1. Mealtime Eating Disorder Cognitions Predict Eating Disorder Behaviors: A Mobile Technology Based Ecological Momentary Assessment Study
Cheri A. Levinson, Ph.D.
Assistant Professor
University of Louisville
Department of Psychological & Brain Sciences
Director, Eating Anxiety Treatment (EAT) Lab

2. Disclosures
I, Cheri Levinson, have no commercial relationships to disclose.

3. Anorexia Nervosa (AN) Background
AN has highest mortality rate of any mental illness
Many patients with AN treated in intensive treatment centers
Goal of treatment is refeeding and weight stabilization
After discharge from intensive treatment approximately 50% of patients relapse
It is this RELAPSE AFTER STABILIZATION that leads to the chronicity, disability, and mortality of AN

4. Relapse after Intensive Treatment
Constant exposure to food in treatment but…
Learning from intensive treatment settings does not seem to occur or generalize to treatment in outpatient settings
Why then such high rates of relapse?
Patients should be learning (but aren’t)
AN seems different from other common mental disorders (depression, anxiety) in this specific way
Patients still struggle with disordered eating behaviors and low weight
Most patients continue to struggle around food and mealtime
What is happening around mealtime?

5. Which Cognitions & When?
Mealtime should be the time of focus
Fears of Weight Gain
Core fear in the eating disorders
Perfectionism
May not learn because of fears of making mistakes
Rumination
May be engaging in cognitive rituals that interfere with learning
Bulik et al., 2003; Curci, Lanciano, Soleti, & Rime, 2013; Fairburn, Cooper, & Shafran, 2003; Levinson et al. (2017). Journal of Abnormal Psychology

6. Do these cognitions predict later eating disorder behaviors?
Are there self-perpetuating cycles between cognitions and behaviors?
These could impair learning
Identifying which cognitions lead to later behaviors may lead to personalized interventions
Now how to measure cognitions???

7. Why a mobile application for eating disorder cognitions?
Responses in daily life
Hard to recruit populations
Eating disorders
Responses right after/during a meal
Why aren’t patients learning??
What is happening during mealtime??
Kahneman et al., 2006; Schneider & Stone, 2015; Shiffman, Stone, & Hufford, 2008

8. Hypotheses
There would be specific cognitions and behaviors that predict each other across ensuing mealtimes, representing a self-reinforcing cycle.
These cognitions would predict subsequent higher anxiety (or alternatively lower anxiety if they serve an avoidance function) and higher eating disorder symptoms at one-month follow-up.

9. Participants N = 66 patients with eating disorders
Most participants are female (n = 64; 97%)
Most participants are European American (n = 56; 84.8%)
Average age is (SD = 7.31)
Most participants primary diagnosis is AN (n = 54; 81.8%)
Most have comorbid anxiety (n = 41;62.1%) or depression (n = 38; 57.6%)
Most are currently in treatment (n = 49; 74.2%)
On average 7.32 hours a week of treatment

10. Procedure Participants never set foot in the lab!
Participants recruited from intensive treatment center
All participants have diagnosis of an eating disorder
Based on treatment team diagnosis, as well as Eating Disorder Diagnostic Inventory
Participants complete self-report measures online
Use status-post iphone application for one week
4 times a day
1 month later complete measures of eating disorder symptoms
We used hierarchical linear models using cross-lag analyses

11. Status-Post

12. Status-Post

13. Cognitions Seven cognitions in three categories
Worries about weight gain/feelings of fatness
I felt worried about gaining weight during the meal
I felt fat during the meal
I am preoccupied with the desire to be thinner
Perfectionistic thoughts
I was concerned about making mistakes during the meal
I had high standards for myself during the meal
Rumination about the meal
Once I started thinking about the meal, I couldn’t stop
I had thoughts or images of the meal that I tried to resist thinking about.

14. Eating Disorder Behaviors
Five eating disorder behaviors
Restriction
Weighing oneself
Body checking
Vomiting or other compensatory behavior
Excessive exercise

15. Additional Measures Anxiety before, during, and after last meal
Eating disorder symptoms (at one month follow up)

16. Hypothesis 1
There would be specific cognitions and behaviors that predict each other across ensuing mealtimes, representing a self-reinforcing cycle.

17. Mealtime Cognitions Predict Subsequent Eating Disorder Behaviors
Restriction
Weighing oneself
Body checking
Compensatory behaviors
Excessive exercise
Fears of Weight gain/Feelings of Fatness
Fear of wt gain ns
.08*
.04*+
Felt fat
.14**
.08**
.06*
Preoccupation with Thinness
.14**+
Perfectionism thoughts
Concern about mistakes
.06*+
.11*
.05*
.07*
High Standards
.12*
Rumination about Meal
Couldn’t stop thinking
.09*
Thoughts or Images
.13**
ns = non-significant; + indicates a reciprocal relationship between cognition & behavior

18. Hypothesis 2
These cognitions would predict subsequent higher anxiety (or alternatively lower anxiety if they serve an avoidance function) and higher eating disorder symptoms at one-month follow-up.

19. Do these cognitions predict subsequent anxiety?
Higher worry about feeling fat significantly predicted lower subsequent anxiety before a meal (b = -.12, SE = .05, p = .02).
Higher worry about weight gain significantly predicted lower subsequent anxiety during a meal (b = -.10, SE = .05, p = .03).
Higher preoccupation with thinness significantly predicted higher subsequent anxiety during a meal (b = .10, SE = .05, p = .05).
Higher inability to stop thinking about the meal significantly predicted lower subsequent anxiety during a meal (b = -.15, SE = .07, p = .02).
Higher thoughts or images about the meal significantly predicted higher subsequent anxiety during a meal (b = .13, SE = .06, p = .05).

20. Do these cognitions predict eating disorder symptoms at one month follow up?
Drive for thinness
Bulimic symptoms
Body dissatisfaction
Fears of Weight gain/Feelings of Fatness
Fear of wt gain
.26* ns
Felt fat
.23*
Preoccupation with Thinness
Perfectionism thoughts
Concern about mistakes
.12*
High Standards
Rumination about Meal
Couldn’t stop thinking
Thoughts or Images
.20*

21. Conclusions
There were self-perpetuating cycles between mealtime cognitions & eating disorder behaviors
Targeting cognitions while disrupting behaviors may decrease anxiety and eating disorder symptoms across time
When targeting high standards patient must also refrain from engaging in excessive exercise
For non-self perpetuating cycles interventions to disrupt eating disorder behaviors should target specific, related cognition
Targeting concern over mistakes may disrupt compensatory behaviors, body checking, and excessive exercise
Mealtime cognitions predicted subsequent anxiety and eating disorder symptoms (at one month follow up)
Targeting these cognitions may decrease high rates of relapse

22. Future Directions
Develop personalized interventions for mealtime cognitions
Using EMA can create a personalized network of symptoms
Levinson et al., (2017) Journal of Abnormal Psychology

23. Future Directions
Then use ecological momentary interventions to target specific cognitions and behaviors
Can communicate to clinicians which symptoms to target for that specific individual

24. QUESTIONS? Contact: Cheri A. Levinson Clinical Treatment &
Research Opportunities
for Individuals with Eating
Disorders are Available!!