating pathology in CBT for BESDs, but not loss of control eating. Further research is needed to elucidate the relationship between anhedonia and BESDs.

Adjunctive mobile health (mHealth) technologies offer promise for improving treatment response to enhanced cognitive-behavior therapy (CBT-E) among individuals with binge-spectrum eating disorders, but research on the key "active" components of these technologies has been very limited. The present study will use a full factorial design to (1) evaluate the optimal combination of complexity of two commonly used mHealth components (i.e., self-monitoring and microinterventions) alongside CBT-E and (2) test whether the optimal complexity level of these interventions is moderated by baseline self-regulation. Secondary aims of the present study include evaluating target engagement associated with each level of these intervention components and quantifying the component interaction effects (i.e., partially additive, fully additive, or synergistic effects).Two hundred and sixty-four participants with binge-spectrum eating disorders will be randomized to six treatment conditions determined by the combination of self-monitoring condition (i.e., standard self-monitoring or skills monitoring) and microinterventions condition (i.e., no microinterventions, automated microinterventions, or just-in-time adaptive interventions) as an augmentation to 16 sessions of CBT-E. Treatment outcomes will be measured using the Eating Disorder Examination and compared by treatment condition using multilevel models.Results will clarify the "active" components in mHealth interventions for binge eating.The present study will provide critical insight into the efficacy of commonly used digital intervention components (i.e., skills monitoring and microinterventions) alongside CBT-E. Furthermore, results of this study may inform personalization of digital intervention intensity based on patient profiles of self-regulation.This study will examine the relative effectiveness of commonly used components of application-based interventions as an augmentation to cognitive-behavioral therapy for binge eating. Findings from this study will inform the development of an optimized digital intervention for individuals with binge eating.

OBJECTIVE Binge planning (BP; i.e., preparatory thoughts and actions to facilitate future binge-eating episodes) is hypothesized to distract individuals from negative affect and increase the salience of food. Thus, individuals who engage in BP may report greater positive eating expectancies (i.e., beliefs about the outcomes of eating) and hedonic hunger (i.e., desire to eat for pleasure), as BP may increase the likelihood of obtaining these expected outcomes; but empirical tests of this possibility are needed. METHOD Prior to starting treatment, adults (N = 86) with bulimia-spectrum eating disorders were assessed for engagement in BP and self-reported on eating expectancies and hedonic hunger. RESULTS Twenty-nine participants (33.7%) reported planning at least one binge-eating episode in the previous 28 days. Compared to individuals who did not report BP, individuals who reported BP had greater expectancies that eating would alleviate negative affect (t = -2.54, p = .013) and boredom (U = 503.50, p = .006). Groups did not differ on levels of hedonic hunger (t = -1.68, p = .096). DISCUSSION These findings suggest that BP status is linked to expectancies that eating will reduce negative affect. However, more data are needed to determine the temporal relationships among eating expectancies, hedonic hunger and BP. TRIAL REGISTRATION NUMBERS NCT02716831, NCT03673540.

Background Mindful awareness, willingness and values clarity have been examined as protective factors across a wide range of problems, including overweight/obesity. However, these variables have almost exclusively been examined at the trait-level. It is possible that these variables also fluctuate within individuals in daily life, and that these intraindividual fluctuations may in turn be related to food craving and dietary lapse. The current study used ecological momentary assessment (EMA) to examine the extent to which momentary mindful awareness, willingness, and values clarity varied within-person, and were associated with craving and likelihood of dietary lapse among weight-loss seeking individuals with overweight/obesity prior to starting a weight loss program. We also examined the extent to which craving was associated with dietary lapse. Methods Adults with overweight/obesity (N = 126) completed one week of EMA prior to enrolling in a randomized controlled trial of behavioral weight loss treatments. They responded to EMA questions assessing dietary lapses, craving, mindful awareness, willingness, and values clarity six-times per day. Results Mindful awareness, willingness, and values clarity demonstrated substantial within-person variability, and higher within-person mindful awareness, willingness, and values clarity were concurrently (but not prospectively) associated with lower craving and likelihood of dietary lapse. Higher craving was concurrently (but not prospectively) associated with higher likelihood of dietary lapse. Between-person, higher mindful awareness, willingness, and values clarity were associated with lower craving and likelihood of dietary lapse, and higher craving was associated with greater frequency of dietary lapses. Conclusion Mindful awareness, willingness, and values clarity vary substantially at the daily level, and may be important mechanisms to target to reduce craving and dietary lapses in the daily lives of individuals with overweight/obesity.

Body dissatisfaction (BD) is supported as a maintenance factor for eating disorders (EDs) characterized by binge eating (BE). Although it is traditionally conceptualized as a trait construct, ecological momentary assessment (EMA) studies have shown that it fluctuates within-day and that momentary elevations in BD prospectively predict near-time ED behaviors. However, less is known about the contextual factors that precipitate these fluctuations in BD. The current study thus sought to examine whether certain internal (i.e., negative affect, shape/weight-related cognitions) and environmental (i.e., attending social events, being exposed to thin-ideal media, spending time on social media) factors prospectively predict momentary elevations in BD in females with BE. Participants (n = 25) completed an EMA protocol over 14 days. Data on BD and internal and environmental factors were analyzed using generalized estimating equations. Results showed that (1) greater than one’s usual negative affect and shape/weight-related cognitions, and (2) spending time on social media prospectively predicted momentary elevations in BD. Interestingly, attending social events prospectively predicted momentary reductions in BD. These findings may have important implications for conceptualizing and managing BD to prevent ED behaviors. Level II, controlled trial without randomization.

Inhibitory control, the ability to inhibit one’s automatic responses to desirable stimuli, may be inadequately targeted in interventions for loss-of-control eating. Promising evidence has identified inhibitory control trainings (ICTs) as an avenue to target inhibitory control directly; however, effects of ICTs on real-world behavior are limited. Compared to typical computerized trainings, virtual reality presents several potential advantages that may address key shortcomings of traditional ICTs, i.e. poor approximation to everyday life. The present study utilized a 2x2 factorial design of treatment type (ICT vs sham) by treatment modality (VR vs standard computer) to examine 1) the feasibility and acceptability of six weeks of daily training; 2) the main and interactive effects of treatment type and modality on target engagement and efficacy (i.e., training compliance, change in LOC eating episodes, inhibitory control, and implicit liking of foods). Participants (N = 35) with ≥ 1x/weekly LOC eating were assigned to one of four conditions and completed ICTs daily for six weeks. The treatment was feasible and acceptable, which was supported by high retention and compliance across time and condition. Although completing daily trainings across treatment types and modalities was associated with large decreases in LOC, there were no significant effects of either treatment type or modality, nor a significant interaction effect, on LOC or mechanistic variables. The mechanism driving overall improvements in LOC may be increased goal salience; future research should test whether goal salience interventions may be an effective and highly disseminable treatment option for LOC eating.

The relationship of dietary restraint in increasing risk for binge eating among individuals with binge-spectrum eating disorders (B-EDs) is well established. However, previous research has not yet identified whether these individuals exhibit heterogeneous profiles of dietary restraint and whether these profiles are associated with differences in eating pathology.Individuals with B-EDs (N = 290) completed the Eating Disorder Examination. Latent profile analysis was conducted on dietary restraint frequency data, including restriction of overall amount of food consumed, avoidance of eating, desire for an empty stomach, food avoidance, and dietary rules. Identified latent profiles were compared on binge eating frequency, compensatory behaviors frequency, and ED pathology using the three-step procedure.A four-class model of dietary restraint best fit the data. Classes significantly differed in frequency of compensatory behaviors (F[3, 286] = 31.01, p .001), EDE Eating Concern (F[3, 286] = 14.36, p .001), EDE Shape Concern (F[3, 286] = 7.06, p .001), EDE Weight Concern (F[3, 286] = 6.83, p .001), and ED Pathology (F[3, 286] = 12.86, p .001), but did not differ in frequency of objective (F[3, 286] = 2.45, p = .06) or subjective binge episodes (F[3, 286] = 1.87, p = .14).Individuals with B-EDs exhibit distinct profiles of dietary restraint, which are associated with frequency of compensatory behaviors and severity of ED pathology.Individuals with binge-spectrum eating disorders have different patterns of restrictive eating symptoms. These profiles of restrictive eating behaviors are associated with differences in severity of compensatory behaviors and cognitive eating disorder symptoms, like shape and weight dissatisfaction. Understanding the relationships between profiles of restrictive eating behaviors and other eating disorder symptoms may allow for personalization of treatment and improvements in treatment efficacy.

Objective Although existing research supports the efficacy of mindfulness- and acceptance-based treatments (MABTs) for eating disorders (EDs), few studies have directly compared outcomes from MABTs to standard CBT. Method Participants (N = 44), treatment-seeking adults with bulimia-spectrum EDs, were screened for eligibility, consented, and randomized to receive 20 sessions of outpatient, individual CBT or MABT treatment. Treatment outcomes (binge eating and compensatory behavior episodes, global ED severity, depressive symptoms, quality of life, emotional awareness/clarity, distress tolerance, values-based decision-making, and emotion modulation) were measured at pre-treatment, post-treatment, and 6-month follow up. Data on feasibility and acceptability are also presented. Results Treatment and assessment retention rates were comparable between MABT and CBT (p range = .51-.73) and between-group differences on acceptability measures were very small (d range = 0.03-0.19). Both conditions produced notable and generally comparable changes in most treatment outcomes at post-treatment (within group d range = 0.06-1.77). Discussion The MABT and CBT conditions demonstrated comparable degrees of feasibility, acceptability, and symptom improvement, suggesting that MABTs warrant further evaluation as ED treatments.

OBJECTIVE: Existing screening tools are inadequate in differentiating binge eating from normative overeating in treatment-seeking individuals with overweight or obesity, as these individuals tend to overendorse loss-of-control (LOC; the hallmark characteristic of binge eating) on self-report measures. In order for treatment centers to efficiently and accurately identify individuals who would benefit from specialized treatment, it is critical to develop effective brief screening tools. This study examined the sensitivity and specificity of a self-report screener designed to be used by an outpatient treatment center on a large scale. METHODS: Participants were treatment-seeking individuals (N = 364) with overweight or obesity who were administered the screener and who completed a subsequent interview assessing for LOC and binge eating. RESULTS: Discriminant analyses revealed that the screener achieved 77.6% sensitivity and 77.0% specificity in predicting clinician-assessed LOC and 75.2% sensitivity and 74.1% specificity in predicting “full-threshold” binge eating (i.e., ≥12 objectively large binge-eating episodes within the past 3 months). Post hoc analyses indicated that male participants were more likely to be misclassified with the screener. CONCLUSIONS: The self-report screener demonstrated satisfactory predictive ability, which is notable given the challenges of discriminating between LOC and normative overeating. However, room for improvement remains. In particular, the inclusion of additional screener items that more fully capture the binge-eating experience in males is warranted.

PURPOSE: Black individuals are at risk for developing eating disorders (EDs), while also facing an increased mental health burden as a marginalized group. However, few studies have examined whether treatment-seeking Black individuals with EDs present with different symptom profiles than White individuals. This study sought to characterize baseline ED symptomatology in Black participants with bulimia nervosa spectrum or binge eating disorder spectrum pathology compared to White participants in a treatment-seeking sample. METHODS: The sample consisted of 33 Black participants and 126 White participants who participated in a clinical trial at a mid-Atlantic University from 2015 to 2020. Data was analyzed using chi-square and independent samples t-tests. RESULTS: Black participants were much less likely to engage in self-induced vomiting, despite being just as likely to meet criteria for a bulimia nervosa spectrum diagnosis and having similar rates of binge-eating and distress towards body image concerns. Black participants were more likely to experience obesity but maintained similar levels of body image concerns as White participants. CONCLUSION: Given the evidence that Black participants often are under-diagnosed, particularly with bulimia nervosa spectrum disorders, these results could suggest that weight biases and/or expectations that patients with bulimia nervosa spectrum disorders will primarily present with self-induced vomiting could be contributing to these diagnostic errors. LEVEL OF EVIDENCE: Level I, randomized controlled trials

The current study aimed to examine the relationships between impulsivity, dietary restraint, and binge eating frequency in individuals with binge-spectrum eating disorders. Secondary data analysis was conducted on baseline data from three ongoing or recently completed clinical trials. 148 participants diagnosed with a DSM-5 eating disorder characterized by binge eating were administered a clinical interview to assess dietary restraint and binge eating frequency and completed a self-report measure of trait impulsivity. Mediation analyses found that increased dietary restraint mediated the relationship between higher impulsivity, particularly greater positive urgency and sensation-seeking, and more frequent binge eating episodes. While more research using momentary assessment methods is necessary to confirm our findings, results from the current study call attention to the potential role of dietary restraint in the impulsivity-binge eating relationship for individuals with binge-spectrum eating disorders. Level V descriptive study.

COVID-19 has been shown to detrimentally affect eating disorder symptoms, including increased dietary restriction and increased binge eating. However, research in this area is thus far limited. Additionally, as a result of the pandemic, many eating disorder treatments have converted to tele-health platforms, however, little is known about patient perceptions of this modality. The aim of the present, exploratory study was to qualitatively examine: (1) The impact of COVID-19 on binge eating spectrum disorder symptoms (2) Patient perceptions of tele-therapy, and (3) Ways to address COVID-19 in eating disorder treatment. Data were collected through one-on-one, semi-structured interviews (N = 11), conducted as part of a mid-program assessment for those undergoing individual, outpatient therapy for binge eating spectrum disorders. After thematic analysis, it was identified that patients reported both symptom deterioration and improvement during COVID-19. Factors surrounding social distancing and stay-at-home measures were found to both improve and worsen symptoms for different patients. Further, patients reported positive perceptions of tele-therapy, particularly appreciating the convenience of this modality. Finally, patients provided variable feedback on the incorporation of COVID-related concerns into their eating disorder treatment, with some participants wishing for this inclusion, and others viewing COVID-19 and their eating disorder as separate issues. Findings from the present study preliminarily identify ways in which binge eating spectrum disorder symptoms may have improved due to COVID-19 and indicate positive patient perceptions of tele-therapy. Our results may be used to inform the adaptation of future eating disorder treatment during COVID-19.

Cognitive Behavior Therapy (CBT) for bulimia nervosa (BN) requires patient skill utilization (use of treatment skills) and skill acquisition (successful skill use) for symptom improvement. Treatment outcomes are unsatisfactory, possibly due to poor skill acquisition and utilization by post-treatment. Just-in-time adaptive interventions (JITAIs), momentary interventions delivered at opportunities for skill practice, may improve skill acquisition and utilization. Participants ( N = 56 individuals with bulimia-spectrum eating disorders) completed electronic self-monitoring in CBT+ and received JITAIs or no JITAIs alongside 16 sessions of CBT. Feasibility, acceptability, target engagement, and treatment outcomes were evaluated. JITAIs demonstrated feasibility and acceptability. Treatment outcomes and target engagement did not differ between conditions. The lack of group differences in target engagement and treatment outcomes may be explained by skill use self-monitoring promoting skill utilization and acquisition or low statistical power. Our findings suggest that JITAIs are feasible and acceptable during CBT for BN and warrant additional study.

Ecological momentary assessment (EMA) studies preliminarily support the transactional model of emotion regulation in eating disorders, such that heightened stress appraisal (i.e., the cognitive evaluation of an event’s demands) results in increased negative affect (NA) and subsequent binge eating (BE). However, the temporal relationships between these variables and the magnitude of stress appraisal that is clinically significant require clarification. The current study aimed to extend previous research by (1) examining the temporal relationship between stress appraisal, changes in NA, and BE using three timepoints, (2) exploring what magnitude of momentary stress appraisal results in clinically significant increases in NA and BE, and (3) characterizing what stressors are associated with clinically significant stress appraisal. 37 adult females completed an EMA protocol assessing momentary stressors, stress appraisal, NA, and BE over 2 week duration. Multilevel mediation models were used to test the study aims. Momentary increases in stress appraisal significantly predicted binge eating through increases in NA. Stress appraisal ratings of 0.50 SD higher relative to one’s average stress appraisal began to significantly predict the likelihood of BE through increases in NA, and the likelihood of BE occurrence increased with every 0.25 increments in momentary stress appraisal. Work/school stressors and interpersonal stressors were the most commonly endorsed stressors of clinically significant stress appraisal. The current study supported the transactional model of emotion dysregulation in a binge eating sample and supports the use of momentary interventions at times of clinically significant stress appraisal to reduce BE risk. Level II, controlled trial without randomization.

Rumination syndrome (RS) is often treated in medical settings with 1–2 sessions of diaphragmatic breathing to target reflexive abdominal wall contraction in response to conditioned cues (e.g., food). However, many patients remain symptomatic and require additional behavioral interventions. In an attempt to augment diaphragmatic breathing with additional interventions, we tested the proof-of-concept of a comprehensive Cognitive-Behavioral Therapy (CBT) for RS. In an uncontrolled trial, adults with RS completed a 5–8 session CBT protocol, delivered by one of two psychology behavioral health providers. CBT included two main phases: awareness training and diaphragmatic breathing (Phase 1) and modularized interventions chosen by the therapist and patient to target secondary maintenance mechanisms (Phase 2). At pre-treatment, post-treatment, and 3-month follow-up, participants completed a semi-structured interview on RS symptoms with an independent evaluator. Of 10 eligible individuals (ages 20–67 years, 50% female) offered treatment, all 10 initiated treatment and eight completed it. All participants endorsed high treatment credibility at Session 1. Permutation-based repeated measures ANOVA showed participants achieved large reductions in regurgitations across treatment [F(1,7) = 17.7, p = .007, η p 2 = .69]. Although participants reduced regurgitations with diaphragmatic breathing during Phase 1, addition of other CBT strategies in Phase 2 produced further large reductions [F(1,7) = 6.3, p = .04, η p 2 = .47]. Of eight treatment completers, treatment gains were maintained at 3-month follow-up for n = 6. Findings provide evidence of feasibility, acceptability, and proof-of-concept for a comprehensive CBT for RS that includes interventions in addition to diaphragmatic breathing to target secondary maintenance mechanisms. Randomized controlled trials are needed.

Objective Although current treatments are effective for some patients with eating disorders, a large number of patients remain partially or fully symptomatic post-treatment. This may be related to poor utilization of treatment skills outside of the therapy office. Smartphone applications that can detect and intervene during moments of need could facilitate such skill use between sessions. Method Individuals (N = 16) participated in a small pilot open trial where they received 21 sessions of in-person Integrative Cognitive-Affective Therapy (ICAT) therapy an app (iCAT+) that delivers ecological momentary interventions (EMI) in response to user-entered data. Data were collected on the feasibility and acceptability of this treatment approach and on preliminary indicators of treatment outcomes. Results Participants found iCAT+ as a treatment augmentation acceptable and indicated it had clinical utility as an adjunct to in-person therapy, although analyses indicated poor compliance with data entry needed to trigger EMI delivery. This suggests that long-term use of EMI requiring ongoing data entry is infeasible. Conclusions We describe lessons learned from our initial pilot trial and future directions for the development of impactful EMI systems that can be used to augment in-person therapies.

A major contributor to the obesity epidemic is the overconsumption of high-calorie foods, which is partly governed by inhibitory control, that is, the ability to override pre-prepotent impulses and drives. Computerized inhibitory control trainings (ICTs) have demonstrated qualified success at affecting real-world health behaviors, and at improving weight loss, particularly when repeated frequently over an extended duration. It has been proposed that gamification (i.e., incorporating game-like elements such as a storyline, sounds, graphics, and rewards) might enhance participant interest and thus training compliance. Previous findings from a mostly female sample did support this hypothesis; however, it might be expected that the effects of gamification differ by gender such that men, who appear more motivated by gaming elements, stand to benefit more from gamification. The present study evaluated whether gender moderated the effect of a gamified ICT on weight loss. Seventy-six overweight individuals received a no-sugar-added dietary prescription and were randomized to 42 daily and 2 weekly ICTs focused on sweet foods that were either gamified or nongamified. Results supported the hypothesis that gamification elements had a positive effect on weight loss for men and not women (p = .03). However, mechanistic hypotheses for the moderating effect (in terms of enjoyment, compliance, and improvements in inhibitory control) were generally not supported (p’s > .20). These results suggest that gamification of ICTs may boost weight loss outcomes for men and not women, but further research is needed to determine the specific mechanisms driving this effect and to arrive at gamification elements that enhance effects for both men and women.

Objective Rumination disorder (RD) is a feeding/eating disorder and disorder of gut-brain interaction characterized by repeated, effortless regurgitations. Diaphragmatic breathing is the most widely used treatment technique for RD, theoretically as a competing response to the habitual contraction of the abdominal wall. However, in light of diaphragmatic breathing’s lack of effectiveness for some patients, we created a comprehensive treatment to test the incremental effect of behavioral exposure on symptom change. Method In a single-case experimental design, we present the treatment of a 27-year-old patient with a 9-year history of untreated RD. The patient completed a comprehensive six-session cognitive-behavioral treatment for RD, comprising a 1-week phase of self-monitoring regurgitations + psychoeducation (Phase A), a 6-week phase of diaphragmatic breathing (+ identification of secondary maintenance mechanisms) (Phase B), and a 3-week phase of diaphragmatic breathing + behavioral exposure (Phase C). We compared change in daily symptom data between Phases B and C, and also report 20-month follow-up data. Results The patient’s daily regurgitation frequency did not change during Phase B (diaphragmatic breathing alone), even with the elimination of foods that had become associated with regurgitations. However, she achieved a significant reduction in regurgitations during Phase C, with symptom remission extending to 20-month follow-up. Phase C included purposefully breaking learned associations with food stimuli using behavioral exposure. Conclusions Our data suggest that when diaphragmatic breathing alone is not effective in reducing symptoms, further cognitive and behavioral techniques like behavioral exposure can augment the effect of diaphragmatic breathing on symptom reduction.

Outcomes from cognitive behavioral therapy (CBT) for bulimia nervosa (BN) and binge-eating disorder (BED) are suboptimal. One potential explanation is that CBT fails to adequately target inhibitory control (i.e., the ability to withhold an automatic response), which is a key maintenance factor for binge eating. Computerized inhibitory control training (ICT) is a promising method for improving inhibitory control but is relatively untested in BN/BED. The present study will evaluate a computer-based ICT as an adjunct to CBT for BN/BED. Participants with BN (n = 30) or BED (n = 30) will be randomized to 12 weeks of either CBT + ICT or CBT + a sham training. Trainings will be completed daily for 4 weeks and weekly for 8 weeks. Primary aims include the following: (a) confirm target engagement (evaluate whether ICT improves inhibitory control), (b) test target validation (evaluate whether improvements in inhibitory control are associated with improvements in binge eating), and (c) evaluate the incremental efficacy of ICT on binge eating. Secondary aims include the following: (a) evaluate ICT feasibility and acceptability and (b) assess the moderating effects of approach tendencies on highly palatable food, dietary restraint, and diagnosis. Data will be used to shape a fully powered clinical trial designed to assess efficacy and dose-response effects of ICT for BN/BED.

Objective Affect regulation, eating expectancies, and attention toward food-related cues are interrelated constructs that have been implicated in the maintenance of binge eating. While these processes show considerable temporal variability, the momentary associations between these domains have not been elucidated. This study examined a model that posited momentary fluctuations in affect, eating expectancies, and attention bias (AB) would interact to predict subsequent binge eating. Method Forty women who endorsed recurrent binge eating completed a 10-day ecological momentary assessment protocol with ambulatory measures of AB (i.e., dot-probe task with palatable food and neutral cues) and self-report assessments of positive and negative affect, eating expectancies (i.e., the belief that eating would improve one's mood), and binge-eating symptoms. Results Generalized linear mixed models indicated higher momentary AB toward palatable food was associated with increased risk of subsequent binge eating, and a two-way interaction showed that moments of higher eating expectancies and negative affect were associated with increased likelihood of subsequent binge eating. Also, a three-way interaction emerged, in that the association between eating expectancies and subsequent binge eating was strongest at lower levels of positive affect and higher AB. Discussion Together, findings partially supported hypotheses and demonstrate meaningful within-person fluctuations in AB that precede binge eating. Further, results demonstrate that the momentary influence of eating expectancies on binge eating depends on both affective state and attentional processes.

BACKGROUND Dietary restraint is a key factor that maintains engagement in binge eating among individuals with binge eating disorder (BED) and bulimia nervosa (BN). Reducing dietary restraint is a key mechanism of change in cognitive-behavioral therapy (CBT) for BN and BED. However, many individuals who undergo CBT fail to adequately reduce dietary restraint during treatment, perhaps due to difficulty utilizing treatment skills to reduce dietary restraint as they go about their daily life. The SenseSupport system, a novel just-in-time, adaptive intervention (JITAI) system that utilizes continuous glucose monitoring to detect periods of dietary restraint, may improve upon CBT to reduce dietary restraint during treatment by providing real-time interventions. OBJECTIVE The present article describes the development and initial evaluation of SenseSupport. We present feasibility, acceptability, target engagement, and initial treatment outcomes data from a small trial utilizing an ABAB design (in which JITAIs were turned on for two weeks and then turned off for two weeks throughout treatment). METHODS Participants (N = 30) were individuals with BED or BN engaging in at least three episodes of 5+ hours without eating per week at baseline. Participants received 12 sessions of CBT and wore continuous glucose monitors to detect eating behaviors and inform delivery of JITAIs. Participants completed four assessments and reported eating disorder behaviors, dietary restraint, and barriers to app use weekly throughout treatment. RESULTS Retention was high (83% at post-treatment). However, rates of CGM data collection were low (67.3% of expected glucose data was collected) and therapists and participants reported frequent app-related issues. Participants reported that the SenseSupport system was comfortable, minimally disruptive, and easy to use. The only form of dietary restraint that decreased significantly more rapidly during JITAIs-On periods relative to JITAIs-Off periods was desire for an empty stomach (t = 1.69, p = .049, d = 0.25), although there was also a trend-level greater decrease in overall restraint during JITAs-on periods compared to JITAIs-Off periods (t = 1.60, p = .06, d = 0.24). There was no significant difference in change in frequency of binge eating during JITAIs-On periods compared to JITAIs-Off periods (p = .23). Participants demonstrated clinically significant, large decreases in binge eating (t = 10.36, p = CONCLUSIONS The present study describes the successful development and implementation of the first intervention system combining passive continuous glucose monitors and JITAIs as an augmentation to CBT for binge-spectrum eating disorders. Despite lower-than-anticipated collection of glucose data, the high acceptability and promising treatment outcomes suggest the SenseSupport system warrants additional study in future fully powered clinical trials. CLINICALTRIAL Clinicaltrials.gov identifier NCT04126694.

Sensor technologies offer exciting potential to objectively measure psychopathological correlates of eating pathology and eating disorder (ED) research utilizing sensors has rapidly proliferated in the past several years. The aims of the present review are: (1) characterize the types of sensors that have been utilized in ED research, (2) identify the psychopathological factors relevant to EDs that have been assessed using sensors, (3) describe the data supporting the validity and reliability of these sensors, (4) discuss limitations associated with these sensors, and (5) identify gaps that persist within the ED literature with regard to use of sensor technologies.A systematic search was conducted of PubMed, PsycINFO, Web of Science, ProQuest, and "gray" literature sources. Eligible publications were empirical studies that utilized sensors to measure at least one psychological variable among clinical ED populations.Sensors have been utilized with ED samples to measure eating behaviors, physical activity, sleep, autonomic nervous system activity, eyeblink startle response, visual attention, and visual-haptic object integration. The reliability and validity of these sensors varies widely and there are a number of significant gaps that remain in the literature with regard to the types of sensors utilized, context in which sensors have been used, and populations studied.The existing literature utilizing sensors within ED research largely support the feasibility and acceptability of these tools. Sensors should continue to be utilized within the field, with a specific focus on examining the reliability and validity of these tools within ED samples and increasing the diversity of samples studied.Sensor technologies, such as those included in modern smartwatches, offer new opportunities to measure factors that may maintain or contribute to symptoms of eating disorders. This article describes the types of sensors that have been used in eating disorders research, challenges that may arise in using these sensors, and discusses new applications of these sensors that may be pursued in future research.

Behavioral treatments for psychological disorders characterized by reward-driven maladaptive behaviors (e.g., substance use disorder, eating disorders, behavioral addictions) primarily seek to reduce hyper-reward response to disorder-specific stimuli. Suboptimal outcomes for these treatments highlight the need to also target hypo-reward response to day-to-day life activities. The present study sought to conduct an initial test of a novel behavioral treatment, Reward Re-Training (RRT) to target hyper- and hypo-reward response in individuals with binge eating. Individuals with binge eating (N = 23) were randomly assigned to either 10 weeks of outpatient, group-based RRT treatment or a waitlist control. RRT was found to be feasible and acceptable, demonstrated large impacts on both hypo- and hyper-reward response (measured by self-report (pre-to post-treatment η

Specific characteristics of sleep (e.g., duration, quality, and fatigue) are positively associated with (ED) behaviors, specifically binge eating (BE) potentially through decreased self-regulation and increased appetite. However, prior work has been largely cross-sectional and has not examined temporal relationships between sleep characteristics and next-day ED behaviors. Thus, the present study examined daily relationships between sleep and ED behaviors among individuals with binge-spectrum EDs.Participants (N = 96) completed 7 daily ecological momentary assessment (EMA) surveys over 7-14 days; morning surveys assessed sleep characteristics and 6 randomly timed surveys each day captured ED behaviors. Analyses examined within-subject and between-subject effects of sleep quality, duration, and fatigue on BE, compensatory purging behaviors, and maladaptive exercise.Within-subject sleep quality was significantly negatively associated with engagement in maladaptive exercise later that day. Additionally, between-subject sleep duration was significantly negatively associated with engagement in compensatory purging behaviors.Within- and between-subjects associations between sleep quality and duration and compensatory behavior engagement indicate that sleep plays an important role in ED behaviors. Future research should incorporate sensor-based measurement of sleep and examine how specific facets of sleep impact BE and treatment response.Level II: Evidence obtained from controlled trial without randomization.

Although altered reward processing is proposed to play a key role in obesity maintenance, the role of food enjoyment and enjoyment of non-food naturally rewarding activities ("non-food enjoyment") in obesity maintenance remains unknown. This study examined how food and non-food enjoyment were associated with baseline body mass index (BMI) and weight loss (WL) following year-long behavioral WL treatment.At baseline, participants (MEMA and retrospective food/non-food enjoyment measures had modest concordance, providing preliminary psychometric support for the EMA measures. Partially consistent with hypotheses, greater EMA food enjoyment was associated with lower BMI (B = -1.03, p = .01) and with greater WL, though the latter association was not statistically significant (B = 1.15, p = .07). Exploratory analyses suggested that race was associated with food enjoyment (non-White participants had greater food enjoyment than White participants, d = 0.81, p = .005), and that race may have affected associations between food enjoyment and weight outcomes. Associations between non-food enjoyment and weight outcomes were small and nonsignificant (ps .93).Results suggest enjoyment from food, but not from non-food domains, is associated with weight outcomes.