Per Södersten

Background: Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment. Objective: This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women. Methods: The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires. Results: There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=–5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals. Conclusions: Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals. Trial Registration: ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209

Introduction Porter and Olmsted Teisberg suggested that the value of healthcare should be measured by treatment outcomes related to costs. Policy should financially reward treatment effects and in an outline of value-based healthcare, they predicted: State control policy yields variable effects, increasing costs Low price policy decreases effects, increasing costs Research and Development (R&D) policy increases effects, decreasing costs Methods The treatment of eating disorders in Region Stockholm, Sweden, in years 2012-2016 makes it possible to test these predictions because a State control, a Low price, and an R&D provider were contracted and the effects and costs of their treatments are publically available from Region Stockholm. Results The State control provider was contracted to provide more care services than the other providers. The average yearly number of patients treated to remission/patients treated was 164/714 (23%) at the State control provider, 41/170 (24) at the Low price provider, and 152/192 (79%) at the R&D provider. The average yearly budget was 73 million Swedish crowns (MSEK) compared to 49 MSEK at the R&D provider and 32 MSEK at the Low price provider (on average 30% lower per care service than the two other providers). The average cost to treat a patient to remission/patients treated was highest at the Low price provider (859 KSEK), followed by the State control provider (464 KSEK) and the R&D provider (327 KSEK). Conclusions The results confirm Porter and Olmsted Teisberg’s three predictions and suggest that an R&D policy increases the value of healthcare.

BACKGROUND Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment. OBJECTIVE This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women. METHODS The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires. RESULTS There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=–5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals. CONCLUSIONS Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals. CLINICALTRIAL ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209

[This corrects the article DOI: 10.2196/24998.].

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Background: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. Objective: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. Methods: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. Results: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall “good” rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the “accuracy” item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. Conclusions: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges.

BACKGROUND Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. OBJECTIVE The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. METHODS Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. RESULTS The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall “good” rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the “accuracy” item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. CONCLUSIONS Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges.

Mental causation takes explanatory priority over evolutionary biology in most accounts of eating disorders. The evolutionary threat of starvation has produced a brain that assists us in the search for food and mental change emerges as a consequence. The major mental causation hypothesis: anxiety causes eating disorders, has been extensively tested and falsified. The subsidiary hypothesis: anxiety and eating disorders are caused by the same genotype, generates inconsistent results because the phenotypes are not traits, but vary along dimensions. Challenging the mental causation hypothesis in Feighner et al. (1972) noted that anorexic patients are physically hyperactive, hoarding for food, and they are rewarded for maintaining a low body weight. In 1996, Feighner’s hypothesis was formalized, relating the patients’ behavioral phenotype to the brain mechanisms of reward and attention (Bergh and Södersten, 1996), and in 2002, the hypothesis was clinically verified by training patients how to eat normally, thus improving outcomes (Bergh et al., 2002). Seventeen years later we provide evidence supporting Feighner’s hypothesis by demonstrating that in 2012, 20 out of 37 patients who were referred by a psychiatrist, had a psychiatric diagnosis that differed from the diagnosis indicated by the SCID-I. Out of the 174 patients who were admitted in 2012, most through self-referral, there was significant disagreement between the outcomes of the SCID-I interview and the patient’s subjective experience of a psychiatric problem in 110 of the cases. In addition, 358 anorexic patients treated to remission scored high on the Comprehensive Psychopathological Rating Scale, but an item response analysis indicated one (unknown) underlying dimension, rather than the three dimensions the scale can dissociate in patients with psychiatric disorders. These results indicate that psychiatric diagnoses, which are reliable and valid in patients with psychiatric disorders, are less well suited for patients with anorexia. The results are in accord with the hypothesis of the present Research Topic, that eating disorders are not always caused by disturbed psychological processes, and support the alternative, clinically relevant hypothesis that the behavioral phenotype of the patients should be addressed directly.

On the standard perspective, anorexia nervosa and other eating disorders are caused by genetically determined, neurochemically mediated mental illnesses. Standard treatment, cognitive behavioral therapy (CBT), targets cognitive processes thought to maintain the disorders. Effective neurochemically based treatments are not available and the rate of remission is ≤25% 1 year after CBT, with unknown outcomes in the long-term. With starvation as the major threat in biological history, the evolutionary perspective focuses on foraging for food and eating behavior. A neural network, including hypothalamic arcuate peptide-neurons, brainstem serotonin- and dopamine-neurons and their prefrontal cortical projections, mediates (rather than controls) the behavioral adaptations to variations in food availability; activation of the network is associated with opposing behavioral outcomes depending upon external variations. In the clinic, the control of eating behavior is therefore outsourced to a machine that provides feedback on how to eat. Hundreds of eating disorders patients have recovered by practicing eating; the rate of remission is 75% in on average 1 year of treatment, the rate of relapse is 10% over 5 years of follow-up and no patient has died. A two-parameter asymptotic exponential growth curve modeled the eating behavior of 17 healthy women but not that of 17 women with anorexia nervosa. When in remission, the eating behavior of the anorexic women approached that of the healthy women. It is suggested that the treatment of eating disorders should focus on eating behavior.

Objective To report the outcomes of eating disorders treatment in Sweden in 2012–2016. Design The number of patients treated and the number of patients not fulfilling an eating disorders diagnosis (remission) at 1 year of follow-up at the clinics listed in the National Quality Registry for Eating Disorders Treatment were analysed. The published outcomes at three clinics, which used survival analysis to estimate outcomes, were compared with their outcomes in the registry. Outcomes at the three biggest clinics were compared. Setting All eating disorders clinics. Participants All patients treated at eating disorders clinics. Intervention Cognitive–behavioural therapy at most clinics and normalisation of eating behaviour at the three clinics with published outcomes. Outcome measure Proportion of patients in remission. Results About 2600 patients were treated annually, fewer than half were followed up and remission rates decreased from 21% in 2014 to 14% in 2016. Outcomes, which differed among clinics and within clinics over time, have been publicly overestimated by excluding patients lost to follow-up. The published estimated rate of remission at three clinics that treated 1200 patients in 1993–2011 was 27%, 28% and 40% at 1 year of follow-up. The average rate of remission over the three last years at the biggest of these clinics was 36% but decreased from 29% and 30% to 16 and 14% at the two other of the biggest clinics. Conclusions With more than half the patients lost to follow-up and no data on relapse in the National Quality Registry, it is difficult to estimate the effects of eating disorders treatment in Sweden. Analysis of time to clinically significant events, including an extended period of follow-up, has improved the quality of the estimates at three clinics. Overestimation of remission rates has misled healthcare policies. The effect of eating disorders treatment has also been overestimated internationally.