Treatment Outcomes and Trajectories of Change in Patients Attributing Their Eating Disorder Onset to Anti-obesity Messaging

Medical Nutrition Education for Health, Not Harm: BMI, Weight Stigma, Eating Disorders, and Social Determinants of Health

Effective nutrition training is fundamental to medical education. Current training is inadequate and can cause harm to students and patients alike; it leaves physicians unprepared to counsel on nutrition, places undue focus on weight and body mass index (BMI), can exacerbate anti-obesity bias, and increase risk for development of eating disorders, while neglecting social determinants of health and communication skills. Physicians and educators hold positions of influence in society; what we say and how we say it matters. We propose actionable approaches to improve nutrition education to minimize harm and pursue evidence-based, effective, and equitable healthcare.

A systematic review of weight stigma and disordered eating cognitions and behaviors

Weight stigma is persistent across contexts and is associated with disordered eating cognitions and behaviors. This systematic review aimed to examine the existing literature that has explored the relationship between weight stigma and disordered eating cognitions and behaviors. We specifically examined three dimensions of weight stigma - experienced, anticipated, and internalized - and adopted an inclusive conceptualization of outcomes related to disordered eating (including constructs such as binge eating, body dissatisfaction, and other cognitions and behaviors such as dietary restraint, unhealthy weight control behaviors, and drive for thinness). We searched PubMed, Embase, CINAHL, Web of Science, Sociological Abstracts, and PsycINFO for English-language, peer-reviewed articles and dissertations with quantitative methodology published through October 2023. The search resulted in 242 articles meeting inclusion criteria. A narrative review found a consistent relationship between greater weight stigma and more disordered eating cognitions and behaviors. Methodological and theoretical limitations are discussed, as are critical avenues for future research and potential clinical implications stemming from this body of research. Given the widespread nature and impact of weight stigma on disordered eating, it is imperative that we intervene to address weight stigma at all levels, from the structural to the intrapersonal.

"You Don't Look Anorexic": Atypical anorexia patient experiences of weight stigma in medical care

Eating disorders (ED) and weight stigma pose significant healthcare challenges. Patients at higher weights, like some with atypical anorexia (AAN), may face increased challenges due to weight stigma. This study analyzed patients' lived experiences with weight stigma in healthcare. Thirty-eight adult patients with AAN completed in-depth, semi-structured interviews regarding healthcare experiences. Guided by narrative inquiry approaches, transcripts were thematically coded. Across the illness trajectory (ED development, pre-treatment, treatment, post-treatment), patients reported that weight stigma in healthcare contributed to initiation and persistence of ED behaviors. Themes included "providers pathologizing patient weight," which patients reported triggered ED behaviors and relapse, "provider minimization and denial" of patients' EDs, which contributed to delays in screening and care, and "overt forms of weight discrimination," leading to healthcare avoidance. Participants reported that weight stigma prolonged ED behaviors, delayed care, created suboptimal treatment environments, deterred help-seeking, and lowered healthcare utilization. This suggests that many providers (pediatricians, primary care providers, ED treatment specialists, other healthcare specialists) may inadvertently reinforce patients' EDs. Increasing training, screening for EDs across the weight spectrum, and targeting health behavior promotion rather than universal weight loss, could enhance quality of care and improve healthcare engagement for patients with EDs, particularly those at higher weights.

Predictors of Treatment Outcome in Eating Disorders: A Roadmap to Inform Future Research Efforts

PURPOSE OF REVIEW

With the current review, we provide a brief summary of recent literature that tests clinically observable characteristics at baseline that may impact treatment response, across eating disorder diagnoses. We then provide a critical discussion regarding how researchers may shift their approach to this research to improve treatment implications and generalizability of these findings.

RECENT FINDINGS

Recent work has broadly replicated prior findings suggesting a negative impact of lower weight status, poor emotion regulation, and early-life trauma on eating disorder treatment outcomes. Findings are more mixed for the relative contributions of illness duration, psychiatric comorbidity, and baseline symptom severity. Recent studies have begun to explore more specific domains of previously tested predictors (e.g., specific comorbidities) as well as previously neglected identity-related and systemic factors. However, recent research continues to use similar sampling techniques and approaches to analysis used in prior work. We propose that resolving remaining questions and illuminating predictors of treatment outcome in eating disorders requires a new approach to research sampling and study design. Suggested changes that can be applied within a traditional clinical trial framework may yield new insights with relevance across transdiagnostic eating disorder presentations.

Mediating effects of a weight-inclusive health promotion program on maladaptive eating in women with high body mass index

Research shows that individuals with a body mass index (BMI) over 30 have experienced an 11-fold increase in restrictive eating and a 7-fold increase in binge eating since the 1990s. Most health promotion programs for higher-weight individuals have not been developed with the high eating disorder risk for this population in mind. The purpose of current study was to test two hypothesized mechanisms underlying improvement in maladaptive eating patterns shown in a weight-inclusive health promotion program designed for women with BMIs at or above 30. Participants (N = 40) were primarily White (93 %), 30-45 years old (M = 39.83, SD = 4.34) with BMIs ranging from 30 to 45 kg/m² (M = 37.42, SD = 3.58). Using the MEMORE macro, we tested a parallel mediation model hypothesizing that internalized weight stigma and intuitive eating would explain improvements on two subscales from the Three-Factor Eating Questionnaire-R18 after a 6-month program. Total effects of the program on uncontrolled (b = -3.76, SE = 0.64, p < .0001) and emotional eating (b = -1.79, SE = 0.34, p < .0001) were significant. The indirect effects (IE) of internalized weight stigma on uncontrolled eating (IE = 1.59, SE = 0.79, 95 % CI = 0.46, 3.49) and emotional eating (IE = 0.67, SE = 0.40, 95 % CI = 0.11, 1.68) were also significant. Likewise, the IEs of intuitive eating on uncontrolled eating (IE = 2.09, SE = 0.70, 95 % CI = 0.60, 3.38) and emotional eating (IE = 1.03, SE = 0.43, 95 % CI = 0.08, 1.82) were significant. These findings indicate that weight-inclusive health promotion programs that directly address weight bias and eating according to cues from the body may help higher-weight individuals improve maladaptive eating patterns via reductions in internalized weight stigma and increases in intuitive eating.

A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope

The ethical approach to treatment non-response and treatment refusal in severe-enduring anorexia nervosa (SE-AN) is the source of significant ethical debate, particularly given the risk of death by suicide or medical complications. A recent article proposed criteria to define when anorexia nervosa (AN) can be diagnosed as 'terminal' in order to facilitate euthanasia or physician-assisted suicide (EAS), otherwise known as medical assistance in dying, for individuals who wish to be relieved of suffering and accept treatment as 'futile'. This author utilises their personal lived experience to reflect on the issues raised, including: treatment refusal, iatrogenic harm, suicidality and desire to end suffering, impact of diagnosis/prognosis, schemas, alexithymia, countertransference, ambivalence, and holding on to hope. Within debates as critical as the bioethics of involuntary treatment, end-of-life and EAS in eating disorders, it is crucial that the literature includes multiple cases and perspectives of individuals with SE-AN that represent a wide range of experiences and explores the complexity of enduring AN illness, complex beliefs, communication patterns and relational dynamics that occur in SE-AN.

'It makes you not want to eat': Perceptions of anti-obesity public health campaigns in individuals diagnosed with an eating disorder

OBJECTIVE

Recent research has highlighted the potentially deleterious effects of anti-obesity public health campaigns on vulnerable audiences such as those at risk of, or diagnosed with, eating disorders (ED). The qualitative experiences of campaigns in this population group have been little explored.

METHODS

Twelve interviews were conducted with participants either currently or previously diagnosed with an ED using the Interpretative Phenomenological Analysis approach. Participants were shown a series of real-world public health campaigns and, using a semi-structured interview guide, asked about their responses to the images used.

RESULTS

Several themes emerged from the data, including the effect of campaigns on participants, perceived effect on others, and general campaign attributes. It was evident that participants felt that anti-obesity campaigns had the potential to confirm ED thoughts and behaviours, and could act as potential triggers. Participants also felt that they could impact vulnerable groups (e.g., young audiences) and stigmatise those living in larger bodies.

CONCLUSION

Campaigns addressing overweight and obesity should consider reframing these conditions and care must be taken to avoid causing potential harm to vulnerable audiences.

Drivers of medicalization in the Canadian Adult Obesity Clinical Practice Guidelines

The new Canadian Adult Obesity Clinical Practice Guidelines frame higher body weight as a chronic, relapsing disease requiring comprehensive medical treatment pathways. In this commentary, we will demonstrate how a process called pharmaceuticalization is informing the new guidelines. We join those questioning the normalization of industry and medical collaboration and interrogate whether the new guidelines meaningfully address stigma.

Atypical Anorexia in Youth: Cautiously Bridging the Treatment Gap

Atypical anorexia nervosa (AAN) is a restrictive eating disorder (ED) that describes individuals who may be normal weighted or overweight; many have a premorbid history of obesity. Pediatric care providers are trained to identify and provide best practices for youth with pediatric obesity; however, most pediatric care providers are not trained to assess and treat restrictive EDs which typically present in youth aged 10 and 14 years. Although individuals with AAN may appear to be within a ‘healthy weight’, many experience malnutrition, psychological symptoms, and severe physiological complications after weight loss. These individuals are presenting to pediatric services at an increasing rate and exhibit acute medical instability along with severe ED psychopathology. One complicating factor is youth with AAN may take longer to be identified by pediatric providers and may be reluctant to engage in treatment. Delayed treatment for AAN, along with all EDs often results in poorer treatment outcomes. A greater understanding of this complex illness is essential to inform medical decisions, such as labs, vitals, hospital admissions, and psychological therapy. Currently, there are no standardized guidelines for treating AAN in youths. This review is designed to present evidence-based treatment to inform and guide best treatment practices.

Influence and effects of weight stigmatisation in media: A systematic

BACKGROUND

The lack of a comprehensive understanding of the role of mass media in perpetuating weight stigma hinders policy formulation. We reviewed the influence of mass media on weight stigmatisation and the effectiveness of media-based interventions designed to prevent or reduce stigma.

METHODS

We conducted a systematic review across seven databases from inception to December 2021. Included studies assessed exposure to or impact of weight stigma in mass media or examined interventions to reduce stigma through media in populations 12+ years. We synthesised data narratively, categorising studies based on similarity in focus to produce a set of integrated findings. The systematic review is registered in PROSPERO (No. CRD42020176306).

FINDINGS

One-hundred-and-thirteen records were eligible for inclusion from 2402 identified; 95 examined the prevalence of stigmatising content in mass media and its impact on stigma. Weight stigma was prevalent across media types, with the dominant discourse viewing overweight and obesity as an individual responsibility and overlooking systemic factors. Exposure to stigmatising content was found to negatively influence attitudes towards people with overweight or obesity. Few studies considered methods of reducing stigma in the media, with only two testing media-based interventions; their results were promising but limited.

INTERPRETATION

Weight stigma in media content is prevalent and harmful, but there is little guidance on reducing it. Future research focus needs to shift from assessing prevalence and impacts to weight stigma interventions.

FUNDING

None.

Clinical Considerations of Ultra-processed Food Addiction Across Weight Classes: an Eating Disorder Treatment and Care Perspective

Purpose of Review

To examine the prevalence rates of ultra-processed food addiction across different weight classes and offer guidelines for diagnosis and treatment. Clinicians are provided with practical considerations in the assessment of ultra-processed food addiction beyond the use of validated instruments.

Recent Findings

The weighted mean prevalence of ultra-processed food addiction is approximately 20% worldwide and varies widely based on the sample. At first glance, there appears a linear relationship between ultra-processed food addiction and BMI class. Further investigation indicates a J-shaped curve with heightened prevalence among the underweight. These findings highlight the need to assess for additional factors that may increase objective or subjective food addiction symptoms including eating disorders, dietary restraint, and other mental health diagnoses.

Summary

While clinical considerations across different weight classes vary, overemphasis on weight status may detract from the clinical utility of the ultra-processed food addiction construct. Considering weight status in conjunction with other psychiatric symptoms helps to better understand the various biopsychosocial mechanisms that influence eating behavior and can inform individualized treatment strategies.

A mixed-studies systematic review of the experiences of body image, disordered eating, and eating disorders during the COVID-19 pandemic

OBJECTIVES

This systematic review assessed the influence of the COVID-19 pandemic and associated restrictions on body image, disordered eating (DE), and eating disorder outcomes.

METHODS

After registration on PROSPERO, a search was conducted for papers published between December 1, 2019 and August 1, 2021, using the databases PsycINFO, PsycARTICLES, CINAHL Plus, AMED, MEDLINE, ERIC, EMBASE, Wiley, and ProQuest (dissertations and theses).

RESULTS

Data from 75 qualitative, quantitative, and mixed-methods studies were synthesized using a convergent integrated approach and presented narratively within four themes: (1) disruptions due to the COVID-19 pandemic; (2) variability in the improvement or exacerbation of symptoms; (3) factors associated with body image and DE outcomes; (4) unique challenges for marginalized and underrepresented groups. Disruptions due to the pandemic included social and functional restrictions. Although most studies reported a worsening of concerns, some participants also reported symptom improvement or no change as a result of the pandemic. Factors associated with worse outcomes included psychological, individual, social, and eating disorder-related variables. Individuals identifying as LGBTQ+ reported unique concerns during COVID-19.

DISCUSSION

There is large variability in individuals' responses to COVID-19 and limited research exploring the effect of the pandemic on body image, DE, and eating disorder outcomes using longitudinal and experimental study designs. In addition, further research is required to investigate the effect of the COVID-19 pandemic on body image and eating concerns among minoritized, racialized, underrepresented, or otherwise marginalized participants. Based on the findings of this review, we make recommendations for individuals, researchers, clinicians, and public health messaging.

PUBLIC SIGNIFICANCE

This review of 75 studies highlights the widespread negative impacts that the COVID-19 pandemic and associated restrictions have had on body image and disordered eating outcomes. It also identifies considerable variations in both the improvement and exacerbation of said outcomes that individuals, researchers, clinicians, and other public health professionals should be mindful of if we are to ensure that vulnerable people get the tailored support they require.