OBJECTIVE: The Nine Item ARFID Scale (NIAS) is a widely used measure assessing symptoms of avoidant/restrictive food intake disorder (ARFID). Previous studies suggest that individuals with eating disorders driven by shape/weight concerns also have elevated scores on the NIAS. To further describe NIAS scores among individuals with diverse current and previous eating disorders, we characterized NIAS scores in a large sample of individuals with eating disorders and evaluated overlap in symptoms measured by the NIAS and the Eating Disorder Examination-Questionnaire (EDE-Q) version 6.0.
METHODS: Our sample comprised 9148 participants from the Eating Disorders Genetics Initiative Sweden (EDGI-SE), who completed surveys including NIAS and EDE-Q. NIAS scores were calculated and compared by eating disorder diagnostic group using descriptive statistics and linear models.
RESULTS: Participants with current anorexia nervosa demonstrated the highest mean NIAS scores and had the greatest proportion (57.0%) of individuals scoring above a clinical cutoff on at least one of the NIAS subscales. Individuals with bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorder also demonstrated elevated NIAS scores compared to individuals with no lifetime history of an eating disorder (ps < 0.05). All subscales of the NIAS showed small to moderate correlations with all subscales of the EDE-Q (rs = 0.26-0.40).
CONCLUSIONS: Our results substantiate that individuals with eating disorders other than ARFID demonstrate elevated scores on the NIAS, suggesting that this tool is inadequate on its own for differentiating ARFID from shape/weight-motivated eating disorders. Further research is needed to inform clinical interventions addressing the co-occurrence of ARFID-related drivers and shape/weight-related motivation for dietary restriction.

OBJECTIVE: The present study aims to examine subjectively and objectively the voice changes in bulimia nervosa (BN) patients at different stages of treatment.
METHODS: The study was conducted with a study group including 10 patients followed up with a diagnosis of BN and a control group consisting of 10 healthy participants of a similar age group without eating disorders. The Reflux Symptom Index (RFS) was used for stroboscopic evaluation. The fundamental frequency (F0), jitter, shimmer, and noise-to-harmonics ratio were determined during acoustic voice analysis. Maximum phonation time was analyzed. A subjective evaluation was performed using the Voice Handicap Index-10 (VHI-10).
RESULTS: Jitter, shimmer, VHI-10 score, and RFS values showed a statistically significant difference in the patient and control groups (P < 0.05). The mean values of jitter, shimmer, VHI-10 score, and RFS were higher in the patient group than in the control group. Maximum phonation time did not differ between groups (P > 0.05) Age and F0 (Hz) values showed no statistically significant difference in the patient and control groups (P > 0.05).
CONCLUSIONS: In BN patients, the laryngopharyngeal reflux mechanism causes negative effects on vocal cord examination and acoustic sound analysis parameters, leading to subjective dissatisfaction.

BACKGROUND: Previous systematic reviews of digital eating disorder interventions have demonstrated effectiveness at improving symptoms of eating disorders; however, our understanding of how these interventions work and what contributes to their effectiveness is limited. Understanding the behavior change techniques (BCTs) that are most commonly included within effective interventions may provide valuable information for researchers and developers. Establishing whether these techniques have been informed by theory will identify whether they target those mechanisms of action that have been identified as core to changing eating disorder behaviors. It will also evaluate the importance of a theoretical approach to digital intervention design.
OBJECTIVE: This study aims to define the BCTs within digital self-management interventions or minimally guided self-help interventions for adults with eating disorders that have been evaluated within randomized controlled trials. It also assessed which of the digital interventions were grounded in theory and the range of modes of delivery included.
METHODS: A literature search identified randomized controlled trials of digital intervention for the treatment of adults with eating disorders with minimal therapist support. Each digital intervention was coded for BCTs using the established BCT Taxonomy v1; for the application of theory using an adapted version of the theory coding scheme (TCS); and for modes of delivery using the Mode of Delivery Ontology. A meta-analysis evaluated the evidence that any individual BCT moderated effect size or that other potential factors such as the application of theory or number of modes of delivery had an effect on eating disorder outcomes.
RESULTS: Digital interventions included an average of 14 (SD 2.6; range 9-18) BCTs. Self-monitoring of behavior was included in all effective interventions, with Problem-solving, Information about antecedents, Feedback on behavior, Self-monitoring of outcomes of behavior, and Action planning identified in >75% (13/17) of effective interventions. Social support and Information about health consequences were more evident in effective interventions at follow-up compared with postintervention measurement. The mean number of modes of delivery was 4 (SD 1.6; range 2-7) out of 12 possible modes, with most interventions (15/17, 88%) being web based. Digital interventions that had a higher score on the TCS had a greater effect size than those with a lower TCS score (subgroup differences: χ21=9.7; P=.002; I²=89.7%) within the meta-analysis. No other subgroup analyses had statistically significant results.
CONCLUSIONS: There was a high level of consistency in terms of the most common BCTs within effective interventions; however, there was no evidence that any specific BCT contributed to intervention efficacy. The interventions that were more strongly informed by theory demonstrated greater improvements in eating disorder outcomes compared to waitlist or treatment-as-usual controls. These results can be used to inform the development of future digital eating disorder interventions.
BACKGROUND: PROSPERO CRD42023410060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=410060.

OBJECTIVE: To investigate the associations among symptoms of attention deficit hyperactivity disorder (ADHD) with binge eating spectrum conditions - BESC - [binge eating disorder (BED), bulimia nervosa (BN), and recurrent binge eating (RBE)], and psychiatric and somatic comorbidity and healthcare utilization in a representative sample of a Brazilian city.
METHODS: A household survey with 2,297 adults and residents in Rio de Janeiro was conducted. The Adult Self-Rating Scale Screener was used to assess ADHD symptoms. BESC was assessed using the Questionnaire of Eating and Weight Patterns 5 and confirmed by telephone interview. Standardized questionnaires were used to assess psychiatric comorbidity. Close-ended questions investigated somatic comorbidity and healthcare utilization.
RESULTS: ADHD symptoms were highly associated with BESC [BED, OR=13.2, 95%CI= 4.3-40.6; BN, OR=27.5, 95%CI= 5.9-128.7; RBE, OR=5.8, 95%CI= 2.9-11.4). However, with further adjustment for psychiatric comorbidity (depression, anxiety, alcohol use and impulsivity), the ORs were no longer significant. Healthcare resource utilization was significantly higher in participants with ADHD and BESC but lost significance after controlling for the psychiatric comorbidity.
CONCLUSIONS: ADHD was associated with an increased prevalence of BESC, and healthcare utilization. Nonetheless, there was an essential interplay among psychiatric comorbidity in the associations of ADHD and BESC.

Bulimia nervosa (BN) and other specific feeding or eating disorders with subthreshold BN symptoms (OSFED-BN) are characterized by recurrent binge eating episodes accompanied by compensatory behaviors, including excessive exercise. We aimed to examine the role of compensatory exercise on several clinical disorder-related variables and the treatment outcomes. The sample included 478 patients diagnosed with either BN or OSFED-BN admitted for a 16-week eating disorder-specific treatment program. A battery of questionnaires was administered to evaluate eating and general psychopathology, and personality traits. Other clinical disorder-related data, including levels of compensatory exercise, were assessed through a semi-structured clinical interview. Between-group comparisons of compensatory exercise levels were analyzed, as a predictive model of risk of poor treatment outcomes. Path analysis was conducted using structural equation models to estimate the direct and indirect effects between the main variables. Higher levels of self-reported compensatory exercise were associated with greater eating psychopathology, general psychopathology, and more dysfunctional personality traits and were a predictor of poor treatment outcomes. Additionally, these levels achieved a mediating role in several paths contributing to a higher likelihood of a poor outcome. Further research is required to determine how psychotherapeutic approaches can be optimized to adequately include adaptive exercise for these patients.

While exercise is generally associated with positive health outcomes, in the context of eating disorders, exercise has high potential to become maladaptive. Maladaptive exercise is compelled or compulsive in nature for the purposes of weight and shape control or to obtain/avoid other eating disorder-relevant consequences. A transdiagnostic eating disorder feature with moderate-to-high prevalence across restrictive- and bulimic-spectrum eating disorders, maladaptive exercise is often associated with negative mental and physical health sequalae. Several proposed threat- and reward-related biobehavioral mechanisms may initiate or perpetuate maladaptive exercise. While exercise is generally contraindicated during periods of acute medical concern, adaptive forms of exercise are also present among those with eating disorders, and facilitation of adaptive exercise has potential to promote physical and mental health benefits during eating disorder recovery. Detailed assessment and targeted interventions are needed to address the clinical conundrum of how and when to integrate exercise into eating disorder treatment.

BACKGROUND: Neurohypophysis (NH) function in eating disorders (ED) remains poorly elucidated. Studies on vasopressin and oxytocin display inconclusive findings regarding their levels and associations with psychological complications in ED. The profile of opioid tone, a crucial NH activity regulator, is also unknown.
OBJECTIVE: To characterise the circadian profile of NH hormones and NH opioid tone using positron emission tomography/MRI (PET/MRI) imaging in patients with ED compared to healthy controls.
METHODS: Twelve-point plasma circadian profiles of copeptin and oxytocin, alongside nutritional and psychological scores, were assessed in age-matched female participants: 13 patients with anorexia nervosa restrictive-type (ANR), 12 patients recovered from AN (ANrec), 14 patients with bulimia nervosa and 12 controls. Neurohypophysis PET/MRI [11C] diprenorphin binding potential (BPND) was evaluated in AN, ANrec and controls.
RESULTS: Results revealed lower copeptin circadian levels in both ANR and ANrec compared to controls, with no oxytocin differences. Bulimia nervosa exhibited elevated copeptin and low oxytocin levels. [11C] diprenorphin pituitary binding was fully localised in NH. Anorexia nervosa restrictive-type displayed lower NH [11C] diprenorphin BPND (indicating higher opioid tone) and volume than controls. In ANR, copeptin inversely correlated with osmolarity. Neurohypophysis [11C] diprenorphin BPND did not correlated with copeptin or oxytocin.
CONCLUSIONS: Copeptin demonstrated significant group differences, highlighting its potential diagnostic and prognostic value. Oxytocin levels exhibited conflicting results, questioning the reliability of peripheral blood assessment. Increased NH opioid tone in anorexia nervosa may influence the vasopressin or oxytocin release, suggesting potential therapeutic applications.

OBJECTIVE: Binge eating and self-induced vomiting are common, transdiagnostic eating disorder (ED) symptoms. Efforts to understand these behaviors in research and clinical settings have historically relied on self-report measures, which may be biased and have limited ecological validity. It may be possible to passively detect binge eating and vomiting using data collected by continuous glucose monitors (CGMs; minimally invasive sensors that measure blood glucose levels), as these behaviors yield characteristic glucose responses.
METHODS: This study developed machine learning classification algorithms to classify binge eating and vomiting among 22 adults with binge-spectrum EDs using CGM data. Participants wore Dexcom G6 CGMs and reported eating episodes and disordered eating symptoms using ecological momentary assessment for 2 weeks. Group-level random forest models were generated to distinguish binge eating from typical eating episodes and to classify instances of vomiting.
RESULTS: The binge eating model had accuracy of 0.88 (95% CI: 0.83, 0.92), sensitivity of 0.56, and specificity of 0.90. The vomiting model demonstrated accuracy of 0.79 (95% CI: 0.62, 0.91), sensitivity of 0.88, and specificity of 0.71.
CONCLUSIONS: Results suggest that CGM may be a promising avenue for passively classifying binge eating and vomiting, with implications for innovative research and clinical applications.

BACKGROUND: Eating disorders (EDs) are serious mental health conditions that affect a person physically and psychologically. In the past, EDs were only recognized as a cultural phenomenon/societal by-product of the West. However, research evidence marks its presence in non-western countries also, including South Asia. This study aims to evaluate the feasibility and acceptability of a manualized psychological intervention called Getting Better Bite by Bite (GBBB) in individuals who screened positive on measures of EDs in Pakistan.
METHODS: The proposed study is a feasibility randomized controlled trial (fRCT). The study will be conducted at five sites across Pakistan: Karachi, Hyderabad, Lahore, Rawalpindi, and Multan to recruit a total of 80 participants. Eligible participants will be randomized to either (1) the intervention group; in which they will receive one-to-one sessions of GBBB along with routine care or (2) the routine care group; in which they will only have access to the routine care. We have received ethics approval by the National Bioethics Committee. The study is registered at clinicaltrials.gov (NCT05724394). The study team has received permission from recruitment centers: hospitals (i.e. the psychiatry department of public and private hospitals based in these cities), fitness centers (i.e., gyms), educational institutes (i.e., colleges and universities), and community settings (i.e. community health clinics). Self-referrals from General Practitioners and community settings will be accepted. The intervention manual has been translated into Urdu and a multidisciplinary team including service users has culturally adapted the content of intervention for local context.
CONCLUSIONS: This study will provide evidence on feasibility and acceptability of a culturally adapted intervention for individuals who screen positive on measures of EDs. The findings of this study will inform a fully powered Randomized Controlled Trial of the proposed intervention.
BACKGROUND: The study is registered on clinicaltrials.gov (NCT05724394). Protocol version (1.0. 1st June 2022).

BACKGROUND: Existing evidence suggests that anterior insula plays a crucial role in cognitive control and emotional regulation and is implicated in the onset and maintenance of bulimia nervosa (BN). However, it remains unclear how structural and functional abnormalities in specific subregions of anterior insula contribute to BN.
METHODS: In this study, we analyzed structural MRI and resting-state functional MRI data from 54 BN patients and 56 healthy controls (HCs). We conducted voxel-based morphometry, amplitude of low frequency fluctuation (conventional band: 0.01-0.08 Hz, slow-5: 0.01-0.027 Hz) and seed-based whole-brain functional connectivity (FC) analysis of the anterior insula subregions for both groups. Additionally, we investigated the correlation between neuroimaging findings and clinical characteristics in the BN group.
RESULTS: Our findings revealed that BN patients exhibited reduced gray matter volume in the right dorsal anterior insula (dAI) and bilateral ventral anterior insula (vAI) and demonstrated decreased ALFF in slow-5 band of bilateral dAI. The BN group also showed increased FC between bilateral dAI and precuneus or right superior frontal gyri which significantly correlated with the severity of BN or its key symptom. In addition, the decreased FC between bilateral vAI and anterior cingulate and paracingulate gyri and/or median cingulate and paracingulate gyri were both significantly correlated with the severity and its restrained eating behavior.
CONCLUSIONS: Our findings further indicate that the functional separation of anterior insula subregions may underlie the pathophysiology of BN. Notably, the vAI associated with emotional processing may serve as a promising neuroimaging biomarker which could inform therapeutic strategy.