An empirical evaluation of the diagnostic threshold between full-threshold and sub-threshold bulimia nervosa

Binge-Spectrum Eating Disorders, Mood, and Food Insecurity in Young Adults With Obesity

BACKGROUND

Disordered eating is common but underrecognized in people with obesity and the relationship of food insecurity, mood, and binge-spectrum eating disorders has not been well addressed in samples with higher weight. Young adults are particularly vulnerable to developing disordered eating.

AIM

The purpose of this study was to compare the prevalence of food insecurity, depressive symptoms, anxiety, and loneliness among young adults (aged 18-35 years) who screened positive for binge-spectrum eating disorders (i.e., binge eating disorder and bulimia nervosa), those with subthreshold forms of these disorders, and individuals who did not screen positive for these conditions.

METHOD

This was a cross-sectional study of young adults with a self-reported body mass index ≥30 kg/m2 from the United States who were recruited online. Participants (N = 1,331; M ± SD age = 28.0 ± 3.4 years; body mass index [BMI] = 36.5 ± 6.2 kg/m2; 73.9% male; 56.3% White) completed surveys that evaluated disordered eating behaviors, food insecurity, mood, and lifestyle factors.

RESULTS

In the sample, 8.0% of participants screened positive for binge-spectrum eating disorder and 16.0% had probable subthreshold symptoms. Higher depressive symptoms (odds ratio [OR] = 1.11, 95% confidence interval [CI] = [1.03, 1.20], p = .01), perceived stress (OR = 1.13, 95% CI = [1.07, 1.19], p < .001), and food insecurity scores (OR = 1.12, 95% CI = [1.03, 1.21], p = .01) were associated with an increased likelihood of threshold binge-spectrum eating disorders.

CONCLUSION

People with disordered eating should also be evaluated for mood disorders and food insecurity and vice versa. Further research is needed to evaluate interventions that address food insecurity and mood disorders, which may help to decrease disordered eating.

Naturalistic symptom trajectories of atypical anorexia nervosa, anorexia nervosa, and bulimia nervosa in a prospective cohort study of United States college students

OBJECTIVE

Research on the natural course of symptoms of atypical anorexia nervosa (AN) relative to AN and bulimia nervosa (BN) is limited yet needed to inform nosology and improve understanding of atypical AN. This study aimed to 1) characterize trajectories of eating disorder and internalizing (anxiety, depression) symptoms in college students with and without a history of atypical AN, AN, and BN; and 2) compare sex and race/ethnicity distributions across groups.

METHOD

United States college students who participated in Spit for Science™, a prospective cohort study, were classified as having a history of atypical AN (n = 125), AN (n = 160), BN (n = 617), or as non-eating-disorder controls (NCs, n = 5876). Generalized and linear mixed-effects models assessed group differences in eating and internalizing symptom trajectories, and logistic regression compared groups on sex and race/ethnicity distributions.

RESULTS

Atypical AN participants demonstrated elevated eating disorder and internalizing symptoms compared to NCs during college, but less severe symptoms than AN and BN participants. Although all eating disorder groups showed signs of improvement in fasting and driven exercise, purging and depression remained elevated. Atypical AN participants showed increasing anxiety and stable binge-eating trajectories compared to AN and/or BN participants. The atypical AN group comprised significantly more people of color than the AN group.

DISCUSSION

Findings underscore that atypical AN is a severe psychiatric disorder. As atypical AN may present as less severe than AN and BN and disproportionately affects people of color, clinicians should be mindful of biases that could delay diagnosis and care.

PUBLIC SIGNIFICANCE

College students with histories of atypical AN, AN, and BN demonstrated improvements in fasting and driven exercise and stable purging and depression levels. Atypical AN students showed worsening anxiety and stable binge-eating trajectories compared to favorable changes among AN and BN students. A higher percentage of atypical AN (vs. AN) students were people of color. Findings may improve the detection of atypical AN in college students.

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.

Fear of weight gain during cognitive behavioral therapy for binge-spectrum eating disorders

PURPOSE

Fear of weight gain may play a central role in maintaining eating disorders (EDs), but research on the role of fear of weight gain during cognitive behavioral therapy (CBT-E) for binge-spectrum EDs is sparse. We examined changes in fear of weight gain during CBT-E for binge-spectrum EDs. We investigated whether fear of weight gain predicted loss of control (LOC) eating or weight change.

METHODS

Participants (N = 63) were adults of any gender recruited as part of a larger trial. Participants received 12 sessions of CBT-E, completed diagnostic assessments at pre-, mid-, and post-treatment, and completed brief surveys before sessions.

RESULTS

Fear of weight gain decreased across treatment, moderated by diagnosis. Those with bulimia nervosa spectrum EDs (BN-spectrum), compared to binge eating disorder, reported higher fear of weight gain at baseline and experienced a larger decrease in fear across treatment. Those reporting higher fear of weight gain at a given session experienced more frequent LOC episodes the following week. Fear of weight gain was not associated with session-by-session changes in BMI.

CONCLUSION

CBT-E results in decreases in fear of weight gain, but levels remain high at post-treatment, especially for those with BN-spectrum EDs. Future interventions should consider targeting fear of weight gain as a maintaining factor for LOC episodes TRIAL REGISTRATION: NCT04076553.

LEVEL OF EVIDENCE

Level II controlled trial without randomization.

Clinical correlates and prognostic impact of binge-eating symptoms in major depressive disorder

Binge-eating (BE) symptoms are relatively common in major depressive disorder (MDD), but their prognostic role is not fully understood. This study compared two groups of patients with MDD experiencing or not BE symptoms to ascertain differences in terms of clinical manifestations, presence of bipolar features, and antidepressant treatment outcomes. The study involved 482 outpatients collected within the Combining Medications to Enhance Depression Outcomes (CO-MED) trial, who were assessed with scales for depressive and hypomanic symptomatology, suicidality, comorbid mental disorders, and childhood traumas. BE symptoms were reported in 95 patients (20%). Patients with MDD experiencing BE symptoms were characterized by higher scores of negative self-outlook ( P = 0.0018), negative outlook of future ( P = 0.0014), irritability ( P = 0.0043), comorbid anxiety disorders (generalized anxiety disorder: P = 0.0006; panic disorder: P &lt; 0.0001; social phobia: P &lt; 0.0001), obsessive-compulsive disorder ( P = 0.0053), hypomanic symptoms (increased talkativeness: P = 0.0029; reduced need for sleep: P = 0.0171), and suicidality (suicidal propensity: P = 0.0013; suicidal risk: P = 0.0148; lifetime suicidal behavior: P = 0.0052). BE symptoms (OR = 2.02; 95% CI = 1.06-3.84) and depression severity (OR = 1.04; 95% CI = 1.00-1.08) were independently associated with lifetime attempted suicide. The presence of BE symptoms might indicate higher severity of depressive disorder. Suicidal risk is a major issue in these patients, whereas the association between BE and bipolar features needs further research.

Hyper-palatable food consumption during binge-eating episodes: A comparison of intake during binge eating and restricting

OBJECTIVE

The study aim was to elucidate the degree to which hyper-palatable foods (HPF) are consumed during binge episodes compared to restricting episodes, and to test the association between HPF intake during each episode and respective episode frequency.

METHOD

This study was a secondary analysis of data from a larger study on eating disorders. The present sample included adults (N = 147, 83% women) diagnosed with sub-threshold (41%) or full-threshold (59%) bulimia nervosa (BN). Foods consumed during binge and restricting episodes were assessed using the Eating Pathology Symptoms Inventory-Clinician Rated Version. A standardized definition of HPF developed previously was applied to foods consumed during binge and restricting episodes. A Wilcoxon matched-pairs signed-rank test was used to test the difference between total caloric intake from HPF (KcalHPF) and percentage of caloric intake from HPF (PercHPF) during binge episodes relative to restricting episodes. Four linear regression models tested HPF intake (KcalHPF and PercHPF) during both episode types (binge and restricting) as predictors of respective episode frequency.

RESULTS

There was a significant difference between median KcalHPF (1846.6 vs. 279.6; Z = -13.38, p < .001) and PercHPF during binge compared to restricting episodes (95% vs. 61%; Z = -7.35, p < .001). Regression analyses demonstrated that KcalHPF during binge episodes was significantly associated with binge episode frequency (B = 0.002; p < .001), but not PercHPF (p = .287).

DISCUSSION

Results suggest that HPF may be primarily consumed during binge episodes among individuals with BN, and may be associated with greater binge-eating frequency.

PUBLIC SIGNIFICANCE

Findings from the current study support an underlying assumption of theoretical models of binge eating, suggesting that highly rewarding, hyper-palatable foods (HPF), may constitute the vast majority of energy intake during binge-eating episodes. Additionally, a substantial amount of energy intake from HPF may occur during restricting episodes among people with bulimia nervosa. Greater HPF intake during binge eating may also be associated with binge-eating severity.

Disordered eating in sexual minority post-9/11 United States veterans

OBJECTIVE

It is well documented that sexual minority individuals are more likely to report disordered eating (DE) than those identifying as heterosexual. Although DE is prevalent in veterans, investigation of potential disparities in DE among sexual minority veterans is limited. This study examined rates of DE in post-9/11 United States (U.S.) veterans identifying as sexual minorities and explored their association with discrimination because of marginalized identities.

METHODS

A national sample of recently separated post-9/11 U.S. veterans were recruited. Women (N = 805; heterosexual [n = 656]; lesbian [n = 51]; bisexual [n = 98]) and men (N = 558; heterosexual [n = 540]; gay [n = 11]; bisexual [n = 7]) completed a survey assessing eating behaviors, mental health, and military experiences. Weighted correlational and regression analyses were conducted. Analyses in men were exploratory.

RESULTS

DE was prevalent across gender and sexual orientation identity groups. Women identifying as bisexual and men identifying as gay reported higher rates of DE and consequent impairment compared to veterans who identified as heterosexual. There were no differences in DE between heterosexual and lesbian female veterans, but lesbian women reported lower DE-related impairment. Experiencing any discrimination in the military was positively related to DE.

DISCUSSION

This study found evidence of disparities in DE among sexual minority U.S. military veterans. While the factors contributing to these differences, such as the role of discrimination, are not completely understood, DE is a health concern for sexual minority veterans and requires continued investigation.

PUBLIC SIGNIFICANCE

Sexual minority individuals experience disparities in disordered eating; yet, this has not been explored in military veterans. This study found that disordered eating is a significant health concerns for veteran women and men, especially among those identifying as sexual minorities. More research is needed to explore why these disparities exist, such as the role of minority stress, in order to address the unique healthcare needs of these veterans.

How Different Are Threshold and Other Specified Feeding and Eating Disorders? Comparing Severity and Treatment Outcome

Background

Other Specified Feeding and Eating Disorders (OSFED) are characterized by less frequent symptoms or symptoms that do not meet full criteria for another eating disorder. Despite its high prevalence, limited research has examined differences in severity and treatment outcome among patients with OSFED compared to threshold EDs [Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED)]. The purpose of the current study was to examine differences in clinical presentation and treatment outcome between a heterogenous group of patients with OSFED or threshold EDs.

Method

Patients with threshold EDs (AN = 42, BN = 50, BED = 14) or OSFED (n = 66) presenting for eating disorder treatment completed self-report questionnaires at intake and discharge to assess eating disorder symptoms, depression symptoms, impairment, and self-esteem.

Results

At intake, OSFED patients showed lower eating concerns compared to patients with BN, but similar levels compared to AN and BED. The OSFED group showed higher restraint symptoms compared to BED, and similar restraint to AN and BN. Global symptoms as well as shape and weight concerns were similar between OSFED and threshold ED groups. There were no differences between diagnostic groups in self-esteem, depression scores, or symptom change from intake to discharge.

Discussion

Our findings suggest that individuals with OSFED showed largely similar ED psychopathology and similar decreases in symptoms across treatment as individuals diagnosed with threshold EDs. Taken together, findings challenge the idea that OSFED is less severe and more resistant to treatment than threshold EDs.