OBJECTIVE:Cognitive-behavioral therapy for ARFID (CBT-AR) has demonstrated preliminary efficacy in open trials, but no studies have examined its effectiveness in real-world settings. We evaluated the effectiveness of virtually delivered CBT-AR for adults with ARFID and examined whether baseline symptom severity within each ARFID profile predicted corresponding symptom improvement. METHOD:N = 549 adults with ARFID received CBT-AR through Equip Health. We collected weight and Pica, ARFID, and Rumination Disorder Interview-ARFID Questionnaire data at intake and throughout treatment. Ordinary least squares regressions examined changes in weight and ARFID symptoms, and whether baseline severity within each profile predicted improvement in that domain, controlling for severity in other profiles and demographic/clinical covariates. RESULTS:Patients requiring weight restoration (n = 243) gained an average of 0.34 lb (0.15 kg) per week (p < 0.001). In the full sample, patients demonstrated significant reductions in sensory sensitivity (b = -0.05, 95% CI [-0.07, -0.04]), fear of aversive consequences (b = -0.04, 95% CI [-0.05, -0.02]), and lack of interest in food/eating (b = -0.04, 95% CI [-0.05, -0.03]; all ps < 0.001). Greater baseline severity within each profile uniquely predicted greater improvement in the corresponding profile (all bs = -0.03, all ps < 0.001). DISCUSSION:CBT-AR delivered virtually under naturalistic conditions is effective for adults with ARFID, producing significant improvements in weight and ARFID symptoms. Though randomized controlled trials are needed to establish definitive efficacy, findings provide preliminary support for dissemination beyond specialized research settings and demonstrate the clinical utility of profile-based treatment planning.

BackgroundEnhanced cognitive behavioral therapy (CBT-E) is the prevailing treatment approach for adult eating disorders. CBT-E is a variant of cognitive behavioral therapy, modified specifically to treat an eating disorder. Systematic reviews have established the effectiveness of CBT-E for adults when delivered face to face. However, few studies have evaluated evidence-based eating disorder treatment outcomes for programs intentionally designed to be delivered remotely. ObjectiveThe objective of this study was to examine the clinical utility of CBT-E for adults with eating disorders using data from a national treatment program designed specifically for remote delivery. MethodsThis was a pre-post observational cohort study conducted in a naturalistic setting where patients received treatment through standard clinical pathways, including typical referral, intake, and treatment processes. The participant sample for the study was identified through retrospective chart review and included adult patients (aged ≥18 y) diagnosed with anorexia nervosa, bulimia nervosa, binge eating disorder, or other specified feeding or eating disorder. For adult patients with these diagnoses, CBT-E is generally the first line of care in the program. CBT-E was developed to be transdiagnostic, and rather than focusing on a specific diagnosis, treatment focuses on treating the problematic beliefs related to weight, shape, and eating that maintain the eating disorder. CBT-E is highly individualized, and the treatment provider creates a treatment plan to match the specific eating disorder symptoms experienced by the patient. The recommended cadence of sessions is weekly. The criterion of utility was the magnitude and consistency of symptom change in weight gain and eating disorder, depression, and anxiety symptoms during CBT-E treatment. Survival analyses assessed patient and treatment characteristics. Multilevel models assessed the changes in outcomes both over time and at weeks 20 and 40, as these time points generally aligned with CBT-E clinical trial end points. ResultsThe patient sample (N=1629) predominantly consisted of White (n=1166, 71.6%), cisgender women (n=1403, 86.1%), with a mean age of 30 (SD 12) years. The overall median length of stay was 22 (95% CI 20-25) weeks. In all, 416 (25.5%) patients required weight restoration. The estimated probability of achieving weight restoration was 0.50 (95% CI 0.43-0.57) just before week 40 of treatment. By 40 weeks of treatment, the probability of achieving subclinical status for eating disorder symptoms was 0.48 (95% CI 0.44-0.51); for depression, the probability was 0.55 (95% CI 0.51-0.59), and for anxiety, the probability was 0.56 (95% CI 0.51-0.60). Time in treatment was significantly associated with improved symptoms across all outcomes (all P<.001). ConclusionsCBT-E delivered via telehealth is clinically useful, resulting in meaningful improvements in weight and eating disorder, depression, and anxiety symptoms in an outpatient setting. However, the absence of a comparison group and inclusion of a single treatment setting may limit generalizability.

Objective: The aim of this paper is to evaluate the effectiveness of enhanced cognitive behavioral therapy (CBT-E) adapted to be delivered via telehealth in a real-world, clinic treatment setting by a multi-disciplinary team for adults with an eating disorder. Method: A retrospective analysis of treatment outcomes was conducted on adult patients (18+) who received adapted CBT-E, a transdiagnostic treatment approach specifically modified for the treatment of eating disorders. Outcome included weight and eating disorder, depression, and anxiety symptoms. Survival analyses were used to assess length of stay, weight restoration and alleviation of eating disorder, depression, and anxiety symptoms; multilevel models assessed outcome trajectories over treatment time. Results: The patient sample (n = 1,718) was predominantly white (73%), cisgender women (86%), with a mean age of 30 (SD = 12). Diagnoses included anorexia nervosa (AN, 56%), binge-eating disorder (BED, 24%), bulimia nervosa (BN, 7%), and other specified feeding and eating disorder (OSFED, 11%). Approximately 51% of patients with weight restoration targets achieved weight restoration (95% of their target weight) by week 40 of treatment. By week 40 in treatment, 49% of patients reached subclinical levels on the EDE-Q, 58% on the PHQ-8, and 56% on the GAD-7. Discussion: Adapted CBT-E delivered via telehealth by a multi-disciplinary team is effective in improving transdiagnostic eating disorder symptoms, depression, and anxiety in an outpatient setting. Outcomes were consistent across diagnoses, demonstrating the feasibility and effectiveness of virtual CBT-E. However, variability in treatment length makes direct comparison with clinical trial end-of-treatment outcomes challenging. ### Competing Interest Statement All authors are employees at Equip Health and some hold stock options. ### Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The project was funded by Equip Health, LLC ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The evaluation of our patient treatment outcomes was reviewed by the Western Institutional Review Board (WIRB). It was determined evaluation of patient treatment outcomes do not meet the definition of human subjects research and are therefore considered exempt from IRB oversight. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes De-identified aggregate data is available upon reasonable request.

Clinical practice guidelines for medical professionals working with children and adolescents recommend routine screening for eating disorders. However, no validated screening tools exist for this age group. The aim of this study was to design and validate a brief, caregiver-based screening tool for eating disorders in children ages 6-12 that can be used in primary care. Caregivers of children aged 6-12 completed a battery of questionnaires (N=1,760). A subsample of caregivers completed semi-structured diagnostic interviews (n=255) to evaluate child eating disorder diagnosis. Standard data science practices were used to determine which questions were best at detecting an eating disorder and the most appropriate scoring threshold. Our final screener consists of two items that were effective at discriminating between children with an eating disorder and those without one and that were general enough to capture multiple diagnoses. As is recommended by organizations such as the AAP, this tool would ideally be administered to all caregivers of children ages 6-12 at yearly wellness visits beginning at the age of 6. ### Competing Interest Statement The research was carried out by Equip Health. Authors are employees of Equip Health. Steinberg, Jones, Freestone, Baker, Hellner and Bohon have stock options in Equip Health. ### Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The project was funded by Equip Health, Inc. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was reviewed and approved by the Biomedical Research Alliance of New York (BRANY) Institutional Review Board (New York, NY). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Purpose: Current eating disorder treatment approaches for youth were developed for use with cisgender girls, which limits the understanding of effectiveness for cisgender boys and transgender and gender expansive (TGE) youth. Here, we compare treatment outcomes for cisgender boys and TGE youth with cisgender girls receiving family-based treatment for an eating disorder. Methods: Patients were aged 6-24 and either active in treatment or discharged from September 1, 2020, to November 1, 2022 (N = 1,235). Patient exposure to treatment varied given individualized length of treatment. Outcomes include eating disorder symptoms, depression, anxiety, suicidality, caregiver burden, and parental con fidence in supervising treatment. Treatment outcomes for cisgender boys and TGE youth were compared with cisgender girls. Results: Patients included n = 975 cisgender girls, n = 152 cisgender boys, and n = 108 TGE youth. Anorexia nervosa was the most common diagnosis. Cisgender boys reported signi ficantly lower eating disorder (b =-2.7 [-4.1,-1.3]), anxiety (b =-1.6 [-2.2,-0.9]), and depression (b =-1.7 [-2.4,-0.9]) symptoms at admission compared with cisgender girls. TGE patients had signi ficantly higher anxiety (b = 1.08 [0.28, 1.91]) and depression (b = 1.72 [0.78, 2.65]) symptoms compared with cisgender girls. Cisgender boys started with signi ficantly lower suicidal ideation (b =-1.28 [-2.19,-0.43]) and TGE patients with signi ficantly higher suicidal ideation (b = 1.63 [0.76, 2.51]) than cisgender girls. All symptoms improved during treatment and improved at similar rates over time in treatment regardless of gender identity. Discussion: Early evidence from this study supports the use of family-based treatment for cisgender boys and TGE youth with eating disorders. Further research is needed on the long-term outcomes of this approach for youth of all genders. (c) 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background Previous research has demonstrated that early weight gain in family-based treatment (FBT) is predictive of remission for adolescents with anorexia nervosa (AN). However, no published data has addressed if early weight gain is also predictive of reaching weight restoration (i.e., 95% EBW) in patients with avoidant/restrictive food intake disorder (ARFID). Furthermore, no studies have evaluated the performance of the statistical models used to predict weight restoration at the end of treatment. This study sought to examine whether early weight gain in ARFID is predictive of weight restoration at 20 weeks using ROC analysis. Additionally, this study assessed how accurately the model classified patients and what types of misclassifications occurred. Methods Participants (n = 130, 57.7% cisgender female 70.0% white) received virtual outpatient FBT. Receiver operating characteristics (ROC) were used to predict successful weight restoration at end of treatment, using early weight gain as the predictor. Twenty weeks was considered as the end of treatment, to align with the definition of end of treatment in FBT clinical trials. ROC analyses demonstrated that gaining at least 6.2 pounds by week 5 of treatment was the strongest predictor of achieving 95% EBW at 20 weeks (AUC = 0.72 [0.63, 0.81]). ROC analyses misclassified 35% of patients; the most common misclassification was predicting that a patient would not achieve 95% EBW when they actually did (61.6%). A logistical regression model, which included the patients’ %EBW at admission in addition to early weight gain as a predictor, outperformed the ROC analyses (AUC = 0.90 [0.85, 0.95]) and provided additional context by showing the probability that a patient would succeed. Conclusion Taken together, research demonstrates that early weight gain is a useful predictor of 95% EBW at 20 weeks of treatment for patients with ARFID who require weight restoration. Furthermore, results suggest that statistical models need to take into account additional information, such as %EBW at admission, along with early weight gain in order to more accurately predict which patients will reach weight restoration at week 20.

Almost five billion individuals worldwide use social networking sites (SNSs) such as Instagram, Facebook, Snapchat, and X (formerly known as Twitter). The social rewards obtained on these sites induce users to spend substantial durations of time on them. However, current research demonstrates mixed findings on whether greater time on SNSs is related to riskier decision-making and impulsive tendencies. To address these findings, we conducted an online study (n = 225) to assess how time across four SNSs relates to impulsive decision-making in the delay discounting task. We included each trial as an individual choice in a regression model predicting preference for the immediate reward, for a total of 20,265 choices. Greater average time across all SNSs was related with a higher likelihood of choosing the immediate, but smaller, reward. In other words, people who spent more time on SNSs also made more impulsive decisions. When including individual platforms, greater time on Instagram and X, but not Facebook or Snapchat, was related with a higher likelihood of choosing the immediate reward. These findings help clarify prior literature on the relationship between platform specific SNS use and impulsive decision-making. We discuss limitations, directions for future research, and broader implications for the field.

Food Insecurity (FI) is associated with a myriad of mental health concerns in children and adolescents. Eating disorder (ED) risk is higher in youth experiencing FI, and FI in childhood is associated with ED diagnoses later in life. Although a growing body of research has shown that FI is associated with a heightened risk for ED-related symptoms, little is known about how experiencing FI may impact ED treatment, particularly in youth. In this study, we characterize the treatment characteristics of youth aged 6-24 (N = 729) with FI receiving family-based treatment for an ED. FI was defined as self-reported experience of FI (family-level FI) at treatment admission, and living in a low income, low access area according to USDA census tract data. Seventeen patients (2.3 % of sample) self-reported family-level FI at intake and 24 (3.3 % of sample) were designated as living in a low income/low access location. Descriptive analyses only were used to characterize the sample due to sample sizes. Group means on measures of weight, ED symptomatology, depression, anxiety, and caregiver burden were evaluated at admission and after four, eight, 12, 16, and 20 weeks of treatment. Results characterize how FI may impact ED treatment and showcase variation in changes. ED treatment must be responsive to needs related to FI as access to and consumption of food is the very foundation of ED treatment.

For many patients with an eating disorder, weight restoration is the first goal of treatment, especially for patients with anorexia nervosa (AN) or avoidant restrictive food intake disorder. Thus, setting an accurate target body weight is critical for treatment outcomes and long-term recovery. However, there is no standard approach for determining a weight target. Determining a target weight for adolescents can be particularly challenging given, developmentally, adolescents are still growing. Here, we compare treatment outcomes for adolescent patients with an eating disorder using two commonly used methods for estimating target body weight. Weight and eating disorder symptom scores were obtained from N=609 patients ages 6-20 enrolled in virtual eating disorder treatment. Target body weights required for weight restoration were determined using an individualized approach, which estimates body weight based on a patient's individual growth charts using weight trajectories prior to eating disorder onset and other clinical data. This was compared with a standardized approach commonly used in clinical trials (i.e., median BMI [mBMI]), which estimates body weight based on normative data and does not consider a patient's individual growth trajectory. The mBMI approach uses Center for Disease Control's age-adjusted BMI growth charts for children to identify the mBMI for age and gender. Once mBMI is determined, this can be used to calculate the body weight required to reach mBMI. Linear mixed effects models examined differences in weight and eating disorder symptoms. Patients were, on average, 15.6 (SD=2.29) years old and predominantly cisgender female (85%) and diagnosed with AN (83%). The median duration of treatment was 23 (14, 39) weeks. Using the individualized approach led to a significantly higher target body weight, [mean difference = 8.4 lbs (SE: 0.75); p<.001]. A majority of patients (70%) had a higher estimated target body weight using the individualized approach. Patients gained on average 8.72 (0.71) lbs before they reached their mBMI and it took an average of 6.35 (0.66) weeks. Patients gained on average 17.48 (0.53) lbs before they reached their individualized target body weight and it took an average of 14.31 (1.01) weeks. Patients who reached their individualized estimated target weight had significantly lower eating disorder symptoms scores compared with when patients reached their mBMI, (β = -1.62 [-1.98, -1.26]). However, this difference may be accounted for by longer treatment duration. Setting an accurate target body weight for weight restoration in eating disorder treatment is critical such that a lower end-of-treatment weight may increase risk for poor long-term outcomes. Our results suggest that using the mBMI approach to estimate target body weight for adolescents may result in an underestimation of weight required for weight restoration in some patients. Although we did not observe significant differences in eating disorder symptom scores based on approach after accounting for treatment duration, given the individualized approach leads to a higher weight target for a majority of adolescents, this may lead to a longer treatment duration, ultimately improving outcomes.

Barriers limit access to eating disorder treatment. Evidence-based treatment delivered using telemedicine could expand access. This study determined the effectiveness of enhanced Family-Based Treatment (FBT+) delivered using telemedicine for children and adolescents with eating disorders. Participants had a confirmed eating disorder diagnosis, lived in states where treatment was available, and lived with a family member willing to participate. Virtual FBT+ was administered by a five-person team including a therapist, dietitian, medical provider, peer mentor, and family mentor for up to 12 months. Measures were recorded at baseline and varying frequencies throughout treatment. Weight was self-reported. Eating disorder symptoms were assessed with the Eating Disorder Examination-Questionnaire Short Form (EDE-QS) and depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Caregiver burden and self-efficacy were measured using the Burden Assessment Scale, and Parent Versus Eating Disorder scale. The majority of patients (N = 210; 6 to 24 years old [mean 16 center dot 1 years]) were cisgender female (83%) White, (71%), required weight restoration (78%), and had anorexia nervosa, restricting type (63%). After 16 weeks, patients on weight restoration gained on average 11 center dot 3 [9 center dot 86, 12 center dot 8] pounds and the average change in EDE-QS score was -6 center dot 31 [-8 center dot 67, -4 center dot 10] points. Similar reductions were seen for depression (-2 center dot 62 [-4 center dot 24, -1 center dot 04]), anxiety (-1 center dot 44 [-1 center dot 12, 0 center dot 78]), and caregiver burden (-4 center dot 41 [2 center dot 45, 6 center dot 31]). Caregiver self-efficacy increased by 4 center dot 56 [3 center dot 53, 5 center dot 61] points. Patients and caregivers reported satisfaction with treatment. Virtual FBT+ for eating disorders can transcend geographical and psychosocial treatment barriers, expanding access to evidence-based eating disorder treatment.

Background Caregiver self-efficacy is thought to be a key component for successful family-based treatment (FBT) for individuals with eating disorders. As such, interventions aimed at enhancing caregiver self-efficacy, often measured via the Parents Versus Anorexia scale, have been a focal point of FBT literature. However, studies looking at the relationship between caregiver self-efficacy and treatment outcomes have been mixed. We aimed to better understand the influence of caregiver self-efficacy on eating disorder treatment outcomes during FBT. Methods Caregiver self-efficacy was measured using the Parents Versus Eating Disorders (PVED) scale, an adapted version of the Parents Versus Anorexia scale, in a sample of 1051 patients with an eating disorder and 1528 caregivers (patients can have more than one caregiver) receiving virtual FBT. Across two multilevel models, we tested how caregiver self-efficacy changed over time and its association with changes in eating disorder symptoms and weight over the first 16 weeks of treatment. Results Over treatment, PVED scores increased ( b = 0.79, SE = 0.04, CI [0.72, 0.86]) and starting PVED scores were predictive of improved eating disorder symptoms ( b = − 0.73, SE = 0.22, CI [− 1.15, − 0.30]), but not weight ( b = − 0.96, SE = 0.59, CI [− 2.10, 0.19]). We also found that PVED change-from-baseline scores were predictive of weight ( b = − 0.48, SE = 0.03, CI [− 0.53, − 0.43]) such that patient weight was lower when caregiver reports of PVED were higher. Likewise, the association between caregiver change in PVED scores and weight varied as a function of treatment time ( b = 0.27, SE = 0.01, CI [0.24, 0.29]). Results were consistent when isolating patients with anorexia nervosa. Conclusions Caregiver self-efficacy during FBT improved over time but was not robustly associated with treatment outcomes. This may, in part, be due to psychometric properties of the PVED scale. We describe these issues and illustrate the need for development of a new measure of self-efficacy for caregivers supporting their loved ones through eating disorder treatment.

OBJECTIVE Weight restoration or weight gain is a common goal in eating disorder treatment. However, approaches to determine expected body weight (EBW) vary. A standardized approach based on normative data for a patient's age and gender uses weight associated with median BMI (mBMI). An individualized approach predicts EBW based on a patient's individual growth trajectory. Little research has examined differences in these approaches. METHOD Weight and clinical data were collected from patients ages 6-20 enrolled in virtual eating disorder treatment. EBW associated with mBMI was compared with EBW using the individualized approach. Linear mixed effects models examined differences in weight, eating disorder symptoms, depression, and anxiety, and whether EBW approach varied by patient characteristics. RESULTS Patients (N = 609) were on average age 15.6 (2.29), 85% were cisgender female, and predominantly diagnosed with anorexia nervosa (83.1%). The individualized approach led to significantly higher EBW on average (mean difference = 8.4 lbs [SE: .75]; p < .001) compared to mBMI; 70% of patients had a higher EBW using the individualized approach. Notably, EBW varied based on gender and diagnosis and it took longer on average to achieve individualized EBW. Time was the strongest predictor of changes in psychosocial outcomes and there were no significant differences by EBW approach. DISCUSSION Results from this study indicate that an individualized approach led to significantly higher EBWs compared with using mBMI. As underestimation of EBW may lead to higher risk of relapse, eating disorder professionals should consider using an individualized approach for setting EBW. PUBLIC SIGNIFICANCE For eating disorder patients who need to gain weight, accurately estimating target body weight for eating disorder treatment is critical to recovery and preventing relapse. An individualized, patient-centered approach to estimating target body weight more accurately estimated target body weight than the standardized, median body mass index approach. Using an individualized approach to treatment may improve a patient's likelihood of full recovery.