NURTURE: development and pilot testing of a novel parenting intervention for mothers with histories of an eating disorder

Preventing eating disorders and disordered eating in genetically vulnerable, high-risk families

OBJECTIVE

To close the chasm between theory about families containing a parent with an eating disorders (EDs) history and lack of selective or indicated prevention programming for such families with an older child or adolescent who is, genetically, at high risk.

METHOD

A search of four major databases for January 2000 through September 2022 yielded no publications that (a) identified genetically high-risk families with offspring ages 10 through 18; (b) devised a prevention program for the family; and (c) evaluated program effects on risk/protective factors. To rectify this gap, research on three lines of family-based prevention is reviewed: (1) programs for adolescents at genetic risk for depression or anxiety; (2) the Stanford-Dresden project for adolescents at high risk for anorexia nervosa; and (3) Sadeh-Sharvit et al.'s work concerning the Parent-Based Prevention program for mothers with an EDs history and a child under age 5.

RESULTS

The significant challenges for innovative prevention programming should be addressed by experts in effective EDs, depression, and anxiety prevention, and in family-based treatment (FBT) for EDs, collaborating with people from genetically vulnerable families. Innovative programming should focus on robust risk factors for EDs, adaptive expression of non-specific risk factors (e.g., temperament), and strengthening family functioning.

DISCUSSION

The field is overdue for development of prevention programs designed for older children or adolescents who are at risk because a parent has an ED. Evidence-based prevention programs for EDs and for depression and anxiety, as well as parent-based prevention informed by FBT, provide a springboard for addressing this gap.

PUBLIC SIGNIFICANCE

The foundation of theory and research is available for stakeholders to develop prevention programming that closes the huge gap between theory and research about families that are genetically vulnerable for eating disorders versus the complete lack of prevention programming for such families that have an older child or adolescent at high risk.

If we build it, will they come? Commentary on "Preventing eating disorders and disordered eating in high-risk families"

Levine and Sadeh-Sharvit (2023) open the door to a logical and evidence-based targeted prevention strategy adapted from the field of depression. Their proposal is likely to benefit parents who are dealing with their own eating disorders and disordered eating while simultaneously breaking the cycle of risk inherent in the intergenerational transmission of eating disorders. The approach honors the wishes of parents who desperately want to buffer their children from the pain they experienced with their own suffering and provides hope for reducing environmental exposures that could augment any genetic risk that children of affected parents may hold.

Outcomes for infants whose mothers had an eating disorder in the perinatal period: A systematic review of the evidence

OBJECTIVE

To establish any health outcomes for infants to age one, associated with their mother having a diagnosis of an active eating disorder during pregnancy or the 12-month postnatal period.

METHOD

A qualitative systematic literature review of numerous databases (Medline, PsycINFO, CINAHL, Scopus, Cochrane Library, MedNar, PsycExtra, National Institute for Health and Care Excellence and Open Grey) was performed examining any infant health outcomes.

RESULTS

This resulted in 22 included studies (17 cohort, 3 cross-sectional, 1 case controlled and 1 mixed methods study). A range of adverse infant outcomes including poor birth, growth and interactional feeding outcomes were identified.

DISCUSSION

Antenatal identification and treatment for women with an eating disorder during the perinatal period and their infants are vital. Optimizing pregnancy nutrition, maternal eating disorder symptoms and feeding interactions appear particularly important.

Parental eating disorders: A systematic review of parenting attitudes, behaviours, and parent-child interactions

A substantial proportion of adults with eating disorders are parents. Studies suggest these parents may experience a range of parenting challenges, and their children may be at an increased risk for the development of eating disorders themselves. With parenting practices being one potential environmental mechanism for the intergenerational transmission of eating disorders, we systematically searched Scopus, Web of Science, PubMed, MEDLINE, PsychINFO, and PsychArticles for controlled studies in which parenting attitudes, behaviours, and parent-child interactions were examined for parents with and without probable eating disorders. 26,512 abstracts were screened, and 167 full-text manuscripts were retrieved, with 33 studies meeting the review inclusion criteria. Studies suggest that parents with eating disorders experience higher levels of parenting stress than control parents, and may on average be more intrusive, less sensitive, and provide less structuring/facilitation in non-feeding interactions with their children. These parents also appear, on average, to experience increased concern about their children's weight, and parent-child mealtime interactions may be problematic and characterised by high levels of conflict. Suggestions for future research are made with a view to enhancing understandings of the intergenerational transmission of eating disorders, which may lead to the identification of intervention targets for parents with eating disorders and their children.

An exploratory study on the intergenerational transmission of obesity and dieting proneness

PURPOSE

There is a paucity of research exploring individuals' memories of parental dieting behavior, engagement in "fat talk", or criticism of weight or eating behavior in childhood. This exploratory study utilized a community sample to further characterize the retrospective report of parenting dieting behavior.

METHODS

A total of 507 participants (78.1% females; 20.7% males; and 1.2% transgender) were recruited to participate in an online, self-administered survey.

RESULTS

Forty percent (216) of participants reported maternal dieting in their family of origin and 34% (182) reported maternal fat talk, 24% (120) reported paternal dieting, and 11% recalled paternal 'fat talk' (58). Subgroup analyses suggest that both male and female participants had greater odds of remembering maternal rather than paternal weight or shape criticism and encouragement to diet (OR = 58.1; and OR = 3.12; p < 0.0001 for male and female participants, respectively). Retrospective report of indirect parental behaviors (e.g. parental dieting) also appears to be associated with direct parental behaviors (e.g. encouraging children to diet). Additionally, participants who recalled maternal encouragement to diet reported a significantly higher adult BMI (β = 1.31, SE = 0.32, p < 0.0001).

CONCLUSION

Results provide preliminary evidence that a sizeable percentage of both adult male and female participants recalled that their parents engaged in fat talk and dieting. In addition, participants recalled parental criticism of their own weight or eating behaviors, which was associated with recall of parental dieting and fat talk.

LEVEL OF EVIDENCE

Level V, Descriptive Study.

Children of Parents with Eating Disorders

PURPOSE OF REVIEW

Our primary goal in this article is to review recent findings (from 2015 and on) concerning children of parents with eating disorders. This review addresses the question of whether the offspring of parents with past or present eating disorders have adverse outcomes. This update is timely and informative because recent research includes controlled studies and large cohort designs and earlier reviews relied on case report evidence.

RECENT FINDINGS

Despite substantial diversity in study design, sample size, and parental eating disorder definition, overall, existing research suggests that the children of parents with eating disorders exhibit compromised development: a greater risk of perinatal complications; a tendency toward extremes of growth at birth; greater problems in feeding and eating behaviors and greater incidence of eating disorder symptoms; more psychological and socioemotional difficulties; and more negative qualities to parent-child interactions. Data on children's cognitive outcomes is thus far inconsistent. Given the relatively high incidence of eating disorder history in individuals of childbearing age, research into its potential effects on children is necessary. However, the methodological shortcomings and a limited evidence base caution in drawing conclusions. Nevertheless, mental health services should address the possible problems that these children face and offer tailored programs.

Associations of parents' self, child, and other "fat talk" with child eating behaviors and weight

OBJECTIVE

Fat talk, negative communication about weight, is common in the media, peer groups, and families. Little is known about parental fat talk directed at oneself or others. This study examined associations between different forms of parental fat talk and child disordered eating behaviors and weight, and differences by child sex and age.

METHOD

Parents of preadolescents or adolescents (n = 581) reported fat talk about themselves (self-fat talk), others (obesity-fat talk), and their child (child-fat talk).

RESULTS

76.0% of parents reported regular self-fat talk in front of children, 51.5% reported obesity-fat talk, and 43.6% reported child-fat talk. Fat talk did not differ significantly between parents of preadolescents and adolescents but was more common with sons than daughters. Of the three forms of fat talk, only child-fat talk was associated with all child eating and weight variables (binge eating, overeating, secretive eating, and overweight/obesity); associations were strongest for adolescent girls. Child sex was associated with secretive eating and overweight/obesity.

CONCLUSIONS

Parents reported using different forms of fat talk frequently. Parent self- and obesity-fat talk were reported more frequently, but child-fat talk was the most strongly associated with children's eating and weight. Because of associations with disordered eating behaviors, intervening to reduce fat talk might contribute to improving pediatric disordered eating and weight-related interventions.

Parental reflective functioning among mothers with eating disorder symptomatology

OBJECTIVE

Reflective Functioning is a vital aspect of parental aptitude and its absence, especially in the presence of psychopathology, can impair attachment. This study sought to clarify the relationship of parental RF among mothers with eating disorder symptomatology.

METHOD

We assessed 59 mothers for ED symptomatology using the Eating Disorder Examination Questionnaire (EDE-Q) and RF through the Parental Reflective Functioning Questionnaire (PRFQ). Bivariate and multivariate analyses compared PRFQ subscales between symptomatic and asymptomatic mothers, using a clinical cutoff score of 4 on the EDE-Q subscales.

RESULTS

Greater weight and shape concerns were found to significantly predict higher RF (p=0.023; p=0.026).

DISCUSSION

This finding could indicate a similar pattern seen among individuals with bulimia nervosa; individuals have higher RF scores, although affect regulation may still be limited. More research is needed with a larger sample to define the relationship between ED symptomatology and RF and identify potential mediators and moderators.

Fathers and mothers with eating-disorder psychopathology: Associations with child eating-disorder behaviors

OBJECTIVE

A limited literature suggests an association between maternal eating disorders and child feeding difficulties, and notes maternal concern about inadvertently transmitting eating disorders. Thus, parents may be an important target for eating-disorder research to guide the development of clinical programs.

METHODS

The current study examined differences in child eating-disorder behaviors and parental feeding practices between a sample of parents (42 fathers, 130 mothers) exhibiting core features of anorexia nervosa, bulimia nervosa, binge-eating disorder, or purging disorder, and a matched sample of parents (n=172) reporting no eating-disorder characteristics.

RESULTS

Parents with eating-disorder psychopathology were significantly more likely than parents without eating-disorder characteristics to report child binge-eating and compulsive exercise. Parents with eating-disorder psychopathology reported greater perceived feeding responsibility, greater concern about their child's weight, and more monitoring of their child's eating than parents without eating-disorder characteristics; however, they did not differ significantly in restriction of their child's diet and pressure-to-eat. Child body mass index z-scores did not differ between parents with versus without eating-disorder characteristics.

CONCLUSION

Our findings suggest some important differences between parents with and without core eating-disorder psychopathology, which could augment clinical interventions for patients with eating disorders who are parents, or could guide pediatric eating-disorder prevention efforts. However, because our study was cross-sectional, findings could indicate increased awareness of or sensitivity to eating-disorder behaviors rather than a psychosocial cause of those behaviors. Longitudinal research and controlled trials examining prevention and intervention can clarify and address these clinical concerns.

Parent-based prevention program for the children of mothers with eating disorders: Feasibility and preliminary outcomes

The children of mothers with eating disorders are at high risk of feeding and eating problems and broader developmental difficulties. The Parent-Based Prevention (PBP) of eating disorders targets risk factors and facilitates behavioral change in parents to mitigate potentially negative outcomes of their children. This pre/post uncontrolled study evaluated the feasibility and preliminary outcomes of PBP. PBP was found to be a feasible intervention for mothers with eating disorders and their spouses, with satisfactory retention rates. A total of 16 intact families were assessed at three measurement points for parents' feeding practices, child outcomes, and maternal functioning. Both parents reported improved feeding practices as well as more positive perceptions of their children in comparison to baseline. These pilot findings suggest that PBP is linked with decreased risk of eating and mental problems among the offspring of mothers with eating disorders.

Obstetric and gynecologic problems associated with eating disorders

OBJECTIVE

This article summarizes the literature on obstetric and gynecologic complications associated with eating disorders.

METHOD

We performed a comprehensive search of the current literature on obstetric and gynecologic complications associated with eating disorders using PubMed. More recent randomized-controlled trials and larger data sets received priority. We also chose those that we felt would be the most relevant to providers.

RESULTS

Common obstetric and gynecologic complications for women with eating disorders include infertility, unplanned pregnancy, miscarriage, poor nutrition during pregnancy, having a baby with small head circumference, postpartum depression and anxiety, sexual dysfunction and complications in the treatment for gynecologic cancers. There are also unique associations by eating disorder diagnosis, such as earlier cessation of breastfeeding in anorexia nervosa; increased polycystic ovarian syndrome in bulimia nervosa; and complications of obesity as a result of binge eating disorder.

DISCUSSION

We focus on possible biological and psychosocial factors underpinning risk for poor obstetric and gynecological outcomes in eating disorders. Understanding these factors may improve both our understanding of the reproductive needs of women with eating disorders and their medical outcomes. We also highlight the importance of building multidisciplinary teams to provide comprehensive care to women with eating disorders during the reproductive years.