Publications by authors named "Nancy Zucker"

87 Publications

Children's Beliefs about Pain: An Exploratory Analysis.

Children (Basel) 2021 May 27;8(6). Epub 2021 May 27.

Department of Psychology and Neuroscience, Duke University, Durham, NC 27708, USA.

Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associated with significant distress and impairment. Little is known about how children understand their pain. Do they attribute it to personal weakness? Do they perceive pain as having global impact, affecting a variety of activities? How do they cope with pain? We explored the pain beliefs of 5- to 9-year-old children with FAP using a novel Teddy Bear Interview task in which children answered questions about a Teddy bear's pain. Responses were analyzed quantitatively and qualitatively. Results indicate that the majority of young children with FAP are optimistic about pain outcomes. Children generated many types of coping strategies for Teddy's pain and adjusted their calibration of Teddy's pain tolerance dependent on the activity being performed. Early warning signs also emerged: a subset of children were pessimistic about Teddy's pain, and several children identified coping strategies that, while developmentally appropriate, could lead to excessive help seeking if not intervened upon (e.g., physician consultation and shot). The Teddy Bear Interview allows children to externalize their pain, making it a useful tool to access cognitive pain constructs in younger children. Thus, these findings highlight the importance of early intervention for childhood FAP.
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http://dx.doi.org/10.3390/children8060452DOI Listing
May 2021

The diagnosis of avoidant restrictive food intake disorder in the presence of gastrointestinal disorders: Opportunities to define shared mechanisms of symptom expression.

Int J Eat Disord 2021 Jun 24;54(6):995-1008. Epub 2021 May 24.

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA.

Objective: Individuals with a gastrointestinal (GI) disorder often alter their diet to manage GI symptoms, adding complexity to understanding the diverse motivations contributing to food avoidance/restriction. When a GI disorder is present, the DSM-5 states that Avoidant/Restrictive Food Intake Disorder (ARFID) can be diagnosed only when eating disturbance exceeds that expected. There is limited guidance to make this determination. This study attempts to address this gap by characterizing the presentation of ARFID in adults with and without a self-reported GI disorder.

Method: Participants were 2,610 adults ages 18-44 who self-identified as "picky eaters." Participants reported on motivations for food avoidance, affective experiences towards food, and perceived impairment. Responses were compared across four groups: GI issues and likely ARFID (L-ARFID/GI), L-ARFID-only, GI-only, and No-ARFID/No-GI.

Results: Groups with a GI disorder (L-ARFID/GI, GI-only) reported more fear of aversive consequences of eating than those without a GI disorder, while groups with L-ARFID (L-ARFID, L-ARFID/GI) evidenced significantly greater sensory aversion to food and indifference to food or eating, negative emotional reactions to food and overall disgust sensitivity, and eating related impairment.

Discussion: Consideration of the interplay of a GI disorder with ARFID can add precision to case conceptualization. Food avoidance may be attempts to manage fears of aversive consequences that are augmented by a history of GI symptoms, while sensory aversions and negative emotional reactions towards foods may be more elevated in ARFID. These findings emphasize the need to consider an ARFID diagnosis in patients with GI disorders to optimize care.
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http://dx.doi.org/10.1002/eat.23536DOI Listing
June 2021

Longitudinal associations of trauma exposure with disordered eating: lessons from the great smoky mountain study.

Eat Disord 2021 May 19:1-18. Epub 2021 May 19.

Department of Psychiatry, University of Vermont, Burlington, Vermont, United States.

Disordered eating is prevalent among trauma survivors, yet little is known about mechanisms underlying this relation. We explored cross-sectional and longitudinal associations of trauma exposure and posttraumatic stress disorder symptoms (PTSD) with disordered eating among 1,420 community-based youth participating in the Great Smoky Mountain Study. Participants were interviewed about trauma exposure, PTSD symptoms, and disordered eating at regular intervals throughout childhood, adolescence, and early adulthood. Our findings confirmed associations of all forms of trauma exposure (violent, sexual, and other) with disordered eating symptoms in childhood and adulthood, although the pattern of results varied by disordered eating symptom and trauma exposure type. Only non-sexual, non-violent trauma exposure in childhood had significant associations with any disordered eating symptoms in adulthood. Within childhood, trauma exposures but not PTSD symptoms showed significant longitudinal associations with bulimia nervosa symptoms and sustained appetite changes and preoccupation with eating. In adulthood, PTSD symptoms but not trauma exposures showed significant longitudinal associations only with bulimia nervosa symptoms. The association of specific PTSD clusters on bulimia nervosa symptoms was significant for reexperiencing, whereas hyperarousal symptoms trended toward significance. The impact of trauma exposures on disordered eating may vary by developmental period.
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http://dx.doi.org/10.1080/10640266.2021.1921326DOI Listing
May 2021

Do children with recurrent abdominal pain grow up to become adolescents who control their weight by fasting? Results from a UK population-based cohort.

Int J Eat Disord 2021 Jun 3;54(6):915-924. Epub 2021 May 3.

Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.

Objective: Gastrointestinal (GI) problems are common in eating disorders, but it is unclear whether these problems predate the onset of disordered eating. Recurrent abdominal pain (RAP) is the most prevalent GI problem of childhood, and this study aimed to explore longitudinal associations between persistent RAP (at ages 7 and 9) and fasting for weight control at 16.

Method: The Avon Longitudinal Study of Parents and Children (ALSPAC) is a UK population cohort of children. Childhood RAP was reported by mothers and defined as RAP 5+ (5 pain episodes in the past year) in our primary analysis, and RAP 3+ (3 pain episodes) in our sensitivity analysis. Fasting for weight control was reported by adolescents at 16. We used logistic regression models to examine associations, with adjustments for potential confounders.

Results: After adjustments, we found no association between childhood RAP 5+ and adolescent fasting for weight control at 16 (OR 1.30 (95% Confidence Intervals [CI] 0.87, 1.94) p = .197). However, we did find an association between RAP 3+ and later fasting, in the fully adjusted model (OR 1.50 [95% CI 1.16, 1.94] p = .002), and after excluding those with pre-existing anxiety (OR 1.52 [95% CI 1.17, 1.97] p = .002).

Discussion: Our findings suggest a possible independent contribution of RAP to later risk of fasting for weight control, and RAP should be enquired about in the assessment of eating disorders. However, frequency of childhood abdominal pain (as captured by ALSPAC) may be less important to long-term outcomes than functional impairment.
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http://dx.doi.org/10.1002/eat.23513DOI Listing
June 2021

Weight-Related Behaviors of Children with Obesity during the COVID-19 Pandemic.

Child Obes 2021 Apr 26. Epub 2021 Apr 26.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.

During the coronavirus disease 2019 (COVID-19) pandemic, children and families have had to adapt their daily lives. The purpose of this study was to describe changes in the weight-related behaviors of children with obesity after the onset of the COVID-19 pandemic. Semistructured interviews ( = 51) were conducted from April to June 2020 with parents of children with obesity. Families were participants in a randomized trial testing a clinic-community pediatric obesity treatment model. During interviews, families described their experience during the COVID-19 pandemic, with a particular emphasis on children's diet, physical activity, sleep, and screen time behaviors. Rapid qualitative analysis methods were used to identify themes around changes in children's weight-related behaviors. The mean child age was 9.7 (±2.8) years and the majority of children were Black (46%) or Hispanic (39%) and from low-income families (62%). Most parent participants were mothers (88%). There were differences in the perceived physical activity level of children, with some parents attributing increases in activity or maintenance of activity level to increased outdoor time, whereas others reported a decline due to lack of outdoor time, school, and structured activities. Key dietary changes included increased snacking and more meals prepared and consumed at home. There was a shift in sleep schedules with children going to bed and waking up later and an increase in leisure-based screen time. Parents played a role in promoting activity and managing children's screen time. The COVID-19 pandemic has created unique lifestyle challenges and opportunities for lifestyle modification. Clinical Trials ID: NCT03339440.
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http://dx.doi.org/10.1089/chi.2021.0038DOI Listing
April 2021

The clash of culture and cuisine: A qualitative exploration of cultural tensions and attitudes toward food and body in Chinese young adult women.

Int J Eat Disord 2021 Feb 31;54(2):174-183. Epub 2020 Dec 31.

Department of Psychology and Neuroscience, Duke University, Durham, North Carolina, USA.

Objective: Accumulating evidence suggests that the prevalence of eating disorders among Chinese women is a public health concern. Prior studies have drawn linkages between conflicting cultural values, identity confusion, and eating disorder symptomatology, which may be relevant for understanding the rise of eating disorders amidst China's rapid economic and sociocultural transformation. Here, we explore how women's experiences with traditional eating norms and modernizing norms of femininity may shape their food and body attitudes.

Method: Chinese young adult women (N = 34; aged 18-22 years) participated in semi-structured interviews focusing on experiences with norms surrounding eating and ideal feminine appearance, perceived conflict between these norms, and their responses to perceived conflict. Interviews were conducted via email (n = 27) or via Skype (n = 7). Participants were not asked about past or present diagnoses of eating disorders. Analysis of responses was guided by the principles of thematic analysis.

Results: Women reported encounters with cultural eating norms and feminine appearance norms, and described factors that motivated continued or discontinued adherence to these norms. Women reported strategies of conflict resolution, which resulted in different emotional and behavioral outcomes including eating disorder symptoms.

Discussion: Women's experiences with norms surrounding eating and appearance indicate the centrality of these encounters in the formation of individual and interpersonal values. Our findings suggest the importance for clinicians to assist clients in exploring the meanings behind internalized attitudes toward food and body, and to help clients balance interpersonal and individual needs.
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http://dx.doi.org/10.1002/eat.23459DOI Listing
February 2021

Internal states and interoception along a spectrum of eating disorder symptomology.

Physiol Behav 2021 Mar 26;230:113307. Epub 2020 Dec 26.

Duke University Department of Psychology and Neuroscience, Durham NC, USA; Duke University School of Medicine, Department of Psychiatry & Behavioral Sciences Durham NC, USA.

Objective: Recent studies on atypical interoceptive capabilities have focused on clinical populations, including anorexia nervosa[1,2]. The present exploratory study aims to characterize the influence of disordered eating symptomology on interoceptive capabilities in college students, a population for which dangerous dieting behaviors may emerge.

Method: Ninety-nine participants were randomized to consume a blinded high calorie or low calorie midday shake. Participants reported frequency of eating disorder cognitions and behaviors; indicated changes in satiety, happiness, and energy pre- and post-consumption; and guessed the calories in their shake. Outcomes (perceived satiety, changes in mood, and caloric guess) were regressed on eating disorder symptoms scores, the high/low calorie shake condition, and the interaction between these predictors.

Results: Those randomized to receive the high calorie shake reported feeling fuller, but only when endorsing lower levels of eating concern. Those randomized to the high calorie shake reported greater post-meal happiness, but only at greater levels of eating concerns. Lastly, those with lower levels of eating restraint reported an expected positive association between level of fullness and calorie guess, but those with higher levels of eating restraint did not exhibit any relationship between perceived fullness and calorie guess.

Discussion: Results of this exploratory suggest that irregular eating habits (e.g., not eating a sufficient amount for lunch) may have direct consequences on interoceptive capabilities. Further, these capacities may be impacted by individual differences in eating concern and restraint. Preliminary findings suggest that impairment in deciphering visceral signals may be associated with the degree of eating disorder symptomology; such impairment may occur at lower levels of symptomatology than normative data would indicate.
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http://dx.doi.org/10.1016/j.physbeh.2020.113307DOI Listing
March 2021

Meal skipping and cognition along a spectrum of restrictive eating.

Eat Behav 2020 12 7;39:101431. Epub 2020 Sep 7.

Duke University Department of Psychology and Neuroscience, Durham, NC, USA; Duke University School of Medicine Department of Psychiatry & Behavioral Sciences, Durham, NC, USA.

Objective: Inadequate nutrition adversely impacts brain development and cognitive functioning (Pollitt et al., 1983). Studies examining the acute impact of eating regular meals on cognition have reported inconsistent findings, necessitating the exploration of individual differences in samples contributing to equivocal results. The present study examines the impact of skipping lunch on cognitive ability in college-aged students by including eating restraint as a moderator.

Methods: Participants were 99 college-aged students (M = 19.7 years, SD = 1.5) randomized to a blinded 'lunch' or 'lunch-omission' condition, and assessed on memory, attention, processing speed, set shifting, and eating disorder symptomology.

Results: Regressing long and short-term memory on the lunch manipulation, eating restraint scores, and their interaction revealed significant interactions: those who had lunch had superior memory performance, but only for those reporting lower levels of eating restraint. Regressing set shifting speed on the manipulation, those who had lunch had slower set shifting speed than those who skipped, but only for those reporting lower levels of eating restraint.

Conclusions: Results suggest that skipping lunch may have immediate consequences on cognition, however, cognitive enhancing effects may be diminished in the presence of even low levels of eating restraint. Findings highlight the significance of purported subclinical levels of eating restraint and may inform health education strategies.
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http://dx.doi.org/10.1016/j.eatbeh.2020.101431DOI Listing
December 2020

Increased emotional eating behaviors in children with autism: Sex differences and links with dietary variety.

Autism 2021 04 1;25(3):603-612. Epub 2020 Aug 1.

Duke University, USA.

Lay Abstract: Although "picky" eating is well documented in autism spectrum disorder, emotional eating has rarely been investigated. This study examined emotional over- and under-eating based on parent ratings of these behaviors in 4- to 17-year-old children with autism spectrum disorder ( = 190) as compared to same-age typically developing children ( = 119). Children with autism spectrum disorder were rated as exhibiting both more emotional over-eating and more emotional under-eating behaviors than their typically developing peers. Furthermore, while sex differences in these emotional eating behaviors were not observed in the typically developing children, girls with autism spectrum disorder were rated as experiencing more emotional over-eating behaviors than boys with autism spectrum disorder. Finally, among all children with autism spectrum disorder, emotional over-eating was linked with increased consumption of sweet foods and decreased consumption of vegetables. These findings have implications for better understanding eating habits in children with autism spectrum disorder and suggest that emotional eating behaviors might have both immediate and downstream health impacts.
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http://dx.doi.org/10.1177/1362361320942087DOI Listing
April 2021

A multi-method assessment of interoception among sexual trauma survivors.

Physiol Behav 2020 11 25;226:113108. Epub 2020 Jul 25.

Department of Psychology and Neuroscience, Duke University.

It is well established that many female sexual trauma survivors experience dissociation, particularly disconnection from the body, in the aftermath of sexual trauma. This study aims to address the open question of how sexual trauma is associated with awareness of inner body sensations (i.e., interoception). Given the important role that interoception has in emotion regulation, a process with which survivors often struggle, it is important to understand the associations between interoception and PTSD symptoms among survivors. Through multi-methods, we assessed associations between interoception, dissociation, and PTSD symptoms among 200 female sexual trauma survivors. We assessed two components of interoception: interoceptive accuracy (IAc: accurately perceiving internal body sensations; via heartbeat perception task) and interoceptive sensibility (IS: self-report perception of sensitivity to interoceptive sensations). We hypothesized that IAc and IS would be positively correlated with PTSD, with interactions between IAc/dissociation and IS/dissociation qualifying those main effects, weakening them for survivors with higher dissociation. Results showed an opposite pattern than was predicted: although IAc did explain significant PTSD variance, as IAc increased, PTSD decreased. Although IAc did explain significant variance in PTSD symptoms, interestingly, IS did not. Consistent with extant literature, dissociation predicted significant variance in PTSD. These correlational results suggest that the ability to more accurately perceive inner body sensations is related to lower PTSD symptoms. Findings provide a foundation for future research that can assess if interventions (such as yoga or exercise) that target increasing interoceptive accuracy lead to decreases in PTSD symptoms. We discuss further clinical implications, limitations and future directions.
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http://dx.doi.org/10.1016/j.physbeh.2020.113108DOI Listing
November 2020

Rationale and design of "Hearts & Parks": study protocol for a pragmatic randomized clinical trial of an integrated clinic-community intervention to treat pediatric obesity.

BMC Pediatr 2020 06 26;20(1):308. Epub 2020 Jun 26.

Duke Clinical Research Institute, Duke University, Durham, NC, 27710, USA.

Background: The prevalence of child and adolescent obesity and severe obesity continues to increase despite decades of policy and research aimed at prevention. Obesity strongly predicts cardiovascular and metabolic disease risk; both begin in childhood. Children who receive intensive behavioral interventions can reduce body mass index (BMI) and reverse disease risk. However, delivering these interventions with fidelity at scale remains a challenge. Clinic-community partnerships offer a promising strategy to provide high-quality clinical care and deliver behavioral treatment in local park and recreation settings. The Hearts & Parks study has three broad objectives: (1) evaluate the effectiveness of the clinic-community model for the treatment of child obesity, (2) define microbiome and metabolomic signatures of obesity and response to lifestyle change, and (3) inform the implementation of similar models in clinical systems.

Methods: Methods are designed for a pragmatic randomized, controlled clinical trial (n = 270) to test the effectiveness of an integrated clinic-community child obesity intervention as compared with usual care. We are powered to detect a difference in body mass index (BMI) between groups at 6 months, with follow up to 12 months. Secondary outcomes include changes in biomarkers for cardiovascular disease, psychosocial risk, and quality of life. Through collection of biospecimens (serum and stool), additional exploratory outcomes include microbiome and metabolomics biomarkers of response to lifestyle modification.

Discussion: We present the study design, enrollment strategy, and intervention details for a randomized clinical trial to measure the effectiveness of a clinic-community child obesity treatment intervention. This study will inform a critical area in child obesity and cardiovascular risk research-defining outcomes, implementation feasibility, and identifying potential molecular mechanisms of treatment response.

Clinical Trial Registration: NCT03339440 .
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http://dx.doi.org/10.1186/s12887-020-02190-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318397PMC
June 2020

Do interoceptive accuracy and interoceptive sensibility predict emotion regulation?

Psychol Res 2020 Jun 16. Epub 2020 Jun 16.

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.

Introduction: Interoception refers to awareness, interpretation, and integration of sensations in the body. While interoceptive accuracy has long been regarded as a core component of emotional experience, less is known about the relationship of interoceptive accuracy and related facets of interoception to emotion regulation deficits. This study explores how interoceptive accuracy and interoceptive sensibility relate to emotion regulation in a non-clinical sample.

Methods: Undergraduate participants completed a heartbeat perception task and the Multidimensional Assessment of Interoceptive Awareness (Noticing and Body Listening sub-scales), and rated their confidence in performance on the heartbeat perception task. Participants also completed self-report measures of emotional awareness and regulation (Profile of Emotional Competence, intrapersonal emotion identification and emotion regulation sub-scales), and rated their use of different coping strategies (Brief COPE).

Results: Noticing predicted emotion identification, emotion regulation, and the use of adaptive but not maladaptive coping strategies. Heartbeat perception accuracy did not significantly contribute to the prediction of any outcome variables.

Discussion: Future work is needed to extend these findings to clinical populations. The results from this study support the use of interoceptive training interventions to promote emotional wellbeing.
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http://dx.doi.org/10.1007/s00426-020-01369-2DOI Listing
June 2020

The Persistence of Picky Eating: Opportunities to Improve Our Strategies and Messaging.

Pediatrics 2020 06;145(6)

Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas.

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http://dx.doi.org/10.1542/peds.2020-0893DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263049PMC
June 2020

Rigidity and Sensory Sensitivity: Independent Contributions to Selective Eating in Children, Adolescents, and Young Adults.

J Clin Child Adolesc Psychol 2020 Mar 19:1-13. Epub 2020 Mar 19.

Department of Speech, Language and Hearing Sciences, The George Washington University.

: Selective or "picky" eating (SE) refers to rejection of a wide range of familiar and unfamiliar foods based on aversions to their sensory properties. When severe, SE can cause symptoms of avoidant/restrictive food intake disorder (ARFID), including weight loss, nutritional deficiencies, and/or psychosocial impairment. SE is highly prevalent in autism spectrum disorder (ASD) compared to both typical development and other developmental disorders. A possible explanation for the high prevalence of SE in ASD is the effect of core ASD symptoms, repetitive/restrictive behaviors (e.g., rigidity), and sensory sensitivity on feeding behaviors. These traits are found not only in ASD but also in other clinical groups and the general population, albeit often at subclinical levels. Identifying mechanisms of SE across various populations is critical to inform intervention approaches.: In 263 unselected children ages 5-17, 534 unselected college students ages 18-22, 179 children with anxiety/obsessive spectrum disorders ages 5-17, and 185 children with ASD ages 4-17, we explored the unique contributions of sensory (i.e., oral texture and olfactory) sensitivities and rigidity as predictors of self/parent-reported SE.: In each sample, rigidity and oral texture sensitivity, controlling for olfactory sensitivity, age, and gender, emerged as significant, independent predictors of SE.: This is the first study to highlight the importance of cognitive/behavioral rigidity to SE, and one of the first to illustrate the domain-specificity of the relationship between sensory sensitivity and SE.
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http://dx.doi.org/10.1080/15374416.2020.1738236DOI Listing
March 2020

Associations of self-reported eating disorder behaviors and personality in a college-educated sample.

Appetite 2020 08 13;151:104669. Epub 2020 Mar 13.

Department of Medicine, Molecular Physiology Institute, USA.

Objective: In order to better understand factors motivating eating disorder (ED) behaviors and better identify persons at-risk for these behaviors, we sought to identify which personality domains and facets were associated with behaviors for weight control.

Methods: ED behavior information was gathered from the University of North Carolina Alumni Heart Study using the question, "have you ever used any of the following to lose weight?" Respondents endorsed any combination of the following: "Vomiting," "Fasting," "Laxatives," "Excessive physical exercise." Personality was measured using the Revised NEO Personality Inventory (NEO-PI-R). One-way ANOVAs were performed comparing personality domains and facets to reported ED behaviors, computed both as separate behaviors and the number of cumulative behaviors.

Results: Of 3496 respondents, 9.41% endorsed ever having used at least one ED behavior, with the majority endorsing only a single ED behavior. For both sexes, endorsing greater numbers of ED behaviors was associated with higher scores on Neuroticism and Openness. For women, the strongest associations for behaviors with personality were: excessive exercise with high Impulsiveness; fasting with high Impulsiveness and low Gregariousness; laxative use/purging with high scores on Activity and Feelings. For men, the strongest associations were: excessive exercise with high Impulsiveness; fasting with high Ideas; laxative use/purging with low Modesty.

Discussion: Data collected from this sample showed a sex-modulated pattern of association between personality domains and facets with ED behaviors. Our findings support that obtaining personality profiles of individuals exhibiting subclinical eating behaviors will enhance our understanding of who is at risk of developing an ED diagnosis.
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http://dx.doi.org/10.1016/j.appet.2020.104669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494136PMC
August 2020

On bells, saliva, and abdominal pain or discomfort: Early aversive visceral conditioning and vulnerability for anorexia nervosa.

Int J Eat Disord 2020 04 6;53(4):508-512. Epub 2020 Mar 6.

Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Gastrointestinal (GI) symptoms are common in anorexia nervosa (AN), can predate illness onset, complicate renourishment, and persist after recovery. We explore how, through processes of aversive visceral conditioning, early GI pain and discomfort may increase vulnerability to AN in some individuals. Processes include enhanced preoccupation with the gut resulting from aversive visceral memories and disruptions in the typical acquisition of self-attunement when children learn to map and interpret interoceptive sensations and develop adaptive actions. We question whether a fear of weight gain, in some cases, may be an epiphenomenon of the recapitulation of actual or perceived GI symptoms that is especially relevant during puberty, especially in girls. This conceptualization has immediate clinical implications and offers ideas for future research. We propose that GI discomfort associated with renourishment may reignite prior aversive visceral experiences. We encourage development of a formulation that organizes the individual's current experience of the body with respect to these prior aversive experiences. Our conceptualization underscores the importance of assessment of GI experiences in individuals with AN; the examination of dietary strategies that minimize GI symptoms and enhance renourishment efficacy; and strategies that attempt to alter this aversive visceral conditioning by mapping sensations to meanings and adaptive actions.
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http://dx.doi.org/10.1002/eat.23255DOI Listing
April 2020

Associations between attention deficit hyperactivity disorder symptoms and eating behaviors in early childhood.

Pediatr Obes 2020 07 2;15(7):e12631. Epub 2020 Mar 2.

Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, North Carolina, USA.

Background: Attention-deficit/hyperactivity disorder (ADHD) symptoms have been linked with eating behaviors and obesity adolescence and young adulthood. Yet, little is known about whether these associations occur during early childhood and few studies have examined these associations prospectively.

Objectives: To assess magnitude and direction of associations between childhood ADHD symptoms and eating behaviors.

Methods: Participants were from the Newborn Epigenetics Study (N = 470, M age = 4 years). Multivariable linear regression models were used to examine cross-sectional associations between ADHD symptoms and eating behaviors. Latent Change Score (LCS) modeling was performed to examine prospective association among a subset of children with available follow-up data. (N = 100, M age = 7 years).

Results: The cross-sectional results showed that attention problem (AP) and hyperactivity (HY) were positively associated with food responsiveness, emotional overeating, desire to drink, and slowness in eating. AP, but not HY, was inversely associated with enjoyment of food. Results of the LCS models revealed AP and HY were both positively associated with prospective changes in emotional overeating and satiety responsiveness. AP was further positively associated with prospective changes in food responsiveness. The reverse relationship predicting changes in ADHD symptoms from earlier assessments of eating behaviors was not significant.

Conclusion: Results suggest a link between ADHD symptoms and obesity-related eating behaviors in early childhood, highlighting the need to address self-regulation and healthy eating behaviors in the prevention of childhood obesity.
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http://dx.doi.org/10.1111/ijpo.12631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7391797PMC
July 2020

Family-Based Treatment for Anorexia Nervosa Symptoms in High-Risk Youth: A Partially-Randomized Preference-Design Study.

Front Psychiatry 2019 22;10:985. Epub 2020 Jan 22.

Department of Psychiatry, Columbia University, New York, NY, United States.

This pilot study adapted family-based treatment (FBT) for youth with potentially prodromal anorexia nervosa (AN). Fifty-nine youth with clinically significant AN symptom constellations, but who never met full Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (DSM-IV) criteria for AN, were enrolled in a partially randomized preference design study. Participants were offered randomization to FBT or supportive psychotherapy (SPT); those who declined to be randomized because of a strong treatment preference were entered into a parallel, non-randomized self-selected intervention study. Without accessing outcome data, an observational analysis with three diagnostic subclasses was designed based on AN symptom severity profiles, combining randomized and non-randomized participants, such that participants receiving FBT and SPT within each subclass were similar on key baseline characteristics. Outcomes of this pilot study were explored by calculating effect sizes for end-of-treatment values within each subclass, and also with a longitudinal mixed effect model that accounted for subclass. Weight trajectory was measured by percent expected body weight. Psychological outcomes were fear of weight gain, feeling fat, importance of weight, and importance of shape. Results show that the pattern of symptom observations over time was dependent on subclass of SAN (least symptomatic, moderately symptomatic, or most symptomatic) and on the target outcome variable category (weight or psychological). Results from this study, which should be considered in the context of the small sample sizes overall and within groups, can generate hypotheses for future, larger research trials on early treatment strategies. Feasibility findings illustrate how the innovative partially randomized preference design has potential broader application for AN intervention research.

Clinical Trial Registration: ClinicalTrials.gov, identifier NCT00418977.
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http://dx.doi.org/10.3389/fpsyt.2019.00985DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6987468PMC
January 2020

Eating disorder recovery in men: A pilot study.

Int J Eat Disord 2019 12 16;52(12):1370-1379. Epub 2019 Aug 16.

Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Objective: This pilot study examined the validity of a comprehensive definition of recovery (physical, behavioral, and cognitive recovery indices) for the first time in men.

Method: Men with an eating disorder history were recruited from former patients at eating disorder centers, university campuses, and fitness centers/gyms. At baseline and a 12-month follow-up, data were collected via online surveys, diagnostic interviews, and measured weight and height from men with an eating disorder history (n = 36) and men with no eating disorder history (n = 27).

Results: Of the men with an eating disorder history, 15 met criteria for an eating disorder, 7 met criteria for partial recovery, and 5 for full recovery. Men who met criteria for full recovery did not differ significantly from men with no eating disorder history and had significantly lower levels of broad eating pathology, thinness and restricting expectancies, body shame, difficulties in stopping thoughts about body, food, or exercise, and male body attitudes related to muscularity and body fat than men with an eating disorder. Men meeting criteria for full recovery had higher levels of body acceptance and intuitive eating than men who met criteria for partial recovery or an eating disorder. In terms of predictive validity, of those fully recovered at baseline, 60% also met full recovery criteria at follow-up.

Discussion: Preliminary findings suggest that a comprehensive definition of recovery applies to men. Although research with larger samples is needed, this research provides some optimism for the potential of recovery in men.
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http://dx.doi.org/10.1002/eat.23153DOI Listing
December 2019

Pre-Pregnancy Weight and Symptoms of Attention Deficit Hyperactivity Disorder and Executive Functioning Behaviors in Preschool Children.

Int J Environ Res Public Health 2019 02 25;16(4). Epub 2019 Feb 25.

Department of Biological Sciences, North Carolina State University, Raleigh, NC 27695, USA.

This study examines pre-pregnancy Body Mass Index (BMI) and gestational weight gain (GWG) in relation to early childhood Attention Deficit Hyperactivity Disorder (ADHD) symptoms and related executive self-regulation behaviors. The analyses sample ( = 331) included a subsample of participants from a birth cohort recruited from prenatal clinics and hospital facilities from April 2005 to June 2011 in Durham, North Carolina. Pre-pregnancy BMI was calculated from weight at the last menstrual period and height was extracted from medical records. Gestational weight gain was calculated from pre-pregnancy weight and weight measured at the time of delivery. ADHD symptoms and executive self-regulation behaviors were assessed by maternal report (mean age = 3 years). Multivariable regression methods with inverse probability weighting (IPW) were used to evaluate associations accounting for sample selection bias and confounding. Pre-pregnancy BMI at levels ≥35 was positively associated with higher ADHD symptoms and worse executive self-regulation behaviors (inhibitory control and attention). Compared to adequate GWG, less than adequate GWG was related to more ADHD hyperactive-impulsive symptoms, whereas greater than adequate GWG was related to more problematic behaviors related to working memory and planning. The findings support a link between maternal weight and child neurodevelopment. Continued research that help identify biological mechanisms are needed.
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http://dx.doi.org/10.3390/ijerph16040667DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6406951PMC
February 2019

The central role of disgust in disorders of food avoidance.

Int J Eat Disord 2019 05 25;52(5):543-553. Epub 2019 Feb 25.

Department of Psychology and Neuroscience, Duke University, Durham, North Carolina.

Background: Individuals with extreme food avoidance such as Avoidant Restrictive Food Intake Disorder (ARFID) experience impairing physical and mental health consequences from nutrition of insufficient variety or/and quantity. Identifying mechanisms contributing to food avoidance is essential to develop effective interventions. Anxiety figures prominently in theoretical models of food avoidance; however, there is limited evidence that repeated exposures to foods increases approach behavior in ARFID. Studying disgust, and relationships between disgust and anxiety, may offer novel insights, as disgust is functionally associated with avoidance of contamination from pathogens (as may occur via ingestion) and is largely resistant to extinction.

Method: This exploratory, cross-sectional study included data from 1,644 adults who completed an online questionnaire. Participant responses were used to measure ARFID classification, picky eating, sensory sensitivity, disgust, and anxiety. Structural equation modeling tested a measurement model of latent disgust and anxiety factors as measured by self-reported frequency of disgust and anxiety reactions. Mediational models were used to explore causal ordering.

Results: A latent disgust factor was more strongly related to severity of picky eating (B ≈ 0.4) and ARFID classification (B ≈ 0.6) than the latent anxiety factor (B ≈ 0.1). Disgust partially mediated the association between anxiety and picky eating and fully mediated the association between anxiety and ARFID. Models testing the reverse causal ordering demonstrated poorer fit. Findings suggest anxiety may be associated with food avoidance in part due to increased disgust.

Conclusions: Disgust may play a prominent role in food avoidance. Findings may inform novel approaches to treatment.
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http://dx.doi.org/10.1002/eat.23047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759364PMC
May 2019

Radcliffe ARFID Workgroup: Toward operationalization of research diagnostic criteria and directions for the field.

Int J Eat Disord 2019 04 13;52(4):361-366. Epub 2019 Feb 13.

Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts.

Objective: Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined.

Method: In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder.

Results: By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment.

Conclusions: This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.
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http://dx.doi.org/10.1002/eat.23042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485247PMC
April 2019

Avoidant Restrictive Food Intake Disorder.

Psychiatr Clin North Am 2019 03 22;42(1):45-57. Epub 2018 Dec 22.

Department of Psychiatry and Behavioral Sciences, Duke School of Medicine, Duke University, Duke Center for Eating Disorders, PO Box 3454, Durham, NC 27710, USA.

Avoidant restrictive food intake disorder (ARFID) is a rearticulated eating disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5), published in 2013. The purpose of this article is to review what is known about ARFID; specifically outline the DSM-5 diagnostic criteria; review the epidemiology; describe the clinical characteristics of patients with this disorder; and discuss evolving treatment approaches. Although this disorder occurs across the lifespan, the focus of recent research has been primarily in children and adolescents with ARFID. Therefore, most of this article is devoted to children and adolescents with ARFID.
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http://dx.doi.org/10.1016/j.psc.2018.10.003DOI Listing
March 2019

Avoidant restrictive food intake disorder: First do no harm.

Int J Eat Disord 2019 04 24;52(4):459-461. Epub 2019 Jan 24.

Division of Child and Family Mental Health and Developmental Neuroscience, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.

Objective: This opinion piece offers some considerations, both medical and psychological, for the use of nasogastric tube (NGT) feedings in the treatment of avoidant restrictive food intake disorder (ARFID) in children and adolescents.

Method: Although there is empirical support for the use of NGT feedings in the treatment of anorexia nervosa, this evidence base does not exist for the treatment of ARFID. As such, there is need to delineate pragmatic considerations in the use of this procedure.

Results: Issues of medical necessity notwithstanding, we advise that the use of this procedure be considered more cautiously due to the oral sensitivities inherent in many individuals with ARFID and the potential psychological consequences. These sensitivities may make the experience of NGT feedings particularly aversive, with the potential of creating iatrogenic conditioned food aversions.

Discussion: This article encourages clinicians to give careful thought and attention when considering NGT feedings in children and adolescents with ARFID.
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http://dx.doi.org/10.1002/eat.23021DOI Listing
April 2019

Feeling and body investigators (FBI): ARFID division-An acceptance-based interoceptive exposure treatment for children with ARFID.

Int J Eat Disord 2019 04 31;52(4):466-472. Epub 2018 Dec 31.

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.

Objective: Individuals with Avoidant Restrictive Food Intake Disorder (ARFID) experience impairing health consequences from insufficient nutritional variety and/or quantity. Early medical conditions and/or somatic symptoms such as abdominal pain may lead some with ARFID to experience somatic sensations as aversive. As such, food avoidance may be part of a broader behavioral repertoire aimed at suppressing bodily sensations. Avoiding these necessary and informative signals (e.g., growls of hunger) may subvert the emergence of healthy self-awareness and self-regulation. Teaching children with ARFID to engage adaptively with bodily sensations may help decrease aversiveness, increase self-awareness, and increase approach behaviors.

Method: Drawing from interventions for panic disorder and irritable bowel syndrome, we developed an acceptance-based interoceptive exposure treatment for young children with ARFID, Feeling and Body Investigators (FBI)-ARFID Division. Using playful cartoons and developmentally sensitive exposures, we teach young children how to map interoceptive sensations onto meanings (e.g., emotions) and actions (e.g., if I feel nervous, I'll hold someone's hand).

Results: We present a case study of a 4-year old child with lifelong poor appetite/food indifference.

Discussion: Some individuals with ARFID may avoid food to avoid internal sensations. Developmentally appropriate interoceptive exposures may decrease ARFID symptoms while increasing more general self-regulation skills.
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http://dx.doi.org/10.1002/eat.22996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511273PMC
April 2019

Sensory Over-Responsivity: An Early Risk Factor for Anxiety and Behavioral Challenges in Young Children.

J Abnorm Child Psychol 2019 06;47(6):1075-1088

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Box 3527 DUMC, Durham, NC, 27710, USA.

Anxiety disorders are prevalent and significantly impact young children and their families. One hypothesized risk factor for anxiety is heightened responses to sensory input. Few studies have explored this hypothesis prospectively. This study had two goals: (1) examine whether sensory over-responsivity is predictive of the development of anxiety in a large prospective sample of children, and (2) identify whether anxiety mediates the relationship between sensory over-responsivity and behavioral challenges. Children's sensory and anxiety symptoms were assessed in a community sample of 917 at 2-5 and again in 191 of these children at 6 years old. Parents also reported on a number of additional behavioral challenges previously found to be associated with both sensory over-responsivity and anxiety separately: irritability, food selectivity, sleep problems, and gastrointestinal problems. Forty three percent of preschool children with sensory over-responsivity also had a concurrent impairing anxiety disorder. Preschool sensory over-responsivity symptoms significantly and positively predicted anxiety symptoms at age six. This relationship was both specific and unidirectional. Finally, school-age anxiety symptoms mediated the relationship between preschool sensory over-responsivity symptoms and both irritability and sleep problems at school-age. These results suggest sensory over-responsivity is a risk factor for anxiety disorders. Furthermore, children who have symptoms of sensory over-responsivity as preschoolers have higher levels of anxiety symptoms at school-age, which in turn is associated with increased levels of school-age behavioral challenges.
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http://dx.doi.org/10.1007/s10802-018-0502-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6508996PMC
June 2019

Neurobiology of social reward valuation in adults with a history of anorexia nervosa.

PLoS One 2018 4;13(12):e0205085. Epub 2018 Dec 4.

Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, United States of America.

Objective: Anorexia nervosa (AN) is a disorder characterized by atypical patterns of reward valuation (e.g. positive valuation of hunger). Atypical reward processing may extend into social domains. If so, such findings would be of prognostic significance as impaired social functioning predicts worse outcome. We explore neural circuits implicated in social reward processing in individuals with a history of AN who are weight-restored relative to controls and examine the effects of illness course on the experience of social value.

Method: 20 weight-restored individuals with a history of AN (AN-WR) and 24 healthy control (HC) participants were assessed using fMRI tasks that tapped social reward: smiling faces and full human figures that varied in attractiveness and weight.

Results: AN-WR differed from HC in attractiveness ratings by weight (negatively correlated in AN-WR). While there were no significant differences when viewing smiling faces, viewing full figures resulted in decreased activation in regions implicated in reward valuation (the right caudate) for AN-WR and this region was negatively correlated with a sustained course of the disorder. Exploratory whole brain analyses revealed reduced activation in regions associated with social reward, self-referential processing, and cognitive reappraisal (e.g., medial prefrontal cortex, striatum, and nucleus accumbens) with sustained disorder course.

Discussion: The rewarding value of full body images decreases with a sustained disorder course. This may reflect an extension of atypical reward processing documented in AN-WR, perhaps as a function of starvation dampening visceral motivational signals; the deployment of cognitive strategies that lessen the experience of reward; and/or the nature of the stimuli themselves as provocative of eating disorder symptoms (e.g., thin bodies). These findings did not extend to smiling face stimuli. Advances in technology (e.g., virtual avatars, text messaging) may provide novel means to build relationships, including therapeutic relationships, to support improved social connections without threats to symptom provocation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205085PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279022PMC
April 2019

Executive functioning and central coherence in anorexia nervosa: Pilot investigation of a neurocognitive endophenotype.

Eur Eat Disord Rev 2018 09 27;26(5):489-498. Epub 2018 Apr 27.

Atlantic Health System, Summit, NJ, USA.

A neurocognitive profile characterized by problems in set shifting, executive functioning, and central coherence may pre-date and maintain anorexia nervosa (AN). To test this pattern as a possible endophenotype for AN, 10 youth with current AN, 14 healthy youth, and their biological parents, participated in a neuropsychological battery. Youth with AN demonstrated significantly weaker central coherence, related to enhanced detail-focused processing. Youth with AN and their parents demonstrated significantly greater psychopathology relative to controls, and youth-parent scores were significantly correlated. The study, limited by a small sample size, found little evidence supporting a neuropsychological endophenotype for AN. Identifying a neurocognitive profile for children and adolescents with AN has important implications for the treatment of young patients.
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http://dx.doi.org/10.1002/erv.2597DOI Listing
September 2018

Associations between maternal cytokine levels during gestation and measures of child cognitive abilities and executive functioning.

Brain Behav Immun 2018 05 26;70:390-397. Epub 2018 Mar 26.

Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA 23298, USA. Electronic address:

Preclinical studies demonstrate that environmentally-induced alterations in inflammatory cytokines generated by the maternal and fetal immune system can significantly impact fetal brain development. Yet, the relationship between maternal cytokines during gestation and later cognitive ability and executive function remains understudied. Children (n = 246) were born of mothers enrolled in the Newborn Epigenetic Study - a prospective pre-birth cohort in the Southeastern US. We characterized seven cytokines [IL-1β, IL-4,IL-6, IL-12p70, IL-17A, tumor necrosis factor-α (TNFα), and interferon-γ (IFNγ)] and one chemokine (IL-8) from maternal plasma collected during pregnancy. We assessed children's cognitive abilities and executive functioning at a mean age of 4.5 (SD = 1.1) years. Children's DAS-II and NIH toolbox scores were regressed on cytokines and the chemokine, controlling for maternal age, race, education, body mass index, IQ, parity, smoking status, delivery type, gestational weeks, and child birth weight and sex. Higher IL-12p70 (β = 4.26, p = 0.023) and IL-17A (β = 3.70, p = 0.042) levels were related to higher DAS-II GCA score, whereas higher IL-1β (β = -6.07, p = 0.003) was related to lower GCA score. Higher IL-12p70 was related to higher performance on NIH toolbox measures of executive functions related to inhibitory control and attention (β = 5.20, p = 0.046) and cognitive flexibility (β = 5.10, p = 0.047). Results suggest that dysregulation in gestational immune activity are associated with child cognitive ability and executive functioning.
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http://dx.doi.org/10.1016/j.bbi.2018.03.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6471612PMC
May 2018