Showing papers by "Stephen Touyz published in 2019"

Evaluating the role of digital intervention design in treatment outcomes and adherence to eTherapy programs for eating disorders: A systematic review and meta‐analysis

Abstract: Objective Despite the existence of reviews which document the effectiveness of online therapies, there is little consensus regarding the exact components of online treatment delivery that are most effective in maintaining user engagement and reducing eating disorder (ED) symptomology. The current review and meta-analysis aimed to determine which components of web-based, ED self-help interventions are associated with lower attrition and improved therapeutic outcome. Method A systematic search of electronic databases (PsycINFO, Medline, Web of Science, Scopus) was conducted for published studies of web-based interventions for EDs and a meta-analysis of the final included studies was performed. Each intervention was coded across four dimensions, including the multimedia channels employed (e.g., text, audio, videos), degree of user interactivity (e.g., online self-monitoring, skills exercises), level of automated feedback (e.g., reminders, personalized feedback), and technological device through which the program was accessed (e.g., smartphone, computer). Results A final 23 papers were included. The results of meta-regressions indicated that higher scores on the multimedia subscale were associated with greater ED symptom improvement in treatment groups. Conversely, a higher degree of feedback in the treatment group was associated with a group difference in ED psychopathology favoring the control group. Other intervention components were not associated with treatment outcome or dropout. Discussion The results are discussed in relation to limitations of the scale used to quantify digital intervention features, as well as the limited diversity and technological sophistication of available ED digital interventions. Such findings indicate the importance of understanding the digital components, which differentiate online therapeutic programs.

The short inventory of grazing (SIG): development and validation of a new brief measure of a common eating behaviour with a compulsive dimension

Abstract: Grazing, the repetitious and unplanned eating of small amounts of food with or without a sense of loss of control (LOC), is an eating pattern of recent interest which is highly prevalent in eating disorders and obesity. The current study aimed to (1) assess psychometric properties of a short inventory of grazing (SIG), consisting of a “grazing in general” item and a “compulsive/LOC grazing” item and (2) examine associations between compulsive and non-compulsive grazing and body mass index (BMI), eating disorder psychopathology, distress and health-related quality of life. Participants recruited from a university and the community (n = 227; 75.3% female; age = 25.00 (9.88; 17.58–57.17) years; BMI = 23.24 (4.91, 14.20–46.06) kg/m2) completed an online test battery including the SIG. Parametric and non-parametric statistics were computed to assess internal consistency, test-retest reliability and construct validity, to test associations between the SIG and the other study variables, and to examine between-group differences. The SIG demonstrated appropriate psychometric properties. Results indicated that both grazing in general and low-frequency LOC grazing are common; however, LOC grazing of moderate-severe frequency and/or associated with marked distress is unusual. Frequency of LOC grazing, but not grazing in general, was significantly associated with higher BMI, psychological distress, compensatory behaviours and lower mental health-related quality of life. The presence of compulsive grazing was also associated with eating disorder caseness and binge-type eating disorder diagnostic groups. Results support the positioning of “compulsive” LOC grazing on a continuum of problematic eating. The SIG is a parsimonious measure of this eating pattern of emergent interest.

Accuracy of self-reported physical activity in patients with anorexia nervosa: links with clinical features

Abstract: High levels of physical activity (PA) have long been described in patients with Anorexia Nervosa (AN). Despite the importance of measuring PA in this population, there are two important factors that remain unknown. First, it is not clear how accurate self-report measures of PA are among patients. Second, little is known about how clinical characteristics are associated with the accuracy of self-reported PA. Therefore, this study aimed to examine the accuracy of self-reported PA compared to an objective measure of PA in patients with AN. It also investigated whether levels of accuracy/inaccuracy were associated with compulsive exercise, motivation to change, and psychological distress. Data were analysed from 34 adult outpatients with AN. Patients wore an accelerometer device (ActiGraph) for 4 days and completed a retrospective self-report measure of exercise (Exercise Participation Screening Questionnaire). They also completed measures of compulsive exercise (Compulsive Exercise Test), motivation to change (The Anorexia Nervosa Stages of Change Questionnaire), and psychological distress (Kessler-10). On the self-report measure, patients accurately reported their time spent in moderate and vigorous intensity PA, however, they significantly under-reported their light physical activity (compared to the accelerometer data). Accurate reporting of total PA was positively associated with higher levels of compulsive exercise. There was evidence to suggest that clinical features, such as motivation to change and psychological distress, may be associated with inaccurate reporting at some levels of PA intensity and not others. Results indicate that patients with AN are likely to under-report their light intensity PA. We also found preliminary evidence for how compulsive exercise, motivation to change, and distress are associated with self-reported PA accuracy. Clinical implications and directions for future research are considered. ACTRN12610000585022 . Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

Eating disorders, bipolar disorders and other mood disorders: complex and under-researched relationships

Abstract: Background Eating disorders are understood to no longer be the remit of lean adolescent girls alone [1], whatever pop culture offerings such as Netflix’s To The Bone might continue to present. Rather, people with eating disorders are much more diverse, often undiagnosed and often suffering in silence. One patient population with a unique but poorly understood vulnerability to eating disorders, as well as obesity and poor physical health, is people with bipolar disorder. Bipolar disorder is a complex, serious mental illness that confers significant functional impairment, primarily due to time spent in manic, depressed, or mixed state episodes, difficulty eliminating subthreshold depressive symptoms, and the financial, social and emotional sequelae of illness episodes. One significant contributor to disability is physical ill health, with the average life expectancy of someone with bipolar disorder notably reduced due to cardiometabolic illnesses like heart disease and type two diabetes mellitus. Furthermore, poorer physical health is associated with poorer mental health in this group, such as higher risk of depressive relapse [2, 3]. The past two decades has seen increased focus on preserving and improving the physical health of people with bipolar disorder, who are often prescribed long-term medication known to be conducive to weight gain [4]. Trials of a number of interventions have attempted to implement lifestyle interventions to promote healthy eating, physical activity, and social connectedness, in order to prevent or reduce the adverse impact of obesity and improve physical health and psycho-social functioning [5]. These have been of limited long-term effectiveness, though early intervention post-first episode psychosis appears to be more promising [6]. The role of disordered eating in contributing to physical and mental health outcomes among individuals with bipolar disorder has rarely been considered, despite the fact that approximately one in three people with bipolar disorder also meet criteria for binge eating disorder, bulimia nervosa, or variants of these disorders [7, 8]. Alongside studies questioning the impact of medication on weight gain in bipolar disorder [9], identifying the role of weight-cycling in higher cardiovascular risk [10], and showing that obesity risk pre-dates medication [11], are reports of a link between eating disorders and high Body Mass Index (BMI, kg/m) [12] and evidence that baseline binge eating predicts medication-associated weight gain [13]. With these recent developments in mind, the authors were curious about what novel interventions for eating disorders and weight disorder in bipolar disorder exist, and conducted a systematic review about their effectiveness. In this search no treatments targeting eating disorders specifically were found to exist [14], despite the movement of this area into the spotlight over 10 years ago [15]. Most treatments of people with a high BMI in bipolar disorder neglect psychological factors with the exception of [16], and people with bipolar disorder are often though not always; see [17] excluded from eating disorder treatment trials e.g. [18, 19]. Hence, the effectiveness of Cognitive Behaviour Therapy (CBT) or other

Cross-sectional comparison of health-related quality of life and other features in people with and without objective and subjective binge eating using a general population sample.

Abstract: OBJECTIVES Evidence suggests that while objective binge eating (OBE) and subjective binge eating (SBE) differ in the amount of food consumed, both are associated with impairment in people with eating disorders. However, only OBE is accounted for in the diagnostic criteria of eating disorders. This study compared the sociodemographic profile and burden of OBE versus SBE at a population level. DESIGN Population-based survey. PARTICIPANTS A representative sample of 3028 men and women. Participants were categorised into four groups based on their reporting of binge eating in the past 3 months: non-binge eating group (no OBE or SBE), OBE group, SBE group and OSBE group (both OBE and SBE). OUTCOME MEASURES Demographics (age, genderand body mass index, BMI), binge eating, distress, weight/shape overvaluation and health-related quality of life. Groups were compared on sociodemographic information, overvaluation and health-related quality of life. The OBE and SBE groups were also compared on the distress related to binge eating. RESULTS No differences were found between the SBE group and OBE group in age, gender, BMI, mental health-related quality of life and overvaluation (all p>0.05). However, differences were found in the OSBE participants, namely that they were younger, had a higher mean BMI, lower mental health-related quality of life and higher overvaluation of weight/shape than the non-binge-eating participants (all p<0.001). Proportions of participants who reported distress related to binge eating in the OBE and SBE groups also did not differ (p=0.678). CONCLUSION There is little difference in the demographic profile or burden of people who engage in OBE versus SBE, supporting the proposed inclusion of SBE in the diagnostic criteria for eating disorders in International Classification of Diseases-11. People who experience both OBE and SBE may experience a relatively higher eating disorder severity and impairment.

Associations between self-reported diabetes mellitus, disordered eating behaviours, weight/shape overvaluation, and health-related quality of life.

Abstract: Eating disorders (ED) and disordered eating behaviours (DEB) have been found to be common in people with diabetes mellitus (DM). However, findings have been inconsistent. This study investigated the association between self-reported diabetes (Type 1 or 2) with ED/DEB (binge eating, subjective binge eating or loss of control overeating, severe dieting and purging) weight/shape overvaluation, and health-related quality of life (HRQoL) in a household survey in South Australia. In 2017 2977 people aged ≥15 years, who were representative of the general population, were interviewed. Participants reported their gender, age, household income, highest educational attainment, area of residence, presence of DM, ED/DEB, level of overvaluation, current HRQoL and height and weight. For the analyses between ED/DEB, self-reported DM and HRQoL, a grouping variable was created: 1) people without ED/DEB or self-reported DM; 2) people without ED/DEB and with self-reported DM; 3) people with ED/DEB and without self-reported DM; and 4) people with ED/DEB and self-reported DM. Analyses were stratified by sex and age group. Subjective binge eating prevalence was higher in people with self-reported DM (6.6% vs 2.8%, p = 0.016), and overvaluation was lower in those with DM (36% vs 43.8%, p = 0.007). In analyses stratified by sex and age group, subjective binge eating was higher in women and in people over 45 years with self-reported DM and overvaluation was lower in men and in people over 45 years with self-reported DM. However, these differences were not significant on tests of gender and age interaction. People in both DM groups scored significantly lower than people without DM groups on physical HRQoL. In contrast, people in both ED/DEB groups scored lower than people without ED/BEB on mental HRQoL. People with self-reported DM had a higher prevalence of subjective binge eating, a lower prevalence of overvaluation and there were no significant effects of age or gender. Furthermore, participants with self-reported DM and comorbid ED or DEB had impairments of both mental and physical HRQoL. Assessing an individual’s sense of control over eating along with other DEB is likely important for identification of these mental health problems.

Understanding the neural mechanisms of lisdexamfetamine dimesylate (LDX) pharmacotherapy in Binge Eating Disorder (BED): a study protocol

Abstract: The efficacy and safety of Lisdexamfetamine dimesylate (LDX) in the treatment of moderate to severe binge eating disorder (BED) has been demonstrated in multiple randomised clinical trials. Despite this, little is known about how LDX acts to improve binge eating symptoms. This study aims to provide a comprehensive understanding of the neural mechanisms by which LDX improves symptoms of BED. We hypothesise that LDX will act by normalising connectivity within neural circuits responsible for reward and impulse control, and that this normalisation will correlate with reduced binge eating episodes. This is an open-label Phase 4 clinical trial of LDX in adults with moderate to severe BED. Enrolment will include 40 adults with moderate to severe BED aged 18–40 years and Body Mass Index (BMI) of 20–45 kg/m2, and 22 healthy controls matched for age, gender and BMI. Clinical interview and validated scales are used to confirm diagnosis and screen for exclusion criteria, which include comorbid anorexia nervosa or bulimia nervosa, use of psychostimulants within the past 6 months, and current use of antipsychotics or noradrenaline reuptake inhibitors. Baseline assessments include clinical symptoms, multimodal neuroimaging, cognitive assessment of reward sensitivity and behavioural inhibition, and an (optional) genetic sample. A subset of these assessments are repeated after eight weeks of treatment with LDX titrated to either 50 or 70 mg. The primary outcome measures are resting-state intrinsic connectivity and the number of binge eating episodes. Analyses will be applied to resting-state fMRI data to characterise pharmacological effects across the functional connectome, and assess correlations with symptom measure changes. Comparison of neural measures between controls and those with BED post-treatment will also be performed to determine whether LDX normalises brain function. First enrolment was in May 2018, and is ongoing. This study is the first comprehensive investigation of the neurobiological changes that occur with LDX treatment in adults with moderate to severe BED. ACTRN12618000623291, Australian and New Zealand Clinical Trials Registry URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374913&isReview=true . Date of Registration: 20 April 2018.

Ten-year time trends in mental and physical health correlates of weight/shape overvaluation.

Abstract: OBJECTIVE: To investigate the relationships between weight/shape overvaluation, health-related quality of life (HRQoL) and functional role impairment (days out of role [DOR]) in the general population over 11 years. METHOD: Five cross-sectional surveys of men and women representative of the South Australian population were conducted in 2005, 2008, 2009, 2015, and 2016 (ntotal = 15,140). Data were collected on demographics, overvaluation, HRQoL, DOR, and eating disorder behaviours. RESULTS: Between 2005 and 2016, the prevalence of moderate overvaluation increased from 18.1% to 40.0%, marked overvaluation from 7.5% to 23.7%, and extreme overvaluation from 3.1% to 9.2% (all p < 0.001). Overvaluation at any level was associated with more DOR in 2005 but not in 2016, and the association between HRQoL impairment and overvaluation weakened over time. CONCLUSION: Although the population prevalence of overvaluation has increased significantly in the past decade, the impairment associated with it appears to have reduced.

Elucidating knowledge and beliefs about obesity and eating disorders among key stakeholders: paving the way for an integrated approach to health promotion

Abstract: Understanding the knowledge and beliefs of key stakeholders is crucial in developing effective public health interventions. Knowledge and beliefs about obesity and eating disorders (EDs) have rarely been considered, despite increasing awareness of the need for integrated health promotion programs. We investigated key aspects of knowledge and beliefs about obesity and EDs among key stakeholders in Australia. Using a semi-structured question guide, eight focus groups and seven individual interviews were conducted with 62 participants including health professionals, personal trainers, teachers and consumer group representatives. An inductive thematic approach was used for data analysis. The findings suggest that, relative to obesity, EDs are poorly understood among teachers, personal trainers, and certain health professionals. Areas of commonality and distinction between the two conditions were identified. Integrated health promotion efforts that focus on shared risk (e.g., low self-esteem, body dissatisfaction) and protective (e.g., healthy eating, regular exercise) factors were supported. Suggested target groups for such efforts included young children, adolescents and parents. The findings indicate areas where the EDs and obesity fields have common ground and can work together in developing integrated health promotion programs.

How eating disordered and non-eating disordered women differ in their use (and effectiveness) of cognitive self-regulation strategies for managing negative experiences.

Abstract: The present study compared the use (and effectiveness) of cognitive self-regulation strategies in eating disordered (ED) and non-eating disordered women (non-ED), and whether ED subgroups differ in their use of avoidant/suppressive strategies and cognitive reappraisal. The participants consisted of 90 adult patients recruited from a specialist eating disorder service and 97 adults without an ED. Cognitive self-regulation strategies were examined on a baseline self-report measure and while looking in a mirror. The results of this study showed that, relative to the non-ED group, ED participants engage in more worry and self-punishment and less distraction and social control strategies in general but not specifically during a body exposure task. Reappraisal strategies were equally likely to be used by clinical and non-clinical groups but participants with anorexia nervosa (AN) found them less effective during the task. Non-ED participants found distraction strategies more effective than the ED group for managing the body exposure experience. ED subgroups used avoidant/suppressive strategies and cognitive reappraisal strategies to a similar extent. The use of maladaptive self-regulation strategies, and the use and effectiveness of some of the more adaptive self-regulation strategies sets eating disorders apart from those without an eating disorder, supporting previous research in the area. Contrary to what was predicted, the results were similar across ED subgroups. The findings highlight the importance of cognitive self-regulation strategies as a focus of research and clinical intervention. Level III: Case-control study.

The Real Happy Study: Protocol for a Prospective Assessment of the Real-World Effectiveness of the HAPIFED Program-a Healthy APproach to weIght management and Food in Eating Disorders.

Abstract: The prevalence of obesity with comorbid binge eating behaviour is growing at a faster rate than that seen for either obesity or eating disorders as separate conditions. Approximately 6% of the population are affected and they potentially face a lifetime of poor physical and mental health outcomes and an inability to sustain long-term weight loss. Current treatment options are inadequate in that they typically address either obesity or eating disorders exclusively, not the combination of both conditions. By treating one condition without treating the other, relapse is common, and patients are often left disappointed with their lack of weight loss. An integrated approach to treating these individuals is needed to prevent a worsening of the comorbidities associated with excess body weight and eating disorders. A new therapy has recently been developed, named HAPIFED, which addresses both overweight/obesity and comorbid binge eating behaviour with the combination of behavioural weight loss therapy and cognitive behaviour therapy-enhanced (CBT-E). The aim of this paper is to document the protocol for the Real Happy Study, which will evaluate the effectiveness of the HAPIFED program in treating overweight or obesity with comorbid binge-eating behaviour in a real-world setting.

Shared associations between histories of victimisation among people with eating disorder symptoms and higher weight.

Abstract: Background:The success of integrated prevention initiatives for eating disorders and obesity is hampered by a lack of shared risk factor research. Bullying and sexual abuse are potentially potent s...

EDITORIAL: Eating disorders in diabetes: Discussion on issues relevant to type 1 diabetes and an overview of the Journal's special issue.

Abstract: Research suggests that women with Type 1 diabetes mellitus (T1DM) have close to 2.5 times the risk for developing an eating disorder compared to women without T1DM [1]. Women with T1DM can present with the full range of eating disordered symptoms however, the majority of research is focused only on those involving insulin restriction as a weight control behavior. It is unclear why girls and women with T1DM have increased rates of disordered eating behaviors and diagnosed eating disorders, but T1DM is strongly associated with a number of common eating disorder risk factors. For example, people with diabetes have twice the risk of clinically significant depression than those without diabetes [2]. Women and girls with T1DM also often have a higher BMI than their peers without diabetes [3]. Far less is known about Type 2 Diabetes (T2DM) and eating disorders [4] but management can be similarly challenging when it is comorbid with an eating disorder. Other aspects of diabetes treatment may also increase the risk of eating disorders. The treatment itself involves paying close attention to refined carbohydrates and to food portions which can parallel the rigid thinking about food, weight, and body image reported by women with eating disorders who do not have diabetes [5]. Such treatment recommendations can lead to feelings of deprivation, resentment and shame, and to binge eating. Studies have found that disturbed eating behaviors in T1DM are strongly predicted by higher Body Mass Index (BMI), higher shape and weight concerns, lower self-esteem, and depressed mood. Positive feelings about appearance, the absence of depression, and a lower BMI may be protective factors [6–9]. Higher diabetes-related family conflict also appears to be a risk factor [10]. Notably, adolescence is a time of increased risk for both eating disorders and for worsening of glycemic control. The latter could reflect metabolic changes during this time, and as well it is the period when responsibility for insulin administration transitions from the parent(s) to the child. Women with T1DM and eating disorders have A1c values approximately 2 or more percentage points higher than similarly aged women with T1DM without eating disorders. (The A1c is a laboratory test that estimates the average blood glucose values over a three-month period.) Patients who restrict insulin as a purging behaviour have higher rates of hospital and emergency room visits, higher rates of medical complications, and more negative attitudes toward T1DM than women who do not report insulin restriction [11–13]. Endorsing just insulin restriction alone was shown to increase mortality risk 3-fold over an 11-year period [14]. Even lower threshold disordered eating behaviors are strongly associated with significant medical and psychological consequences [15]. Although current treatment encourages a goal A1c of 7% or below, this target can seem unattainable and lead to disengagement from selfmanagement of T1DM. Alternatively, diabetes treatment goals can also encourage perfectionism and lead to frustration, because blood glucose cannot be kept in range at all times. Diabetes specialists report feeling frustrated by the dearth of specialized treatment programs for eating