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Eating Disorder Research Program Research Overview
The Eating Disorder Research Program focuses on the intersection of epidemiology, biological indices, and healthcare delivery to improve outcomes and reduce the burden of disease in youth with eating disorders.
Research in the field of eating disorders has been primarily female/girl-centric. Our work regularly includes males, and we continually strive to include examination of sex differences in our work. Sex as a biological variable underlies all the areas in which we work.
Related Publications
Timko CA, DeFilipp L, Dakanalis A. Sex differences in adolescent anorexia and bulimia nervosa: beyond the signs and symptoms. Curr Psychiatry Rep. 2019 Jan 12;21(1):1. PMID: 30637488; PMCID: PMC6559358.
With one of the highest mortality rates of all psychiatric illnesses, it is imperative that we find ways to improve treatment for youth with eating disorders. Our work takes multiple approaches to do this – including examining the efficacy of augmenting family-based approaches, integrating technology into the treatment of eating disorders, and exploring the real-world effectiveness of treatment. Our work is designed to improve outcome and to increase dissemination of effective treatments.
Related Publications
Timko CA, Bhattacharya A, Fitzpatrick KK, Howe H, Rodriguez D, Mears C, Heckert K, Ubel PA, Ehrenreich-May J, Peebles R. The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family-based treatment for adolescents with anorexia nervosa. Contemp Clin Trials. 2021 Apr;103:106313. Epub 2021 Feb 1. PMID: 33539993.
Timko CA, Fitzpatrick KK, Goulazian T, Kirby D, Parks E, Morrow L, Scharko AM, Peebles R. Conducting a pilot randomized controlled trial on a medical inpatient unit utilizing cognitive remediation therapy for adolescents with restrictive eating disorders: protocol updates and reflections on feasibility. J Clin Psychol Med Settings. 2020 Jun;27(2):226-234. PMID: 32052249.
Timko CA, Zucker NL, Herbert JD, Rodriguez D, Merwin RM. An open trial of acceptance-based separated family treatment (ASFT) for adolescents with anorexia nervosa. Behav Res Ther. 2015 Jun; 69:63-74. PMID: 25898341
Anorexia has a typical age of onset in adolescents – a time of significant brain development and reorganization, including the development of executive functioning. Executive function is a group of inter-related processes that allow individuals to plan, execute, and monitor goal-directed behaviors. Executive functioning is governed in part by frontal lobe structures. Set shifting (or flexibility) refers to an aspect of executive functioning that entails the ability to shift attention from one task or concept to another. Set shifting difficulties are believed to underlie and maintain anorexia and contribute to behavioral perseveration (e.g., rigid rules regarding food consumption).
Reward processes are disrupted in youth with eating disorders. Contamination of reward and punishment occurs such that avoiding food becomes rewarding and eating or approaching food becomes feared. If not re-nourished, dopamine reward circuits facilitate reward/avoidance learning and eventually anorexia nervosa behavior becomes a habit.
Our work includes a strong focus on understanding the impact of eating disorders on the development of executive functioning, the relationship between executive functioning and reward in eating disorders, and how this can impact outcome.
Related Publication
Timko CA, Herrington JD, Bhattacharya A, Kuschner ES, Yerys BE. Caregiver report of executive functioning in adolescent females with anorexia nervosa or autism spectrum disorder. Front Psychol. 2021 Feb 9;11:586264. PMID: 33633624
While clinical trials are important, most youth with eating disorders are treated in the community. It is imperative that we increase our knowledge regarding how well treatments work in “real world” settings. It is also important to understand how effective treatment programs are and what we can do to improve them.
Related Presentation
Garber AK, Machen VI, Park, CC, Peebles R: Changing approaches to refeeding malnourished patients with eating disorders: results of an international survey. Society for Adolescent Health and Medicine Annual Meeting, Seattle, WA (Platform Presentation), Feb. 2018. J Adolesc Health. 62(2):S100.
Related Publications
Forman SF, Grodin LF, Graham DA, Sylvester CJ, Rosen DS, Kapphahn CJ, Callahan ST, Sigel EJ, Bravender T, Peebles R, Romano M, Rome ES, Fisher M, Malizio JB, Mammel KA, Hergenroeder AC, Buckelew SM, Golden NH, Woods ER. An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses. J Adolesc Health. 2011 Dec.49(6):594-600. PMID: 22098769
Peebles R, Lesser A, Park CC, Heckert K, Timko CA, Lantzouni E, Liebman R, Weaver L. Outcomes of an inpatient medical nutritional rehabilitation protocol in children and adolescents with eating disorders. J Eat Disord. 2017 Mar 1;5:7. PMID: 28265411; PMCID: PMC5331684.
Wood SM, White K, Peebles R, Pickel J, Alausa M, Mehringer J, Dowshen N. Outcomes of a rapid adolescent telehealth scale-up during the COVID-19 pandemic. J Adolesc Health. 2020 August;67(2):172-178. PMID: 32611509
Avoidant/Restrictive Food Intake Disorder (ARFID) is a heterogeneous eating disorder associated with serious medical and psychosocial complications. Preliminary evidence supports three clinical subtypes, yet little is known regarding their underlying traits and treatment course. Our work leverages both retrospective and prospective research methodology to examine differences among groups in clinical characteristics (demographics, types/amount of food consumed) and clinical severity (rates of hospitalization, degree of malnutrition, and treatment course). The goal of this line of research is to determine best practice in ARFID treatment – including matching appropriate treatment intensity and modality to ARFID subtype, as well as leading to future work to deep phenotype the three ARFID subtypes and their underlying mechanisms.
Recognizing that patients with eating disorders who are engaged in clinical care are likely to represent a fraction of those affected, we have used the Internet to access larger, community-based patient samples. This research is aimed at understanding who might try to maintain their illness by visiting “pro-eating disorder” websites and forums. We have published seminal work on the use of these websites in pediatric populations and how this use was often unknown to their parents. This work led to new understandings of how prevalent disordered eating is in the “walking wounded” – young adults who were not in traditional medical care settings, but nonetheless suffering greatly from severe eating disorder thoughts and behaviors. This work also introduced innovative methodology of searching for and characterizing these websites in the early days of social media use. We have also used Facebook to better access undergraduate populations and understand risk of eating disordered behaviors in male and female undergraduate athletes and non-athlete controls.
Related Publications
Wilson JL, Peebles R, Hardy KK, Litt IF. Surfing for thinness: a pilot study of pro-eating disorder web site usage in adolescents with eating disorders. Pediatrics. 2006 Dec;118(6): e1635-43. PMID: 17142493
Borzekowski DLG, Schenk S, Wilson JL, Peebles R. e-Ana and e-Mia: a content analysis of pro-eating disorder websites. Am J of Public Health. 2010 Aug;100(8):1526-34. PMID: 20558807
Peebles R, Wilson JL, Litt IF, Hardy KK, Lock JD, Mann JR, Borzekowski DJ. Disordered eating in a digital age: eating behaviors, health, and quality of life in users of websites with pro-eating disorder content. J Med Internet Res. 2012 Oct 25;14(5): e148. PMID: 23099628
Juarascio AS, Shoaib A, Timko CA. Pro-eating disorder communities on social networking sites: a content analysis. Eat Disord. 2010 Oct-Dec;18(5):393-407. PMID: 20865593
Hormes JM, Kearns B, Timko CA. Craving Facebook? Behavioral addiction to online social networking and its association with emotion regulation deficits. Addiction. 2014 Dec;109(12):2079-88. PMID: 25170590.
Identifying associations between commonly obtained biologic markers and behavioral determinants of eating disorders is critical to better understanding their pathophysiology, as well as ways of stratifying risk earlier in the disease trajectory to target earlier and more effective interventions. Exercise is both a feature of illness but also important for wellness in eating disorders. We aim to additionally characterize when exercise can be both helpful and harmful medically and psychiatrically using actigraph technology throughout treatment.
Related Publications
Heiss S, Vaschillo B, Vaschillo EG, Timko CA, Hormes JM. Heart rate variability as a biobehavioral marker of diverse psychopathologies: A review and argument for an "ideal range." Neurosci Biobehav Rev. 2021 Feb;121:144-155. Epub 2020 Dec 9. PMID: 33309905
Nagata JM, Carlson JL, Kao JM, Golden NH, Murray SB, Peebles R. Characterization and correlates of exercise among adolescents with anorexia nervosa and bulimia nervosa. Int J Eat Disor. 2017 Dec;50(12):1394-1403. PMID: 29112280
Nagata JM, Carlson JL, Golden NH, Murray SB, Long J, Leonard MB, Peebles R. Associations between exercise, bone mineral density, and body composition in adolescents with anorexia nervosa. Eat Weight Disord. 2019 Oct;24(5): 939-945. PMID: 29949128
Benau EM, Plumhoff J, Timko CA. Women's dieting goals (weight loss, weight maintenance, or not dieting) predict exercise motivation, goals, and engagement in undergraduate women: A self-determination theory framework. Inter J Sport and Exercise Psychology. 2019 Nov 2;17(6):553-67. doi: 10.1080/1612197X.2017.1421683
The Eating Disorder Research Program team is interested in the science of weight change in youth with eating disorders. Nearly 40 percent of our patients have a history of prior higher weight before their eating disorder, and require weight gain to recover, even above cut-points thought to be "unhealthy" by the medical community. Understanding what comprises a truly "healthy weight" for individuals with eating disorders, and how we can think more broadly and without bias about weight regulation is critical to these adolescents achieving a full and lasting recovery. Our research to date does not indicate harm in successful weight restoration to prior growth trajectories in any type of eating disorder. We are examining bone health, lipid profiles, glucose regulation, hormonal markers, and psychological outcome measures as youth with eating disorders undergo treatment to attempt to reduce the influence of weight bias in treatment goal weight-setting as well as long-term outcomes.
Related Publications
Seetharaman S, Golden NH, Halpern-Felsher B, Peebles R, Payne A, Carlson JL. Effect of a prior history of overweight on return of menses in adolescents with eating disorders. J Adolesc Health. 2017 April;60(4):469-471. PMID: 27998699
Nagata JM, Carlson JL, Golden NH, Long J, Murray SB, Peebles R. Comparisons of bone density and body composition among adolescents with anorexia nervosa and atypical anorexia nervosa. Int J Eating Disord. 2019 May;52(5):591-596. PMID: 30771231