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Egbert AH, Irizarry B, Lualdi E, Tortolani CC, Donaldson DL, Goldschmidt AB. A qualitative assessment of provider-perceived barriers to implementing family-based treatment for anorexia nervosa in low-income community settings. J Eat Disord 2024; 12:51. [PMID: 38664842 PMCID: PMC11045456 DOI: 10.1186/s40337-024-01008-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Family-based treatment (FBT) is a front-line empirically supported intervention for adolescent anorexia nervosa, but it is often inaccessible to families from lower income backgrounds, as it is most typically available in specialty research and private practice settings. In preparation for a pilot trial of FBT delivered in the home setting, this study qualitatively examined provider perceptions of implementing FBT in lower-income communities. METHODS Eating disorder clinicians working in community clinics (therapists, medical doctors, dietitians, and social workers; n = 9) were interviewed about their experiences using FBT. Interview transcripts were analyzed both deductively, using an approach consistent with applied thematic analysis, and inductively, using the Replicating Effective Programs implementation framework, to examine barriers to FBT implementation. RESULTS Prevailing themes included concern about the time and resources required of caregivers to participate in FBT, which may not be feasible for those who work full time, have other caregiving demands, and/or lack family support. Psychosocial problems outside of the eating disorder, such as food insecurity, other untreated mental health concerns (in themselves or other family members), or externalizing behaviors on the part of the adolescent, were also discussed as barriers, and participants noted that the lack of cohesive treatment teams in the community make it difficult to ensure continuity of care. CONCLUSION Findings from this qualitative study indicate the need to address systemic socioeconomic barriers to improve the efficacy of implementation of FBT in the community and to understand how provider perceptions of these barriers influence their uptake of FBT.
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Affiliation(s)
- Amy H Egbert
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Department of Psychological Sciences, The University of Connecticut, Storrs, CT, USA.
| | - Bailey Irizarry
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Christina C Tortolani
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Counseling, Educational Leadership, and School Psychology, Rhode Island College, Providence, RI, USA
| | - Deidre L Donaldson
- Department of Family Medicine, Warren Alpert Medical School of Brown University/Gateway Healthcare, Providence, RI, USA
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Haynos AF, Egbert AH, Fitzsimmons-Craft EE, Levinson CA, Schleider JL. Not niche: eating disorders as an example in the dangers of overspecialisation. Br J Psychiatry 2024; 224:82-85. [PMID: 38097370 PMCID: PMC10932815 DOI: 10.1192/bjp.2023.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Labelling specific psychiatric concerns as 'niche' topics relegated to specialty journals obstructs high-quality research and clinical care for these issues. Despite their severity, eating disorders are under-represented in high-impact journals, underfunded, and under-addressed in psychiatric training. We provide recommendations to stimulate broad knowledge dissemination for under-acknowledged, yet severe, psychiatric disorders.
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Affiliation(s)
- Ann F. Haynos
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA; and Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amy H. Egbert
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | | | - Cheri A. Levinson
- Department of Psychological and Brain Sciences, Department of Pediatrics, Division of Child and Adolescent Psychiatry, University of Louisville, Kentucky, USA
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Goldschmidt AB, Tortolani CC, Accurso EC, Dunbar EMP, Egbert AH, Donaldson D, Donaldson AA. Adapting family-based treatment for adolescent anorexia nervosa delivered in the home: A novel approach for improving access to care and generalizability of skill acquisition. J Eat Disord 2023; 11:130. [PMID: 37543601 PMCID: PMC10403819 DOI: 10.1186/s40337-023-00850-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Anorexia nervosa (AN) is a serious mental illness associated with high rates of morbidity and mortality. Family-based treatment (FBT) is a well-established treatment for adolescent AN, yet it is underutilized in community settings and is unavailable to many families, particularly those from lower income and racial and ethnic minority backgrounds. Furthermore, some families do not respond optimally to FBT, possibly because of challenges translating skills acquired in office-based treatment settings to naturalistic settings. Home-based treatment could reduce barriers to access and enhance generalization of newly learned treatment skills. Home-based models demonstrate initial feasibility, acceptability, and efficacy for adolescent AN, however, FBT principles have yet to be applied as a stand-alone intervention in a home-based level of care. This paper describes the rationale for and process of adapting FBT principles/interventions to improve fit within a home-based model delivered in the context of community mental health, and discusses potential strengths and opportunities associated with this approach. RESULTS Adaptations were made through consultation with collaborating community agencies and were guided by the complex interventions framework. The primary modifications included: (1) altered dose; (2) multiple family meals; (3) additional support for meal preparation and supervision; (4) clinician attendance at medical appointments; (5) cultural adaptation; and (6) introduction of distress tolerance and emotion regulation skills. CONCLUSIONS Implementing FBT in the home may present one promising and novel approach to enhance engagement and treatment outcomes for adolescents with restrictive eating disorders, particularly those who are underserved, but evaluation of efficacy/effectiveness is needed.
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Affiliation(s)
- Andrea B Goldschmidt
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Christina C Tortolani
- Department of Counseling, Educational Leadership, and School Psychology, Rhode Island College, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | | | - Amy H Egbert
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
- Department of Psychological Sciences, University of Connecticut, Connecticut, Storz, USA
| | - Deidre Donaldson
- Department of Family Medicine, Warren Alpert Medical School of Brown University/Gateway Healthcare, Providence, RI, USA
| | - Abigail A Donaldson
- Department of Pediatrics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
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Egbert AH, Gorrell S, Smith KE, Goldschmidt AB, Hughes EK, Sawyer SM, Yeo M, Lock J, Le Grange D. When eating disorder attitudes and cognitions persist after weight restoration: An exploratory examination of non-cognitive responders to family-based treatment for adolescent anorexia nervosa. Eur Eat Disord Rev 2023; 31:425-432. [PMID: 36715459 PMCID: PMC10116695 DOI: 10.1002/erv.2968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/18/2022] [Accepted: 01/07/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Family-based treatment (FBT) is a well-established intervention for adolescent anorexia nervosa (AN). Although FBT is efficacious in promoting weight gain and improvements in psychological symptoms, for some adolescents, cognitive/attitudinal recovery lags behind weight gain. This study conducted an exploratory post hoc analysis of outcomes of adolescents who achieved weight gain by the end of FBT but continued to experience elevated psychological symptoms post-treatment. METHODS Data were drawn from two randomised controlled trials (RCTs) testing two forms of FBT (conjoint/whole family and parent-focussed). Descriptive statistics and generalised estimating equations were used to examine differences in treatment outcomes between non-cognitive responders (NCRs) (those who regained weight but continued to experience psychological symptoms) and full responders (FRs) (those who achieved both weight and cognitive restoration by the end of treatment) (n = 80; 83.7% female, Agemean [SD] = 14.66 [1.73]). RESULTS By 12 months post-treatment, there were no differences in weight between NCRs and FRs. However, NCRs had a slower trajectory of weight gain than FRs and continued to have elevated levels of psychological symptoms throughout the follow-up period. CONCLUSIONS A subset of adolescents appear to continue to experience clinically significant levels of eating pathology up to 12 months after FBT even when weight restoration is achieved.
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Affiliation(s)
- Amy H Egbert
- Department of Psychological Sciences, The University of Connecticut, Storrs, Connecticut, USA
| | - Sasha Gorrell
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Kathryn E Smith
- Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrea B Goldschmidt
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Elizabeth K Hughes
- Centre for Adolescent Health, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Susan M Sawyer
- Centre for Adolescent Health, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Michelle Yeo
- Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - James Lock
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
- Department of Psychiatry & Behavioral Neuroscience (Emeritus), The University of Chicago, Chicago, Illinois, USA
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Bates CR, Bakula DM, Egbert AH, Gerhardt CA, Davis AM, Psihogios AM. Addressing Barriers to Career Development Awards for Early Career Women in Pediatric Psychology. J Pediatr Psychol 2023; 48:320-329. [PMID: 36898037 PMCID: PMC10118852 DOI: 10.1093/jpepsy/jsad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/24/2023] [Accepted: 02/11/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE To provide person and system-level recommendations for supporting early career women in the field of pediatric psychology in writing and submitting National Institutes of Health (NIH) Career Development Award (K award) applications. Recommendations are provided in the context of common barriers, with a focus on practical solutions. METHODS Publicly available NIH reporter data were compiled to examine rates of funding for Society of Pediatric Psychology (SPP) members. Barriers that women face when initiating programs of research are described and applied to the field of pediatric psychology. RESULTS Of current SPP members, 3.9% (n = 50) have ever received an NIH K award. Approximately 88.5% of SPP members identify as women, including 89.0% of SPP K award recipients. A table of person- and systems-level recommendations is provided to offer strategies for mentees, mentors/sponsors, institutions, and national organizations to address the barriers discussed. CONCLUSIONS By addressing gender-specific barriers to submitting K award applications, we hope to increase the number of women K awardees and support the scientific advancement of pediatric psychology.
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Affiliation(s)
- Carolyn R Bates
- Department of Pediatrics, University of Kansas Medical Center, USA.,Center for Children's Healthy Lifestyles & Nutrition, USA
| | - Dana M Bakula
- Center for Children's Healthy Lifestyles & Nutrition, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Mercy Kansas City, USA.,University of Missouri, Kansas City School of Medicine, USA
| | - Amy H Egbert
- Department of Psychological Sciences, The University of Connecticut, USA
| | - Cynthia A Gerhardt
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, USA
| | - Ann M Davis
- Department of Pediatrics, University of Kansas Medical Center, USA.,Center for Children's Healthy Lifestyles & Nutrition, USA
| | - Alexandra M Psihogios
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, USA
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Manasse SM, Haedt-Matt AA, Smith KE, Egbert AH, O’Sullivan K, Koren D, Engel S, Goldschmidt AB. The moderating role of sleep duration on momentary relations between negative affect and loss-of-control eating in children and adolescents. Eur Eat Disord Rev 2022; 30:815-822. [PMID: 35474597 PMCID: PMC10860376 DOI: 10.1002/erv.2908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 03/01/2022] [Accepted: 04/08/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Loss-of-control (LOC) eating is associated with eating disorders and obesity, and thus it is imperative to understand its momentary risk factors in order to improve intervention efforts. Negative affect has been proposed as a momentary risk factor for LOC eating, but the evidence for its effects in children and adolescents is mixed. Short sleep duration (which is very common in youth), may be one variable that moderates the relation between negative affect and subsequent LOC eating. As such, we aimed to examine the moderating role of within-person sleep duration on the momentary relations between negative affect and subsequent LOC eating. METHOD We recruited children (N = 30) with overweight/obesity ages 8-14, who completed a 2-week ecological momentary assessment protocol assessing negative affect and LOC eating several times per day, while also wearing a sleep actigraphy device and completing sleep diaries. RESULTS Consistent with hypotheses, within-person sleep duration moderated the next-day momentary relation between within-person negative affect and LOC eating, such that shorter sleep duration strengthened the positive relation between negative affect and loss-of-control eating. CONCLUSIONS Results suggest that, in children and adolescents, fluctuations in sleep duration may influence susceptibility to losing control over eating after experiencing negative affect. Future research should further investigate other metrics of sleep disturbance as they relate to emotion regulation and LOC eating. Such research will set the stage for augmenting paediatric interventions to better target maintenance factors for LOC eating.
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Affiliation(s)
- Stephanie M. Manasse
- Center for Weight, Eating, and Lifestyle Sciences, Drexel University, Philadelphia, PA
| | | | - Kathryn E. Smith
- Department of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles, CA
| | - Amy H. Egbert
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Weight Control and Diabetes Research Center/The Miriam Hospital, Providence, RI
| | - Katie O’Sullivan
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Dorit Koren
- Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA
| | | | - Andrea B. Goldschmidt
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Weight Control and Diabetes Research Center/The Miriam Hospital, Providence, RI
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Goldschmidt AB, Tortolani CC, Egbert AH, Brick LA, Elwy AR, Donaldson D, Le Grange D. Implementation and outcomes of home-based treatments for adolescents with anorexia nervosa: Study protocol for a pilot effectiveness-implementation trial. Int J Eat Disord 2022; 55:1627-1634. [PMID: 36324297 PMCID: PMC10018372 DOI: 10.1002/eat.23796] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Although family-based treatment (FBT) is considered a first-line treatment for adolescent anorexia nervosa (AN), it is underutilized in community settings and is unavailable to many families for a multitude of practical reasons (e.g., costs of treatment, transportation constraints). Adapting FBT interventions for delivery in home-based and community-based settings may reduce pragmatic barriers to treatment uptake and engagement. METHODS This pilot effectiveness-implementation trial will assess outcomes, implementation, and mechanisms of FBT adapted for the home setting (FBT-HB), delivered in the context of community-based behavioral health agencies. Adolescents with AN-spectrum disorders (n = 50) and their caregivers will be randomly assigned to either FBT-HB or home-based treatment as usual (TAU; integrated family therapy approach). Caregivers and adolescents will provide data on weight, eating, and putative treatment mechanisms, including caregiver self-efficacy and adolescent eating-related and weight-related distress. Implementation constructs of feasibility, acceptability, and appropriateness will be measured among providers and participating families. HYPOTHESES We expect that FBT-HB will be feasible, acceptable, and appropriate, and will outperform TAU in terms of improvements in adolescent weight and eating-related psychopathology. We further expect that caregiver self-efficacy and adolescent eating-related and weight-related distress, but not general distress, will show greater improvements in FBT-HB relative to TAU and will be associated with better adolescent weight and eating outcomes in FBT-HB. POTENTIAL IMPLICATIONS The proposed study has clear potential to advance scientific and clinical understanding of the real-world effectiveness of FBT for AN, including whether adapting it for the home setting improves its accessibility and effects on treatment outcome.
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Affiliation(s)
| | - Christina C. Tortolani
- Department of Counseling, Educational Leadership, and School Psychology, Rhode Island College, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - Amy H. Egbert
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - Leslie A. Brick
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - A. Rani Elwy
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - Deidre Donaldson
- Department of Family Medicine, Warren Alpert Medical School of Brown University/Gateway Healthcare, Providence, RI, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
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Bodell LP, Egbert AH, Anaya C, Wildes JE. Associations between emotion reactivity and eating disorder symptoms in a transdiagnostic treatment-seeking sample. Int J Eat Disord 2022; 55:1390-1396. [PMID: 36086863 DOI: 10.1002/eat.23808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Individuals with eating disorders (EDs) demonstrate difficulties with emotion regulation, and these difficulties have been associated with severity and maintenance of ED symptoms. Although emotion reactivity (i.e., the strength and duration of emotional experiences) is distinct from emotion regulation, few studies have examined emotion reactivity in the context of EDs. The purpose of the current study was to examine longitudinal associations between emotion reactivity and ED symptoms and impairment in individuals with EDs. METHOD Individuals seeking outpatient ED treatment (N = 265) completed questionnaires assessing ED symptoms and severity, emotion reactivity, and emotion regulation difficulties at treatment intake and bi-monthly during treatment. RESULTS Individuals with anorexia nervosa or binge eating or purging presentations had higher emotion reactivity scores than a non-ED comparison group. Controlling for age, diagnosis, and emotion regulation difficulties, emotion reactivity was positively associated with ED severity, ED-related impairment, and loss of control eating severity. Moreover, emotion reactivity, but not emotion regulation difficulties, was associated with change in ED symptoms during treatment. DISCUSSION Findings support that emotion reactivity may differ based on ED presentations and may be an important correlate of ED symptom severity. PUBLIC SIGNIFICANCE Emotion reactivity refers to the strength and duration of an emotional experience. This study found that higher emotion reactivity was related to greater eating disorder symptom severity and eating disorder-related impairment. It may be beneficial to consider the role of emotion reactivity in conceptualizations of eating disorders, particularly those characterized by binge eating or purging.
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Affiliation(s)
- Lindsay P Bodell
- Department of Psychology, University of Western Ontario, London, Ontario, Canada
| | - Amy H Egbert
- The Miriam Hospital/Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Carolina Anaya
- Department of Psychology, Michigan State University, East Lansing, Michigan, USA
| | - Jennifer E Wildes
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois, USA
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Egbert AH, Smith KE, Ranzenhofer LM, Goldschmidt AB, Hilbert A. The Role of Affective Instability in Loss of Control Eating in Youth with Overweight/Obesity Across Development: Findings from Two EMA Studies. Res Child Adolesc Psychopathol 2022; 50:945-957. [PMID: 35039971 PMCID: PMC10375484 DOI: 10.1007/s10802-021-00886-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/26/2022]
Abstract
Affective instability is common during adolescence, but at high levels it is associated with a variety of internalizing and externalizing disorders, including eating disorders. Although most models focus on affective intensity as a mechanism for explaining eating disorders in adults, affective instability may be more developmentally relevant at predicting eating behaviors in youth. Using ecological momentary assessment, this manuscript explored the association between loss of control over eating (LOC), a key component of dysregulated eating in youth, and affective instability in youth with overweight/obesity in two separate studies, one with youth in middle childhood and early adolescence (Study 1: ages eight to 13) and one in youth in early through middle adolescence (Study 2: ages 12-17). Overall, there was no association between affective instability and LOC in Study 1, but in Study 2, age moderated the association between positive affective instability and LOC, such that greater between-person positive affective instability (i.e., relative to peers) was associated with lower average LOC for youth earlier in adolescence and higher average LOC for those later in adolescence. Negative affective instability was also associated with LOC in Study 2, such that on days when youth reported less within-person negative affective instability (i.e., relative to their own average), they also reported greater average LOC. Findings across the two studies indicate that the association between affective instability and LOC may not emerge until adolescence, and when it does, both positive and negative affective instability may be important to consider.
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Affiliation(s)
- Amy H Egbert
- Department of Psychiatry and Human Behavior, The Miriam Hospital/Alpert Medical School of Brown University, Providence, RI, USA.
| | - Kathryn E Smith
- Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lisa M Ranzenhofer
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Anja Hilbert
- Integrated Research and Treatment Center Adiposity Diseases, Department of Psychosomatic Medicine and Psychotherapy, Behavioral Medicine Research Unit, University of Leipzig Medical Center, Leipzig, Germany
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10
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Rea EM, Nicholson LM, Mead MP, Egbert AH, Bohnert AM. Daily relations between nap occurrence, duration, and timing and nocturnal sleep patterns in college students. Sleep Health 2022; 8:356-363. [PMID: 35732554 PMCID: PMC9378669 DOI: 10.1016/j.sleh.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 04/19/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE/DESIGN Sleep patterns change during college, and students may nap to compensate for lost sleep. Despite the increased prevalence of napping among students, few studies have investigated daily relations between napping and nocturnal sleep, as well as how timing of naps and nocturnal sleep might influence one another. The present study used daily diaries to capture the occurrence, timing, and duration of napping and relation to nocturnal sleep. SETTING/PARTICIPANTS Daily diary data, collected for 4-7 days, from 654 college students from a mid-sized midwestern university (81.5% female). MEASUREMENT Participants reported nightly sleep durations, bedtimes, and wake times as well as nap durations and nap start times. RESULTS Multilevel modeling (MLM) and multi-level logistic regressions revealed bidirectional relations between nocturnal sleep and napping. Regarding nocturnal sleep and its relation to next day napping, nocturnal sleep (including shorter duration and later bedtime) was associated with increased odds of napping and longer napping the following day. Shorter sleep duration was also associated with taking an earlier nap, while later bedtime was associated with a later nap the following day. Regarding napping and its association with same-night nocturnal sleep, taking a nap was associated with longer sleep duration that night, however, later nap start times and longer nap durations were associated with later bedtimes that night. CONCLUSIONS Findings provide evidence for bidirectional associations between napping and nocturnal sleep. Future studies are needed to explore how naps could be optimized to promote nocturnal sleep among college students, as well as for whom naps might be most beneficial.
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Affiliation(s)
- Elizabeth M Rea
- Department of Psychology, Loyola University of Chicago, Chicago, IL, USA.
| | - Laura M Nicholson
- Department of Psychology, Loyola University of Chicago, Chicago, IL, USA
| | - Michael P Mead
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy H Egbert
- Department of Psychiatry and Human Behavior, The Miriam Hospital/Alpert Medical School of Brown University, Providence, RI, USA
| | - Amy M Bohnert
- Department of Psychology, Loyola University of Chicago, Chicago, IL, USA
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11
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Egbert AH, Hunt RA, Williams KL, Burke NL, Mathis KJ. Reporting racial and ethnic diversity in eating disorder research over the past 20 years. Int J Eat Disord 2022; 55:455-462. [PMID: 34997609 DOI: 10.1002/eat.23666] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Recent public awareness of racial and ethnic disparities has again brought to light issues of diversity, equity, and inclusion in the eating disorders field. However, empirical information on racial and ethnic representation in eating disorders research is limited, making it difficult to understand where improvements are needed. METHOD This study reviewed all studies including human participants published in the International Journal of Eating Disorders in 2000, 2010, and 2020. Differences in likelihood of reporting race and ethnicity were calculated based on study year, location, and diagnostic categories. RESULTS Out of 377 manuscripts, 45.2% reported information on the race and ethnicity of study participants. Studies conducted in the United States were more likely to report (128/173), and those conducted in Europe were less likely to report (5/61) on race and ethnicity than those conducted outside of those regions. Rates of reporting increased from 2000 to 2020. White participants made up approximately 70% of the samples that reported race and ethnicity data. Hispanic participants made up approximately 10% of samples reporting race and ethnicity. Participants from all other races and ethnicities made up less than 5% each. DISCUSSION Although rates of reporting race and ethnicity increased over time, most participants were White. Rates of reporting also differed by the geographical region, which may reflect variability in how information on race and ethnicity is collected across countries. More attention toward capturing the cultural background of research participants and more inclusivity in research are needed in the eating disorders field.
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Affiliation(s)
- Amy H Egbert
- Department of Psychiatry and Human Behavior, The Miriam Hospital/Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Rowan A Hunt
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Kayla L Williams
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Natasha L Burke
- Department of Psychology, Fordham University, Bronx, New York, USA
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Goel NJ, Jennings Mathis K, Egbert AH, Petterway F, Breithaupt L, Eddy KT, Franko DL, Graham AK. Accountability in promoting representation of historically marginalized racial and ethnic populations in the eating disorders field: A call to action. Int J Eat Disord 2022; 55:463-469. [PMID: 35092322 PMCID: PMC9305786 DOI: 10.1002/eat.23682] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
Abstract
Promoting representation of historically marginalized racial and ethnic populations in the eating disorders (EDs) field among professionals and the populations studied and served has long been discussed, with limited progress. This may be due to a reinforcing feedback loop in which individuals from dominant cultures conduct research and deliver treatment, participate in research, and receive diagnoses and treatment. This insularity maintains underrepresentation: EDs in historically marginalized populations are understudied, undetected, and undertreated. An Early Career Investigators Workshop generated recommendations for change that were not inherently novel but made apparent that accountability is missing. This paper serves as a call to action to spearhead a paradigm shift from equality to equity in the ED field. We provide a theoretical framework, suggest ways to disrupt the feedback loop, and summarize actionable steps to increase accountability in ED leadership and research toward enhancing racial/ethnic justice, equity, diversity, and inclusion (JEDI). These actionable steps are outlined in the service of challenging our field to reflect the diversity of our global community. We must develop and implement measurable metrics to assess our progress toward increasing diversity of underrepresented racial/ethnic groups and to address JEDI issues in our providers, patients, and research participants.
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Affiliation(s)
- Neha J. Goel
- Department of PsychologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | | | - Amy H. Egbert
- Department of Psychiatry and Human BehaviorThe Miriam Hospital/Warren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Felicia Petterway
- Eating Disorders Clinical and Research ProgramMassachusetts General HospitalBostonMassachusettsUSA,Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Lauren Breithaupt
- Eating Disorders Clinical and Research ProgramMassachusetts General HospitalBostonMassachusettsUSA,Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Kamryn T. Eddy
- Eating Disorders Clinical and Research ProgramMassachusetts General HospitalBostonMassachusettsUSA,Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Debra L. Franko
- Eating Disorders Clinical and Research ProgramMassachusetts General HospitalBostonMassachusettsUSA,Department of Applied PsychologyNortheastern UniversityBostonMassachusettsUSA
| | - Andrea K. Graham
- Department of Medical Social SciencesNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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13
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Goldschmidt AB, Mason TB, Smith KE, Egbert AH, Engel ESG, Haedt-Matt A. Typology of eating episodes in children and adolescents with overweight/obesity. Eat Behav 2022; 44:101596. [PMID: 35091193 PMCID: PMC8885845 DOI: 10.1016/j.eatbeh.2022.101596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/07/2022] [Accepted: 01/17/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Research suggests that youth with overweight/obesity can be subtyped according to disinhibited eating tendencies. No research has attempted to subtype classes of eating episodes along sensational, psychological, and hedonic dimensions. METHODS Youth (N = 39; 55% female) aged 8-14 y with overweight/obesity completed a 2-week ecological momentary assessment protocol in which they reported on all eating episodes and their sensational, environmental, affective, and interpersonal contexts. Latent profile analysis (LPA) was used to classify episodes based on loss of control (LOC) while eating, self-reported overeating, food palatability, hunger, and cravings. Classes were compared on affective, interpersonal, appearance-related, and environmental correlates using Wald chi-square tests. RESULTS LPA identified three classes of eating episodes involving high levels of LOC/self-reported overeating ("binge-like" class), low levels of hunger ("eating-in-the-absence-of-hunger" class), and high hunger and cravings ("appetitive eating" class). Binge-like eating was associated with the highest levels of body dissatisfaction, interpersonal distress, and positive affect, and was most likely to occur in the after-school hours. CONCLUSIONS Binge-like eating tends to occur in a psychological context relative to other types of eating episodes in youth with overweight/obesity. Future research should explore whether certain classes of eating episodes are associated with distinct weight trajectories over time.
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Affiliation(s)
- Andrea B. Goldschmidt
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Weight Control and Diabetes Research Center/The Miriam Hospital, Providence, RI
| | - Tyler B. Mason
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA
| | - Kathryn E. Smith
- Department of Psychiatry and Behavioral Science, University of Southern California, Los Angeles, CA
| | - Amy H. Egbert
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Weight Control and Diabetes Research Center/The Miriam Hospital, Providence, RI
| | - E. Scott G. Engel
- Department of Biobehavioral Research, Sanford Research, Fargo, ND,Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota
| | - Alissa Haedt-Matt
- Department of Psychology, Illinois Institute of Technology, Chicago, IL
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14
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Abstract
BACKGROUND Existing research suggests that greater sleep variability may increase risk for weight gain. College often marks a transition to a less consistent daily schedule, which may adversely impact sleep routines and further increase risk for weight gain. The current study is among the first to explore relations between nighttime sleep variability and daytime sleep (napping) and body weight among first-year college students. METHODS Using daily diary methods, first-year college students (N = 307; 84.7% female) self-reported their sleep for seven days. Several indices were created to capture sleep variability for reported bedtime, wake time, and sleep duration, including weekday versus weekend differences (WvW), day to day differences (D2D), and overall standard deviation (SD). Napping was also assessed. Based on body mass index (BMI), individuals were categorized as underweight, healthy weight, overweight, and obese. RESULTS Across indices, students' sleep varied over an hour on average across the week. Hierarchical regressions revealed that greater differences in wake time D2D, wake time SD, and sleep duration WvW were all associated with higher BMI, after accounting for gender, depressive symptoms, and sleep duration. Longer napping was also associated with higher BMI, using the same covariates. Finally, greater sleep variability was reported by overweight and obese than healthy weight individuals. CONCLUSION These findings suggest that sleep variability, particularly wake times and napping may be important modifiable sleep behaviors to investigate in future studies. More longitudinal research is needed to explore relations between multiple facets of sleep variability and weight gain, including possible mechanisms.
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Affiliation(s)
| | | | - Jennette P Moreno
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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15
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Egbert AH, Haedt-Matt A, Smith KE, Culbert K, Engel S, Goldschmidt AB. Momentary associations between positive affect dimensions and dysregulated eating during puberty in a diverse sample of youth with overweight/obesity. Int J Eat Disord 2020; 53:1667-1677. [PMID: 32706499 PMCID: PMC7878851 DOI: 10.1002/eat.23342] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The link between dysregulated positive affect and binge-eating behavior in youth with obesity is poorly understood. In addition, it is unclear how putative associations differ across developmental periods of rapid biological and emotional change, such as puberty, and in racial and ethnic minority youth, who are more likely to be overweight but are underrepresented in the literature. METHOD This study used a 2-week ecological momentary assessment protocol to examine independent and interactive effects of positive affect intensity/instability, and pubertal stage on two components of binge-eating behavior, loss of control eating (LOCE), and overeating. RESULTS Participants were 38 youth with overweight/obesity (ages 8-14 years; 78% African American/Hispanic). Positive affect instability was calculated using probability of acute change (PAC), representing the likelihood of extreme affective changes, and mean squared successive difference (MSSD), representing the average change in affect over successive recordings. There were no main effects of positive affect intensity on LOCE or overeating, but positive affect instability was negatively associated with overeating severity using both MSSD (p = .005) and PAC metrics (p = .001). However, moderation analyses including interactions with pubertal status revealed more extreme changes in positive affect (i.e., higher PAC) were related to greater overeating (p = .001) and LOCE severity (p = .043) in mid-late pubertal youth but not in pre-early pubertal youth. DISCUSSION Pubertal status may influence the association between disruptions in positive affect and dysregulated eating in youth, and positive affect instability may be important to consider in order to understand the emotional correlates of binge eating in youth with overweight/obesity.
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Affiliation(s)
- Amy H. Egbert
- Loyola University of Chicago,The Miriam Hospital/Alpert Medical School of Brown University
| | | | - Kathryn E. Smith
- Department of Psychiatry and Behavioral Science, University of Southern California
| | - Kristen Culbert
- Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine
| | - Scott Engel
- Center for Bio-behavioral Research, Sanford Research; Department of Psychiatry and Behavioral Science
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16
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Egbert AH, Nicholson L, Sroka A, Silton R, Bohnert AM. Binge eating, but not dietary restraint, moderates the association between unhealthy food marketing exposure and sugary food consumption. Eat Behav 2020; 38:101401. [PMID: 32470905 DOI: 10.1016/j.eatbeh.2020.101401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
Restrained eaters, those who exercise dietary restraint and often experience dietary lapses, may be particularly susceptible to food marketing. Findings are mixed as to whether restrained eaters consume more food after exposure to unhealthy food marketing, and little is known about whether food marketing may have more impact on those who exercise successful dietary restraint as compared with those who experience dietary lapses, such as binge eating. In the current study, participants were 38 young women, ages 18-22 years old. Both dietary restraint and binge eating were measured by the Eating Disorder Examination-Questionnaire. Participants viewed both unhealthy food commercials and non-food commercials two separate times in the laboratory, and ad libitum candy intake was subsequently measured. Results indicated that participants who endorsed binge eating ate significantly more candy than those who did not endorse binge eating after they viewed unhealthy food commercials F (1, 35) = 20.49, p < .001, η2 = 0.37, but not after viewing non-food commercials. No significant differences in candy eaten emerged when comparing those who endorsed dietary restraint as compared to those who did not, regardless of commercial type. Findings demonstrate the importance of specific operational definitions of restrained eating to consider the differences between those who report binge eating, and those who do not. They also suggest that individuals who engage in binge eating may be particularly susceptible to overeating in response to unhealthy food marketing, marking a possible area for intervention.
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Affiliation(s)
- Amy H Egbert
- Loyola University Chicago, United States of America.
| | | | - Anna Sroka
- Loyola University Chicago, United States of America
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17
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Brosof LC, Egbert AH, Reilly EE, Wonderlich JA, Karam A, Vanzhula I, Steward T, Levinson CA. Intolerance of uncertainty moderates the relationship between high personal standards but not evaluative concerns perfectionism and eating disorder symptoms cross-sectionally and prospectively. Eat Behav 2019; 35:101340. [PMID: 31731235 DOI: 10.1016/j.eatbeh.2019.101340] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 11/18/2022]
Abstract
Two dimensions of perfectionism related to eating disorder (ED) symptoms are evaluative concerns and high standards. Evaluative concerns are consistently linked with ED symptoms, whereas there are conflicting results regarding high standards and ED symptoms. High standards are unrelated to ED symptoms in some studies and are linked to higher ED symptoms in others. Intolerance of uncertainty (IU) may influence the relation between high standards and ED symptoms; individuals elevated in both IU and high standards may find it distressing to be uncertain about future situations for fear of not living up to high expectations and use ED behaviors to cope with such uncertainty. In the current study (N = 216), we explored whether IU moderates the relationships between high standards and evaluative concerns and ED symptoms, both cross-sectionally and prospectively across two weeks. IU significantly moderated high standards and ED symptoms both cross-sectionally and across time while accounting for baseline ED symptoms, but did not moderate the relationship between evaluative concerns and ED symptoms. Higher standards were associated with greater ED symptoms in individuals higher, but not lower in IU. These findings suggest high standards may only contribute to ED symptoms when individuals are also high in IU.
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Affiliation(s)
- Leigh C Brosof
- University of Louisville, Department of Psychological and Brain Sciences, Louisville, KY, USA.
| | - Amy H Egbert
- Loyola University Chicago, Department of Psychology, Chicago, IL, USA
| | - Erin E Reilly
- University of California, San Diego, Department of Psychiatry, San Diego, CA, USA(2); Hofstra University, Department of Psychology, Hempstead, NY, USA(1)
| | | | - Anna Karam
- Washington University in St. Louis, Department of Psychological and Brain Sciences, USA
| | - Irina Vanzhula
- University of Louisville, Department of Psychological and Brain Sciences, Louisville, KY, USA
| | - Trevor Steward
- Bellvitge University Hospital-IDIBELL, Department of Psychiatry, Barcelona, Spain; School of Psychological Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Cheri A Levinson
- University of Louisville, Department of Psychological and Brain Sciences, Louisville, KY, USA
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Distel LML, Egbert AH, Bohnert AM, Santiago CD. Chronic Stress and Food Insecurity: Examining Key Environmental Family Factors Related to Body Mass Index Among Low-Income Mexican-Origin Youth. Fam Community Health 2019; 42:213-220. [PMID: 31107732 DOI: 10.1097/fch.0000000000000228] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Low-income children of Mexican immigrants are at high risk for obesity. Drawing on a sample of 104 Mexican American children (Mage = 8.39 years; 61% female), this longitudinal study considered relations between food insecurity and chronic stress (ie, parent report and hair cortisol measurement) on body mass index (BMI) and examined whether stress moderated associations between food insecurity and BMI. Analyses revealed that undocumented status was associated with food insecurity and chronic stress but not when accounting for poverty. Food insecurity was only associated with higher BMI for children with the highest hair cortisol. Results suggest that chronic stress may impact body weight among food-insecure children.
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Affiliation(s)
- Laura M L Distel
- Department of Psychology, Loyola University Chicago, Chicago, Illinois
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19
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Sala M, Egbert AH, Lavender JM, Goldschmidt AB. Affect, reward, and punishment in anorexia nervosa: a narrative overview. Eat Weight Disord 2018; 23:731-737. [PMID: 30288725 PMCID: PMC7479630 DOI: 10.1007/s40519-018-0588-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/26/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Anorexia nervosa (AN) is a serious psychiatric disorder that is difficult to treat and often follows a protracted course. A number of theoretical models have been proposed for the etiology and maintenance of AN. Two domains that have received substantial attention in the literature on AN are affect and reward/punishment processes. However, despite an overlap in the nature and implications of these processes, studies of AN addressing these constructs have typically investigated them independently. PURPOSE The purpose of this narrative review is to integrate the literature on the role of affect, reward, and punishment in AN. METHOD We provide a focused narrative overview of the literature relating to the affect, reward, and punishment in AN via a synthesis of recent reviews and meta-analyses. RESULTS We first describe several prominent affect and reward/punishment-based conceptualizations of AN, followed by a brief overview of the existing empirical literature in these domains. CONCLUSION We provide a critical discussion of the disparate nature of these literatures in AN, including associated limitations. We then conclude with an extensive discussion of directions for future research that integrate the study of affect and reward/punishment processes in AN. LEVEL OF EVIDENCE Level V, narrative review.
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Affiliation(s)
- Margarita Sala
- Department of Psychology, Southern Methodist University, PO Box 750442, Dallas, TX, 75206, USA.
| | - Amy H Egbert
- Department of Psychology, Loyola University Chicago, Chicago, IL, USA
| | - Jason M Lavender
- Department of Psychiatry, University of California, La Jolla, San Diego, CA, USA
| | - Andrea B Goldschmidt
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Weight Control and Diabetes Research Center/The Miriam Hospital, Providence, RI, USA
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