Chewing and spitting out food as a compensatory behavior in patients with eating disorders

The relationship between non-purging compensatory behaviors, clinical severity, and treatment outcomes in adults with binge-spectrum eating disorders

Non-purging compensatory behaviors (NPCB; e.g. driven exercise, fasting, other extreme behaviors) are a subcategory of compensatory behaviors typically characterized as infrequent and less severe. Limited prior research has studied NPCB despite their increasing prevalence among adults with binge-spectrum eating disorders (B-ED). More research is needed to understand the types of NPCB present among B-ED and the association between NPCB, clinical severity, and treatment outcomes. Secondary analyses were conducted among 155 adults with B-ED in cognitive-behavioral (CBT)-based clinical trials. At baseline and post-treatment, clinical interviews of eating pathology assessed binge eating frequency, purging compensatory behavior frequency, and global eating pathology. The following NPCB were also assessed: driven exercise, 24-h fasting, 8+ waking hours of compensatory fasting, chewing and spitting, and other extreme weight control behaviors. Participants engaging in NPCB reported higher global eating pathology than those not engaging in NPCB. Frequency of chewing and spitting and 24-h fasting significantly decreased over treatment. Engagement in NPCB at baseline did not predict CBT outcomes. The current study highlights the prevalence and clinical severity of NPCB in B-ED but offers promising results regarding the potential for CBT to improve these behaviors. More research is needed on other extreme weight control behaviors reported qualitatively in our sample and on the maintenance of improvements in non-purging behaviors after CBT.

One size does not fit all: Exploring how the five-factor model facets predict disordered eating behaviours among adolescent and young adult males and females

There is a wealth of research that has highlighted the relationship between personality and eating disorders. It has been suggested that understanding how subclinical disordered eating behaviours are uniquely associated with personality can help to improve the conceptualization of individuals with eating disorders. This study aimed to explore how the facets of the Five-Factor Model (FFM) predicted restrictive eating, binge eating, purging, chewing and spitting, excessive exercising and muscle building among males and females. An online survey assessing disordered eating behaviours, FFM and general psychopathology was completed by 394 females and 167 males aged between 16 and 30 years. Simultaneous equations path models were systematically generated for each disordered eating behaviour to identify how the FFM facets, body dissatisfaction and age predicted behaviour. The results indicated that each of the six disordered behaviours were predicted by a unique pattern of thinking, feeling and behaving. Considerable differences between males and females were found for each path model, suggesting differences between males and females in the personality traits that drive disordered eating behaviours. It was concluded that it is important to take personality into account when treating males and females who engage in disordered eating behaviours.

Chew and spit (CHSP) in a large adolescent sample: prevalence, impact on health-related quality of life, and relation to other disordered eating features

A recent general population study of Chew and Spit (CHSP) behavior in adults found a 0.4% prevalence, predominantly in females. The current study explores this further by examining the same phenomenon in secondary-school aged adolescents. This study also explores the relationship between CHSP and other demographic and eating disorder (ED) features in 5111 adolescents (11-to-19 years of age) from 13 schools in New South Wales, Australia. Participants completed measures of ED symptoms and behaviors and change to impairment with two components: psychological distress (K-10) and health related quality of life (HRQoL; PedsQL). CHSP was found to have a 12.2% (95% CI 0.114, 0.132]) point-prevalence rate. Participants who indicated engaging in CHSP reported significantly higher levels of psychological distress (K-10) and lower HRQoL scores (PedsQL) compared to those that did not report CHSP. There was a dose-response relationship between CHSP frequency, psychological distress and HRQoL physical scores but not for HRQoL emotional and HRQoL social scores. Participants who reported regular CHSP were more likely to be female, younger, and to engage in compensatory behaviors such as purging. The high frequency of CHSP behavior in adolescents with disordered eating could suggest that CHSP should be considered in routine ED screening practices. Future studies may examine how to treat CHSP or investigate more focused treatment approaches, in order to target the behavior of CHSP more directly.

Chew and spit (CHSP) in bariatric patients: a case series

BACKGROUND

Studies into the disordered eating behaviour of chew and spit have alluded to several cohorts more likely to engage in the behaviour, one such group being bariatric surgery candidates and patients. Weight-loss surgery candidates have received little to no attention regarding engaging in chew and spit behaviour. Changes in pre- and post- surgery eating pathology related to chew and spit behaviour has yet to be explored and described in academic literature.

CASE PRESENTATION

The current study reports on three cases of individual women, aged 30, 35, and 62 respectively, who indicated engagement in chew and spit. All three cases underwent bariatric surgery (two underwent gastric bypass, one underwent vertical sleeve gastrectomy). Eating pathology-including chew and spit behaviour, anxiety and depression, and adherence to the Norwegian nutritional guidelines were examined pre-operatively and post-operatively (one and two-year follow-up). At baseline (pre-surgery), two participants reported that they engaged in chew and spit, compared to one patient post-surgery. All three cases reported that they, to at least some extent, adhered to dietary guidelines post-surgery. Subjective bingeing frequency appeared to be relatively low for all three cases, further declining in frequency at one-year follow-up. At baseline, one participant reported clinically significant depression and anxiety, with no clinically significant depression or anxiety reported at follow-ups in participants that chew and spit.

CONCLUSIONS

The current study provides a starting point for the exploration of chew and spit as a pathological symptom of disordered eating in bariatric patients. It highlights the need to further explore chew and spit before and after weight-loss surgery.

Chew and Spit (CHSP): An interpretative phenomenological analysis (IPA)

Chew and Spit (CHSP) is a prevalent disordered eating symptom and has been thought to be associated with a number of adverse effects. In the current study, 18 participants (>90% female, aged between 18 and 51) took part in answering questions about their experiences, struggles, concerns, methods of coping, and personal meaning of CHSP and how it has impacted their lives. Data collection and analysis were conducted in accordance with Interpretative Phenomenological Analysis (IPA) methodology. Findings revealed 7 primary themes of CHSP, which highlighted that CHSP may be: (1) associated with negative emotions - primarily shame; (2) exacerbated by stress and may be a mechanism to help regain control; (3) temporarily provides pleasure; (4) a distraction or form of escapism; (5) a self-soothing or coping mechanism; (6) addictive, ritualistic, and similar to other eating disorders in that it can become part of an individual's self-identity; and (7) adversely impacting psychological, physiological, and social health. Some of the identified superordinate themes were in line with previous studies hypotheses. However, overall the findings indicated that individuals who CHSP are often embroiled in what they may perceive as a struggle, with no specific, efficacious, approach to helping them control the behavior. Future studies should focus on the treatment of CHSP, including treatment of CHSP as a potential primary symptom of pathological eating. Moreover, the perceived implications of engaging in CHSP should be examined more closely, with clinicians screening for the behavior and carefully considering their approach when attempting to treat patients for CHSP.

Prevalence of chew and spit and its relation to other features of disordered eating in a community sample

BACKGROUND

Until recently, research into Chew and Spit (CHSP) behavior has predominantly focused on clinical samples, and little is known of its prevalence in the community. The current study aimed to bridge this gap by exploring CHSP features in a representative sample of the general population. We hypothesized that the point-prevalence of CHSP would be less than 1%; concurrent with other eating disorder symptomology, and associated with poorer health related quality of life (HRQoL).

METHODOLOGY

Using the 2016, respondent-based, South Australian Health Omnibus Survey (HOS), data were collected on 3047 participants aged ≥15 years old. HRQoL was assessed with the Short-Form health-questionnaire-v1 (SF-12).

RESULTS

CHSP point prevalence was 0.4% (95% CI .23 to .69%; n = 13), and was more prevalent in people with compensatory disordered eating behaviors. The median age of those with CHSP was 39, and both mental and physical HRQoL were reduced compared with the general population (Mdn: MHQoL = 49; HRQoL = 50), with MHQoL being significantly lower in those with symptoms of a clinically diagnosable ED and concurrently engaged in CHSP (z = -2.33, p = .020).

CONCLUSIONS

Due to the low prevalence of CHSP, the reliability of inferential statistics may increase the chance of Type II errors, therefore, future studies should use larger samples. Although CHSP is not "common" in a wider community sample, its prevalence appears to be similar to other ED associated symptoms.

Improving prediction of eating-related behavioral outcomes with zero-sensitive regression models

Objective

Outcome variables gauging the frequency of specific disordered eating behaviors (e.g., binge eating, vomiting) are common in the study of eating and health behaviors. The nature of such data presents several analytical challenges, which may be best addressed through the application of underutilized statistical approaches. The current study examined several approaches to predicting count-based behaviors, including zero-sensitive (i.e., zero-inflated and hurdle) regression models.

Method

Exploration of alternative models to predict eating-related behaviors occurred in two parts. In Part 1, participants (N = 524; 54% female) completed the Eating Disorder Examination-Questionnaire and Daily Stress Inventory. We considered the theoretical basis and practical utility of several alternative approaches for predicting the frequency of binge eating and compensatory behaviors, including ordinary least squares (OLS), logistic, Poisson, negative binomial, and zero-sensitive models. In Part 2, we completed Monte Carlo simulations comparing negative binomial, zero-inflated negative binomial, and negative binomial hurdle models to further explore when these models are most useful.

Results

Traditional OLS regression models were generally a poor fit for the data structure. Zero-sensitive models, which are not limited to traditional distribution assumptions, were preferable for predicting count-based outcomes. In the data presented, zero-sensitive models were useful in modeling behaviors that were relatively rare (laxative use and vomiting, 9.7% endorsed) along with those that were somewhat common (binge eating, 33.4% endorsed; driven exercise, 40.7% endorsed). Simulations indicated missing data, sample size, and the number of zeros may impact model fit.

Discussion

Zero-sensitive approaches hold promise for answering key questions about the presence and frequency of common eating-related behaviors and improving the specificity of relevant statistical models. Hurdle models may also be appropriate when theoretically justified.

Updates in the epidemiology of eating disorders in Asia and the Pacific

PURPOSE OF REVIEW

This review summarizes and contextualizes the recent epidemiologic data on eating disorders in the Asia and Pacific regions.

RECENT FINDINGS

Gaps in epidemiologic data on eating disorders from the Asia and Pacific regions stem, in part, from omission of eating disorder-specific assessments in large nationally representative cohort studies of mental disorders. Available data - often from clinical and school-going cohorts - support that the prevalence of both eating disorders and associated attitudes and behaviors in many Asian and Pacific regions studied may be comparable to those reported in Europe and North America. Moreover, the prevalence of eating disorders in some regions of Asia may be increasing. Some of the national and subnational regions with the highest annual percent increases in disability-adjusted life years per 100 000 caused by eating disorders over the past two decades are located in Asia.

SUMMARY

Notwithstanding sparse epidemiologic data concerning eating disorders in Asia and the Pacific, available evidence supports comparable prevalence to other global regions and that associated health burdens in some regions of Asia may be rising. This further supports that eating disorders are trans-national in distribution and challenges the previous understanding that they were primarily culture-bound to the Global North.

Chew and Spit (CHSP): a systematic review

BACKGROUND

This systematic review is an evaluation of the empirical literature relating to the disordered eating behaviour Chew and Spit (CHSP). Current theories postulate that CHSP is a symptom exhibited by individuals with recurrent binge eating and Bulimia Nervosa.

AIMS

The review aimed to identify and critically assess studies that have examined the distribution of CHSP behaviour, its relationship to eating disorders, its physical and psychosocial consequences and treatment.

METHODS

A systematic database search with broad inclusion criteria, dated to January 2016 was conducted. Data were extracted by two authors and papers appraised for quality using a modified Downs and Black Quality Index.

RESULTS

Nine studies met the inclusion criteria. All were of clinical samples and majority (n = 7) were of low quality. The pathological action of chewing food but not swallowing was reported more often in those with restrictive type eating disorders, such as Anorexia Nervosa, than binge eating type disorders. CHSP also was reported to be an indicator of overall severity of an eating disorder and to appear more often in younger individuals. No studies of treatment were found.

CONCLUSIONS

Conclusions were limited due to the low quality and small numbers of studies based on clinical samples only. Further research is needed to address gaps in knowledge regarding the physiological, psychological, social, socioeconomic impact and treatment for those engaging in CHSP.