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. Author manuscript; available in PMC: 2022 Aug 1.
Published in final edited form as: Eat Behav. 2021 Jun 25;42:101534. doi: 10.1016/j.eatbeh.2021.101534

Promoviendo una Alimentación Saludable (PAS) Results: Engaging Latino Families in Eating Disorder Treatment

Mae Lynn Reyes-Rodríguez 1, Hunna J Watson 1,2,3, Tosha Woods Smith 1, Donald H Baucom 4, Cynthia M Bulik 1,5,6
PMCID: PMC8380698  NIHMSID: NIHMS1720485  PMID: 34217036

Abstract

Latinos/as are underrepresented in eating disorders clinical trials. This study compared results of a culturally adapted individual cognitive-behavioral treatment (CBT) for binge-spectrum eating disorders that included or excluded a family enhanced module (CBT + FE), in a proof-of-principle pilot study with a sample of Latina adults and one family member per patient. Twenty-five patients (Mage = 37 yrs) and 25 family members (Mage = 40 yrs) were randomized to CBT (n = 13) or CBT+ FE (n = 12). DSM-IV eating disorder diagnoses were: 48% (n = 12) bulimia nervosa, 28% (n = 7) binge-eating disorder, and 24% (n = 6) eating disorder not otherwise specified. Effect sizes favored CBT + FE on adherence and retention, and scores on treatment satisfaction and therapeutic alliance were high, indicating treatment acceptability. In spite of the hypothesis that family outcomes such as support, familism, cohesion, pride, family cultural conflict, burden, and marital satisfaction (in couples) would be superior in CBT + FE, the preliminary data were inconclusive and results were mixed. The hypothesis that eating disorder outcomes including global eating psychopathology, binge eating, and purging would improve in in CBT + FE was not supported. There was some evidence that patients in CBT improved more particularly on binge eating, otherwise the groups had no differences. In conclusion, the results suggest that CBT + FE could enhance treatment adherence and retention, although this did not automatically translate to better family and symptom outcomes.

Keywords: eating disorders, Latinas, cultural adaptation, family enhancement, treatment, CBT, clinical trial

Eating disorder prevalence in the Latino population is comparable or even higher than the non-Latino population (Franko et al., 2007; Marques et al., 2011; Perez et al., 2016; Udo & Grilo, 2018). However, cultural and system barriers prevent Latinos/as from accessing specialized treatment (Marques et al., 2011; Reyes-Rodríguez, Ramirez et al., 2013), therefore contributing to health disparities (Marques et al., 2011).

Full recognition of cultural values is fundamental to providing not only adequate treatment (Kempa & Thomas, 2000), but also ensuring delivery of culturally sensitive evidence-based treatment (Bernal & Scharrón-del-Río, 2001; Bernal & Domenech Rodríguez, 2012). One critical cultural value that has received considerable attention is the role of the family and its relationship to food and body image in Latino culture (Altabe & O’Garo, 2002; Shea et al., 2012). Family is a strong Latino cultural value (familismo); and Latino families tend to reflect a profound interdependence between parents and their children, which often continues into adulthood (La Roche, 2002). Moreover, familismo can play an important role in the mental health help-seeking patterns of Latinos/as (Villatoro et al., 2014).

Qualitative data on cultural treatment adaptation for eating disorders in Latinas suggest that having family support can enhance engagement and retention (Cachelin, Shea et al., 2014; Reyes-Rodríguez et al., 2014; Reyes-Rodríguez et al., 2019). However, the misconception that eating disorders are a White European problem has contributed to the misinformation and stigma in the Latino population (Reyes-Rodríguez et al., 2013). The lack of information and understanding of eating disorders in Latinos/as have been associated with conflicts and distress on the family dynamic (Cachelin, Gil-Rivas et al., 2014; Guadalupe-Rodríguez et al., 2011). One topic that emerged in a qualitative study conducted with Latino families with a family member with an eating disorder was the need for psychological support due to caregiver burnout, in part due to the lack of support and understanding of the condition (Guadalupe-Rodríguez et al., 2011). Incorporating family members/caregivers in the treatment would not only help them develop a better understanding of the eating disorder, but also guide them on how better to support their loved one (Reyes-Rodríguez et al., 2019). Although caregiver burden has been documented primarily in patients with anorexia nervosa due to the challenging refeeding process, families with a loved one struggling with binge-type eating disorders may also experience high levels of stress due to changes on the family dynamic, financial stressors, or even legal issues secondary to stealing food or money to sustain binge eating behaviors, among others (Peñas-Lledo et al., 2002; Perkins et al.,2004). In addition, many eating disorders patients migrate from one eating disorder to another during the course of illness, so even those with primary binge-spectrum eating disorders commonly engage in concerning periods of restriction (Eddy et al., 2008; Schaumberg et al., 2019). Considering the potential demands of caring for a family member with an eating disorder and the psychological distress family members may experience, including an intervention that addresses the psychological distress experienced by primary caregivers could prevent caregiver burden and subsequently positively affect the wellbeing of the patient (Magaña et al., 2007).

In Latino/a patients with chronic mental health problems other than eating disorders, family support plays a critical role in medication compliance (Ramirez Garcia et al., 2006) and relapse prevention (Markowitz et al., 2009). Other studies with Latinos/as have documented the positive impact of family involvement in maternal depression symptoms (Valdez et al., 2013), engagement in mental health treatment (Chang et al., 2013), and treatment retention (Marquez & Rámirez García, 2013). The mechanisms whereby inclusion of family members in treatment confers a therapeutic advantage remain unknown.

Although family interventions for adults with eating disorders are limited (Fleming et al., 2021), new research has emerged during the past years. The couple-based model, Uniting Couples (in the treatment) of Anorexia Nervosa (UCAN) leverages the resources of the couple relationship in recovery, and combines cognitive-behavioral couple therapy (CBCT) with CBT-based interventions for AN (Kirby et al., 2015). The intervention seeks to enhance relationship satisfaction, in recognition that interpersonal problems are a maintaining factor of eating disorder symptoms, and helps the couple directly address eating disorder behaviors (Bulik et al., 2011; Kirby et al., 2015). The UCAN approach has been expanded under the umbrella of UNITE (Uniting couples in the Treatment of Eating Disorders) to adults with partial and full binge-eating disorder (BED) (Runfola et al., 2018). Although these studies are limited, it is encouraging evidence that family interventions might augment conventional treatment for adults with eating disorders (Fleming et al., 2021, Pisetsky et al., 2016, Schmidt et al., 2013).

Most of the evidence-based treatment for eating disorders have been developed primarily for White European populations and are not necessarily culturally sensitive for Latinos/as. In fact, culturally sensitive evidence-based treatments for Latinos/as are scarce (Davis & Yager, 1992; Kempa & Thomas, 2000). With the exception of a few studies (Cachelin et al., 2019; Grilo et al., 2014), there is a lack of representation of diverse samples in clinical trials, and existing studies often lack individuals who are less acculturated and monolingual Spanish speakers (Poker et al., 2004). Language barriers, system mistrust due to migratory status and acculturative stress are some of the barriers faced by those who are less acculturated (Cachelin & Striegel-Moore, 2006; Reyes-Rodríguez, Ramirez et al., 2013). Acculturative stress, which is the stress associated with the adaptation to a new culture (Berry, 2006) has been associated as a moderator of body dissatisfaction and eating disorders in the Latino population (Perez et al., 2002). The integration of culture, context and language as part of the cultural adaptation appears to be more relevant and necessary for those who are less acculturated in order to enhance engagement and retention into treatment (Griner & Smith, 2006).

This study addresses this gap in the eating disorder field by combining the family value in the Latino culture with the new body of research of expanding the inclusion of family in treatment for adults with eating disorders. The study’s purpose was to compare a culturally adapted individual CBT for binge-spectrum eating disorders versus individual CBT plus a family enhanced module, in a proof-of-principle study, in a community sample of Latina adults with eating disorders and inclusion of one family member per patient. The primary outcomes included treatment feasibility and acceptability, and secondary outcomes included changes in eating disorder symptoms, family functioning, and caregiver burden in participating relatives (Reyes-Rodríguez, Bulik et al., 2013). This is one of the few studies conducted with less acculturated Latinas using a culturally sensitive treatment protocol.

Methods

Overview

The present study was a proof-of-principle pilot trial and is the fourth stage in a planned four-stage research program (K23-MH087954; PI: Reyes-Rodríguez). The overarching study is called “Promoviendo una Alimentación Saludable”-PAS Project (Promoting healthy eating patterns) and aimed to develop, refine, and evaluate a family enhanced intervention (FE) as an adjunct to a culturally sensitive CBT for eating disorders in Latinas. More detailed information on the PAS Project and methods of the current pilot RCT can be found in Reyes-Rodríguez, Bulik et al. (2013).

Hypotheses

Our work was guided by three hypotheses. Hypothesis # 1 (primary): The feasibility, acceptability, and attendance of participants in CBT + FE will be superior to individual CBT. Hypothesis # 2: (secondary): Patients and family members in CBT + FE will report better family outcomes (i.e., on family support, family cohesion, family pride, family cultural conflict, and marital satisfaction, and caregiver burden) than patients in individual CBT and their family members. Hypothesis # 3 (secondary): Patients in CBT + FE will show greater decreases in eating disorder symptoms compared with individual CBT.

Participants

Participants were Latina adults (18+ years) with an eating disorder (i.e., binge eating type threshold or sub-threshold diagnoses), and with an adult family member or significant other who was able to participate in the study whether living with them or not. Latinas with different levels of acculturation (e.g., English speaking or monolingual Spanish-speaking) and with any migratory status were invited to participate. Participants were excluded if they endorsed suicide risk at the time of the recruitment, lifetime bipolar disorder, lifetime psychotic disorder, and alcohol and substance dependence in the past three months. A detailed description of the methods including inclusion and exclusion criteria is discussed elsewhere (Reyes-Rodríguez, Bulik, et al., 2013).

Procedure

A community-based approach was used as part of the culturally sensitive adaptation. Three sites of a community-based non-profit mental health clinic served as the primary settings for the PAS Project. Therapists from the community clinic with Master’s degrees in social work were trained in CBT for eating disorders and supervised by the PI (MLR). All sessions were audio-recorded for supervision purposes and treatment fidelity. A psychiatrist from the same community clinic was recruited for medical management for those patients on medication. The PI, a clinical psychologist, served as the third therapist in the study. To minimize transportation costs for participants and other logistical issues that could prevent patients from adhering to treatment, treatment occurred at four different sites (three community mental health clinics and one hospital clinic). Individuals who met inclusion criteria at baseline were randomly assigned to individual CBT (n =13) or CBT + FE (n =12). A computerized process, integrated into the database system, was used to generate the randomization after documentation of consent was entered. The assessor conducting the follow-up assessments was blind to randomization condition.

Treatment

The CBT for binge-type eating disorders was previously tested in Latinas in Puerto Rico where the inclusion of family members was found necessary as part of the cultural adaptation (Reyes et al., 2006). A patient guideline was developed in order to help the patient to navigate through the CBT treatment. Although no major changes in the content of the treatment were required, in an early test case of the current research program, other adaptations to address system barriers and targeting other Latino values were recommended in the delivery process in order to enhance the engagement and retention (Reyes-Rodríguez et al., 2014). Patients randomized to individual CBT received 25 individual CBT sessions and up to three nutritional sessions. Based on patient/relative preference, treatment sessions were conducted in either English or Spanish. Patients randomized to CBT + FE received 19 individual CBT sessions and 6 family sessions with a previously identified family member or significant other and up to three nutritional sessions. The CBT sessions included behavioral techniques to replace binge eating and purging behaviors with a stable pattern of regular eating. The FE sessions included eating disorder psychoeducation, information about how to support a family member with eating disorders, and coping skills to reduce caregiver burden. Family sessions were modified depending on the family member involved. For spouses/partners, sessions were focused on general couple functioning including communication, sharing thoughts and problem solving and eating disorder-specific topics such as eating together, body image, and intimacy, some of them adapted from a couple-based treatment for AN (UCAN) (Bulik et al., 2011). For other family members some of the topics included communication skills, positive conflict resolution, establishing healthy boundaries within family members and the identification of family patterns that were exacerbating eating disorder cognitions or behaviors.

Measures

The assessment battery included outcome measures of treatment acceptability, family relationships and caregiver burden, and ED symptoms and also demographic, acculturation, and comorbid psychiatric symptoms, which provided information about the sample at baseline. The study included assessment time points: baseline, week-6 of treatment, end-of-treatment, and 3-month follow-up after treatment. With the exception of a clinician-led interview to administer the Eating Disorder Examination (EDE), all measures were self-report via questionnaire. All questionnaires were culturally sensitive for Latinos/as (e.g., developed or previously adapted for the Latino population), and available in both Spanish and English. Participants (patient and family member) in both groups completed the appropriate set of measures. The family measures were collected from the family or significant other that was enrolled in the study. A detailed description of all measures has been published previously (Reyes-Rodríguez et al., 2013).

Treatment acceptability.

The Psychotherapy Alliance Scale-10 (PAS-10) (Bernal et al., 1999) measured therapeutic alliance. Ten items were scored on a Likert scale ranging from totally disagree (1) to totally agree (7). Cronbach alpha for PAS-10 was 0.99. Treatment satisfaction was measured with the Patient Satisfaction (PS) scale (Greenfield & Attkisson, 1989; Negrón-Velázquez et al., 1998). Eight items were rated on a 4-point Likert scale and higher scores indicated higher satisfaction. Treatment adherence at the conclusion of treatment was measured by the number of sessions attended. Treatment retention was defined a priori as completion of at least 75% of sessions. Cronbach alpha for PS was 0.27. The low Cronbach’s alpha for PS is likely due to restriction of range in the sample because patients typically assigned each item the highest response option.

Family relationships and caregiver burden.

The Family Support Scale (FSS), adapted by the PI from the Therapeutic Alliance Scale (Bernal et al., 1999) measured perceived support about the ED from the patient’s family member (higher scores indicate greater perceived support from the participating family member or significant other). The items explored emotional support experienced by patients regarding their eating disorder with the participating family member (e.g., comfortable talking, perceived support, feeling understood, not feeling judged, comfortable calling for support, among others). Ten items were scored on a 5-point Likert scale ranging from disagree (1) to agree (5). Cronbach alpha for FSS was 0.82. The Familism Scale (FS) (Sabogal et al. 1987) measured family attitudes and values including feelings of family loyalty and attachment (higher score indicates higher levels of familismo). The measure contains 14 items rated from 1 (strongly disagree) to 5 (strongly agree). The following three measures were originally adapted and translated for the National Latino and Asian American Survey (NLAAS), a nationally representative household survey of Latinos in the United States (Alegria et al., 2004). Cronbach’s alphas in the current study for FS were 0.79 for patients and 0.85 for family report. The Family Cohesion Scale (FCS) (Alegria et al., 2004; Olson, 1986; Olson, 1989) assessed family closeness and communication, and has 3 items rated on a Likert scale with responses from strongly agree (1) to strongly disagree (4) (lower score indicates greater perceived cohesion). Cronbach’s alphas for FCS were 0.82 for patients and 0.47 for family report. Family pride (FPS) was assessed with a 7-item subscale from the Family Environment Scale (Alegria et al., 2004; Olson, 1986; Olson, 1989), which is rated on a Likert scale ranging from 1 (strongly agree) to 4 (strongly disagree) (lower score indicates higher family pride). Cronbach’s alphas for FPS were 0.84 for patients and 0.87 for family report. The Family Cultural Conflict scale (FCC) from the NLAAS was used and contains five items from the Family Culture/Stress scale of the Hispanic Stress Inventory (Cervantes et al., 1991) that measures conflict with the family because of conflicting personal goals and belief symptoms that depart from family unity. The response options range from 1 (hardly ever) to 3 (often) with higher scores representing higher levels of family cultural conflict. Cronbach’s alphas for FCC were 0.74 for patients and 0.84 for family report. The Family Burden Interview Schedule – Short Form (FBIS-SF) (Tessler & Gamache, 1996) measured family burden due to the ED across domains of financial burden, routine family activities, family leisure, family interaction, and mental and physical health effects on others (lower score indicates lesser perceived burden). Cronbach alpha for FBIS-SF was 0.93 for family report. For married couples participating together in the study, the Dyadic Adjustment Scale (DAS) (Youngblut et al., 2006) was used to measure marital satisfaction, where higher scores indicate greater levels of marital satisfaction. The DAS has 32 items and the response options range from always disagree (0) to always agree (5). Cronbach’s alphas for DAS were 0.89 for patients and 0.93 for family report.

Eating disorder symptoms.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 2000) diagnosis of ED was established using the Eating Disorder Examination (EDE) interview (Fairburn & Beglin, 1994; Reyes et al., 2005). The self-report Eating Disorder Examination Questionnaire (EDE-Q) (Elder & Grilo, 2007; Fairburn & Cooper, 1993) was used to monitor eating disorder symptoms at each of the four assessment points. Purging episodes were scored as the sum of the self-induced vomiting and laxative misuse episodes. Cronbach’s alpha was 0.86 for the EDE global and 0.85 for the EDE-Q global.

Acculturation.

Acculturation was assessed with the Acculturation Rating Scale for Mexican-American II (ARSMA-II) (Cuellar et al., 1995), where higher scores indicate a higher level of acculturation to Western norms. Items were rated on a Likert scale from not at all (1) to extremely often or almost always (5). Although the ARSMA II measure was initially developed for Mexican respondents, it has been adapted and used with other Latinos subgroups (Dennis, et al., 2016). For those items asking about country of origin from participant and their prior generations, items were modified to provide Latin American country options. In the current study, Cronbach’s alpha was 0.90 for ARMSA-II. Stress related to acculturation was explored with the Acculturative Distress scale (ADS) adapted for the NLAAS (Alegria et al., 2004), which assesses respondent’s experiences related to language barriers, discrimination, isolation from loves ones in country of origin, immigration, and fear of deportation, where higher scores indicate greater levels of acculturation stress. The scale consists of nine items with dichotomous response categories of “yes” (1) or “no” (5). Items can also be rated as “not applicable” and sum score was prorated based on the items completed. Cronbach’s alpha was 0.61 for the ADS.

Comorbid psychiatric symptoms.

Depression was evaluated with the Beck Depression Inventory-Revised (BDI-R) (Beck et al., 1961; Bonilla et al., 2004) and additional psychopathology was measured using the Symptom Checklist-36 (SCL-36) (McNeil et al., 1989). On both measures, higher scores indicate greater psychopathology. In addition, patients were asked about any history of trauma and, those who answered positive, completed the post-traumatic stress disorder (PTSD) section of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) (First et al., 1997). Cronbach’s alpha were 0.81 for BDI-R and 0.94 for SCL-36.

Data analytic strategy

This study is a proof-of-principle study to collect information about feasibility, effect sizes, and to inform whether a larger-scale evaluation in the future may be warranted. The study is considerably underpowered to detect statistically significant differences in intervention outcomes (see supplemental material). For this reason, Cohen’s d effect size between groups was the outcome metric and was interpreted using the conventions of nil 0–0.2, small ≥ 0.2, medium ≥ 0.5, and large ≥ 0.8 (Cohen, 1988). For interest, the P values of statistical tests are provided in the supplemental material. To evaluate the randomization and determine whether the groups differed significantly on baseline measures, two-tailed Mann-Whitney tests and Fisher exact tests were performed on continuous and categorical variables, respectively. Any values unevenly distributed at baseline (P < 0.05) and the baseline score on the outcome were included as covariates in the following statistical models. Analyses of covariance (ANCOVAs) tested group differences on the primary outcome measures of therapeutic alliance, treatment satisfaction, and adherence, and logistic regression was used for retention. For secondary measures, repeated measures ANCOVAs involving 2 to 3 measurement occasions (week-6 of treatment for some measures, and end-of-treatment and follow-up) were used. Cohen’s d was estimated from model marginal means. Positive effect sizes can be interpreted as an outcome favoring CBT + FE, and negative effect sizes as favoring CBT. There were complete data at baseline and on week-6 measures. A monotone attrition pattern was observed with 28% of patients missing data at end-of-treatment and 36% at follow-up (32% and 40% of relatives missing, respectively). Little’s MCAR test was not significant (patients: χ2(107) = 82.59, P = 0.96; relatives: χ2(25) = 37.10, P = 0.06). Missing data were imputed with monotonic multiple imputation and then intent-to-treat analysis results were pooled with Rubin’s rules (Rubin, 1987).

Results

Participant demographics

The sample comprised 25 participants (M ± SD: 37 ± 9 years, range = 18–75) and 25 family members. A CONSORT flow chart is presented in Figure 1. Diagnostically, 28% of patients (n = 7) were diagnosed with BED, 28% (n = 7) BN non-purging type, 20% (n = 5) BN purging type, and 24% (n = 6) EDNOS. Each patient’s native language was Spanish, and no patient spoke English exclusively. Most patients were born in Mexico (44%) or the U.S. (16%), and a diverse representation from other Latin America countries comprised the remainder of the sample (i.e., Honduras, El Salvador, Peru, Colombia, Guatemala, Venezuela, Bolivia). Due to the complexity and accuracy issues of collecting race on the Latino population, this study focused on ethnicity and country of origin; therefore, information on race was not collected. Most of the relatives were partner/husband (n = 18) and the rest were a sibling (n = 2), parent (n = 2), extended family or adult offspring (n = 3). Demographic and baseline variables are in Table 1. Significant between-group differences at baseline on SCL-36 (P = 0.02), family support (P = 0.008), and family cohesion-patient report (P = 0.003) were detected.

Figure 1.

Figure 1.

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PAS Flow Diagram

Table 1.

Demographic and acculturation measures at baseline

Variable CBT (N = 13) CBT + FE (N = 12) P
Demographics
Female sex 13 (100%) 12 (100%) 1.00
Age (patients, in yrs) 35.4 (9.4) 39.8 (8.4) 0.31
Age (relatives, in yrs) 41.0 (12.8) 40.0 (8.8) 0.83
Place of birth 0.24
 US 2 (15%) 2 (17%)
 Mexico 4 (31%) 7 (58%)
 Other Latin American country 7 (54%) 3 (25%)
Spoken language 0.37
 Spanish only 3 (23%) 1 (8%)
 Mostly Spanish, some English 4 (31%) 7 (58%)
 Spanish and English 6 (46%) 4 (33%)
 Mostly English, some Spanish 0 0
 English only 0 0
Education completed (yrs) 11.3 (3.3) 12.4 (3.4) 0.41
Marital status 0.32
 Single 4 (31%) 1 (8%)
 Married/defacto 9 (69%) 11 (92%)
Relationship to patient – relative* 0.38
 Husband/partner 8 (62%) 10 (83%)
 Sibling 1 (8%) 1 (8%)
 Parent 2 (15%) 0
 Extended family 1 (8%) 1 (8%)
 Adult child 1 (8%) 0
Acculturation and time in the US
ARSMA-II 3.0 (0.5) 3.1 (0.7) 0.90
ADS Acculturative distress 31.7 (10.7) 28.4 (10.8) 0.46
Time in US (yrs) 14.2 (8.8) 16.4 (10.7) 0.89
Psychiatric comorbidity
BDI-R 26.1 (9.0) 20.8 (6.4) 0.13
SCL-36 65.54 (23.3) 40.58 (24.2) 0.02*
MINI Post-traumatic stress disorder 3 (23%) 3 (25%) 1.00
Baseline scores on outcome measures
Family outcomes
FSS Family support 37.2 (7.4) 44.8 (5.2) 0.008**
FS Familism – patients 50.8 (8.9) 54.2 (8.4) 0.35
FS Familism – relatives 59.9 (9.5) 56.9 (11.7) 0.55
FCS Family cohesion – patients 5.9 (1.9) 3.6 (1.2) 0.003**
FCS Family cohesion – relatives 4.4 (1.6) 3.75 (1.0) 0.55
FPS Family pride – patients 13.3 (4.1) 9.0 (1.8)
FPS Family pride – relatives 10.8 (4.4) 9.7 (3.2)
FCCS Family cultural conflict – patients 10.1 (2.4) 9.0 (3.1)
FCCS Family cultural conflict – relatives 7.0 (2.8) 6.9 (2.4)
FBIS-SF Family burden 7.5 (9.3) 6.2 (7.2)
DAS Marital satisfaction – patients 57.2 (16.6) 69.8 (33.0)
DAS Marital satisfaction - relatives 59.2 (13.8) 63.4 (28.6)
Eating disorder symptoms
EDE Binge episodes 9.3 (10.2) 11.8 (10.4) 0.50
EDE Purging episodes 8.9 (23.0) 8.0 (25.3)
EDE Global 3.2 (1.6) 3.2 (1.3) 1.00
EDE-Q Binge episodes 9.8 (11.2) 10.2 (9.2) 0.80
EDE-Q Purging episodes 7.9 (15.7) 13.5 (13.2)
EDE-Q Global 3.8 (1.0) 4.1 (0.7) 0.40
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Note.

*

P < 0.05.

**

P < 0.01.

***

P < 0.001.

Means and standard deviations or counts and percentages are given. The DAS Dyadic Adjustment Scale was administered only to dyads that were married. ARSMA-II = Acculturation Rating Scale for Mexican Americans-II. BDI = Beck Depression Inventory-Revised. SCL-36 = Symptom Checklist-36. MINI = Mini International Neuropsychiatric Interview. FSS = Family Support scale. FCS = Family Cohesion Scale. FPS = Family Pride Scale. FCCS = Family Cultural Conflict Scale. FBIS-SF = Family Burden Interview Schedule – Short Form. DAS = Dyadic Adjustment Scale. EDE = Eating Disorder Examination. EDE-Q = Eating Disorder Examination-Questionnaire. P values reflect tests of baseline differences between groups. *This variable was dichotomized in the test of baseline differences to characterize a romantic (i.e., husband/partner) vs non-romantic (i.e., other) relationship with the patient.

Treatment acceptability

Table 2 shows treatment outcomes (see Supplementary Table 1 for P values of the ANCOVAs). Favoring CBT + FE, there was a medium effect size for adherence and a large effect size for retention. Favoring CBT, there was a large effect size on therapeutic alliance. Both groups scored highly on therapeutic alliance and treatment satisfaction. There were no group differences on treatment satisfaction, according to effect size.

Table 2.

PAS pilot RCT outcomes at end-of-treatment and 3-month follow-up

End-of-Treatment
 3-Month Follow-Up
M (s.e.)
 Cohen’s d [95% CI] Magnitude Favors M (s.e.)
 Cohen’s d [95% CI] Magnitude Favors
CBT CBT + FE CBT CBT + FE
Primary outcomes
Treatment acceptability
PAS-10 Therapeutic alliancea 71.00 (3.20) 59.75 (3.37) −0.97 (−1.76, −0.11) large CBT – – – – –
SSS Treatment satisfaction 3.65 (0.21) 3.59 (0.27) −0.07 (−0.85, 0.72) nil – – – – – –
Adherence 17.20 (2.76) 23.29 (2.91) 0.61 (−0.21, 1.39) medium CBT+FE – – – – –
Retentionb 62% 83% 1.25 [-0.38, 2.88] large CBT+FE – – – – –
Secondary outcomes
Family outcomes
FSS Family support 43.83 (2.51) 43.58 (2.12) −0.03 (−0.81, 0.76) nil – 42.18 (4.10) 43.3 (3.51) 0.08 (−0.71, 0.86) nil –
FS Familism – patients 51.46 (2.49) 51.98 (2.63) 0.06 (−0.73, 0.84) nil – 51.11 (2.67) 49.18 (2.26) −0.22 (−1.00, 0.58) small CBT
FS Familism – relatives 60.49 (3.82) 54.31 (4.63) −0.41 (−1.19, 0.39) small CBT 56.51 (3.96) 55.45 (3.64) −0.08 (−0.86, 0.71) nil –
FCS Family cohesion – patients 4.97 (0.67) 4.10 (0.56) 0.40 (−0.41, 1.17) small CBT+FE 4.58 (0.50) 4.09 (0.48) 0.28 (−0.52, 1.06) small CBT+FE
FCS Family cohesion – relatives 3.65 (0.25) 3.57 (0.32) 0.08 (−0.71, 0.86) nil – 3.98 (0.40) 3.50 (0.51) 0.30 (−0.50, 1.08) small CBT+FE
FPS Family pride – patients 10.90 (1.32) 12.58 (1.13) −0.38 (−1.16, 0.42) small CBT 11.96 (1.76) 11.98 (1.82) 0.00 (−0.79, 0.78) nil –
FPS Family pride – relatives 11.42 (1.28) 8.57 (1.09) 0.67 (−0.15, 1.46) medium CBT+FE 12.57 (1.10) 8.11 (1.08) 1.16 (0.27, 1.96) large CBT+FE
FCCS Family cultural conflict – patients 8.23 (1.15) 9.14 (1.05) −0.23 (−1.01, 0.56) small CBT 8.21 (1.00) 8.80 (1.05) −0.16 (−0.94, 0.63) nil –
FCCS Family cultural conflict – relatives 7.26 (0.51) 8.04 (0.49) −0.44 (−1.22, 0.37) small CBT 7.22 (0.68) 7.48 (0.62) −0.11 (−0.89, 0.68) nil –
FBI-SF Family burden 1.47 (0.60) 2.38 (0.62) −0.42 (−1.20, 0.38) small CBT 1.47 (0.60) 2.07 (0.65) −0.27 (−1.05, 0.52) small CBT
DAS Marital satisfaction – patients 57.56 (5.47) 58.84 (4.22) 0.09 (−0.87, 1.04) nil – 55.57 (7.96) 58.89 (5.43) 0.17 (−0.79, 1.12) nil –
DAS Marital satisfaction – relatives 59.72 (2.94) 55.94 (3.05) −0.43 (−1.37, 0.55) small CBT 65.03 (7.33) 56.51 (4.36) −0.50 (−1.44, 0.49) small CBT
Eating disorder symptoms
EDE Binge episodes 4.14 (2.45) 5.04 (2.33) −0.11 (−0.89, 0.68) nil – – – – – –
EDE Purging episodesc 0 0 0 (0,0) nil – – – – – –
EDE Global 2.41 (0.61) 2.82 (0.63) −0.19 (−0.97, 0.61) nil – – – – – –
EDE-Q Binge episodes −0.79 (1.80) 4.79 (1.92) −0.85 (−1.64, 0.00) large CBT −1.56 (2.32) 6.22 (3.03) −0.82 (−1.61, 0.02) large CBT
EDE-Q Purging episodes −1.49 (1.41) 5.56 (1.84) −1.23 (−2.04, −0.34) large CBT 0.30 (0.52) 0.11 (0.55) 0.10 (−0.69, 0.88) nil –
EDE-Q Global 2.26 (0.52) 2.16 (0.51) 0.05 (−0.73, 0.84) nil – 2.21 (0.49) 2.42 (0.52) −0.12 (−0.90, 0.67) nil –
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Note. Intent-to-treat results are provided with missing data from dropout estimated with monotonic multiple imputation modelling. The effect sizes were calculated from the marginal mean and standard error estimates of statistical models shown in this table. The models adjusted for the baseline score on the outcome, and patient-report analyses adjusted for baseline SCL-36, FSS family support, and FCS family cohesion-patient report scores. The “favors” column shows the group favored by the effect size estimate and a result is shown only when the effect size estimate is small in magnitude or larger. Positive effect sizes favor CBT + FE. The DAS Dyadic Adjustment scale is a measure of marital satisfaction and was only administered to couple dyads participating in therapy. Lower scores on FCS, FPS, FBI-SF, EDE, and EDE-Q, and higher scores on PAS-10, SSS, FS, FCCS, FBI-SF, and DAS indicate better outcomes. PAS-10 = Psychotherapy Alliance Scale-10. SSS = Service Satisfaction Scale. FSS = Family Support scale. FS = Familism scale. FCS = Family Cohesion Scale. FPS = Family Pride Scale. FCCS = Family Cultural Conflict Scale. FBIS-SF = Family Burden Interview Schedule – Short Form. DAS = Dyadic Adjustment Scale. EDE = Eating Disorder Examination. EDE-Q = Eating Disorder Examination-Questionnaire.

a

Measured at 6 weeks in treatment (i.e., not end of treatment).

b

Logistic regression was used for this outcome, and the odds ratio was converted to Cohen’s d.

c

Multiple imputation could not be used to estimate missing data because all purging frequency scores were zero—completer results are shown.

Family relationships and caregiver burden

On the basis of the effect size magnitudes, patients in CBT + FE reported greater family cohesion at post-treatment and follow-up, compared with patients in CBT. In contrast, patients in CBT reported greater family pride and lower family cultural conflict at post-treatment and greater familism at follow-up. Relatives in CBT + FE reported greater family pride at post-treatment, and greater family pride and family cohesion at follow-up compared with relatives in CBT. However, relatives in CBT reported greater familism, lower family cultural conflict, lower family burden, and higher marital satisfaction at post-treatment, and lower family burden and higher marital satisfaction at follow-up, than relatives in CBT + FE. The prediction regarding better family outcomes in CBT + FE was not clearly supported.

Eating disorder symptoms

CBT + FE patients did not have better outcomes on eating disorder symptom measures at post-treatment or follow-up. CBT patients had lower EDE-Q binge episodes and EDE-Q purging episodes at post-treatment and lower EDE-Q binge episodes at follow-up compared with CBT + FE patients. In both groups, scores on purging were low at 3-month follow-up. The hypothesis that patients receiving CBT + FE would have fewer eating disorder symptoms following treatment was not supported.

Discussion

This proof-of-principle pilot trial evaluated whether actively incorporating family members in culturally tailored CBT for binge-spectrum eating disorders would improve outcomes in Latina patients. The primary outcomes included treatment feasibility and acceptability, and secondary outcomes included changes in eating disorder symptoms, family functioning, and caregiver burden in participating relatives. This is one of the few clinical trials on the eating disorders field evaluating cultural adaptation treatment for Latinas, particularly with emphasis on less acculturated individuals.

We expected that CBT tailored to the family context would be more acceptable than individual-based delivery of CBT due to the cultural value of familismo. Effect sizes favored CBT + FE on adherence and retention, and scores on treatment satisfaction and therapeutic alliance were high, indicating treatment acceptability. Integrating a family member in treatment appears to enhance the engagement and retention, which could address the low level of mental health service utilization in the Latino population (US Surgeon National Report, 2001). Appointment reminders, transportation, and positive feedback on progress were some of the benefits mentioned by patients about having a family member actively involved in treatment (Reyes-Rodríguez et al., 2014; Reyes-Rodríguez et al., 2019). However, it is important to highlight that both conditions were well accepted by patients. Some of the cultural adaptations incorporated in the study (i.e., providing bilingual services, using a community-based approach, telephone appointment reminders, and treatment at no cost) could influence general treatment acceptability. In addition, the cultural adaptations implemented seem to have helped with the overall high rate of retention (62% CBT and 83% CBT+ FE) compared with the high rate of dropout in non-Latino clinical trials (29–73%) (Fassino et al., 2009). Therapeutic alliance was rated as significantly higher in CBT, which is not surprising due to the complexity of having a third party engaged in the therapeutic process (Rait, 2000); however, both groups rated therapeutic alliance highly.

In spite of the hypothesis that family outcomes such as support, familism, cohesion, pride, family cultural conflict, burden, and marital satisfaction (in couples) would be superior in CBT + FE, the preliminary data were inconclusive and results were mixed. The family sessions contributed to greater family cohesion. Having a better understanding about the eating disorder, knowing how to better support the loved one, and identification of potential triggers in the family dynamic can be associated with the sense of family cohesion (Reyes-Rodríguez et al., 2019). Surprisingly, other family outcomes (i.e., family pride, family conflicts, and familism) were more improved in the individual CBT at some assessment time points. Although the current data do not provide a clear explanation for this result, it was identified by therapists that some family dynamics were beyond the scope of the six family sessions that were focused primarily on the eating disorder (Reyes-Rodríguez et al., 2019). Family issues beyond the eating disorder that could be identified in the family sessions but not fully addressed due to the limited number of family sessions may also have contributed to the emergence of additional family conflicts. Emotional distress in partners (i.e., depression, anxiety) and other profound marital problems were contributing factors to the complexity of the family dynamic (Reyes-Rodríguez et al., 2019). Integrating an intervention focused on couple dynamics with extended sessions, such as UCAN (Bulik et al., 2012) or UNITE-BED (Kirby et al., 2015; Runfola et al., 2018) could provide more support for couples struggling with marital conflict. The inclusion of a family member in treatment could contribute to family members gaining a better understanding of the eating disorder illness and how they can support their loved one, therefore resulting in more effective family interactions that benefit the patient’s recovery process. For most patients, having the opportunity to openly discuss their challenges with the eating disorder, and for the family members, providing support guided by a professional, fosters an environment with better communication and support. Feeling understood and supported by loved ones has been identified as crucial for Latinas with eating disorders (Reyes-Rodríguez, Ramirez et al., 2013; Reyes-Rodríguez et al., 2019). Other studies exploring the feasibility of cultural adaptation treatment for eating disorder in Latinas have found the lack of support from the family or interference dynamics as a potential treatment barrier (Cachelin, Shea, et al., 2014; Shea et al., 2012).

The hypothesis that eating disorder outcomes including global eating psychopathology, binge eating, and purging would be superior in CBT + FE was not supported. There was some evidence that patients in CBT did better particularly on binge eating, otherwise no differences between groups emerged. It is important to mention that comparing two active treatments with a small sample size can limit the possibility of identifying any possible group differences. Accordingly, the results suggest that CBT + FE could enhance treatment adherence and retention, although this did not automatically translate to better family and symptom outcomes. The family component can be used as an adjunct intervention for those who might benefit if engagement and retention are particularly compromised. In cases where family dynamics are identified as a trigger or barrier for treatment, adding the psychoeducational sessions with family could be beneficial.

Study strengths include the multi-perspective assessment (clinician, patient, family member), multi-site community-based methodology, and focus on an underserved population. The small sample size limits statistical power and generalizability. Also, the role of the PI as a therapist in the study could add bias and limits the generalizability of the community-based approach. Recruiting and training additional community therapists and/or assigning the treatment conditions to separate but similar community settings could address the potential bias introduced by having the PI serve as therapist. Moreover, therapist turnover in community settings can be a real-world challenge encountered in conducting community-based interventions and should be considered when developing and disseminating community approaches to evidence-based care. Another limitation is attrition, which is a common problem in eating disorder treatment trials. Finally, all of our patients were female, so it is unclear if our observations can be generalized to Latino males with eating disorders.

This proof-of-principle pilot RCT reinforces the need for continued study of the use of family-enhanced CBT and suggests that a culturally sensitive approach that incorporates the family context into CBT for Latinas with eating disorders may improve treatment retention— particularly less acculturated individuals. A community-based approach appears to be an appropriate model for the Latino community, especially given the hesitancy about seeking treatment by undocumented individuals for fear of discovery and deportation. Strategies and liaisons between clinical researchers and community clinicians are necessary to make evidence-based treatments transportable and accessible. Treatments are expensive and the lack of health insurance is one of the most challenging barriers Latinas face when accessing health care in the United States (Caraballo et al., 2020). This study also confirms the results of prior studies documenting the feasibility and appropriateness of evidence-based treatment such as CBT or CBT guided self-help for binge-type eating disorders in Latinas, especially when cultural adaptations are integrated (Cachelin et al., 2014; Reyes-Rodríguez et al., 2014; Shea et al., 2016). This study represents one of the few evaluating treatment outcomes with a culturally tailored approach that could potentially be an avenue for more accessible, effective services for the Latino population.

Supplementary Material

Supplement Material

Financial Support

This research was supported by an NIMH grant (K-23-MH087954) to the first author at the University of North Carolina at Chapel Hill. The NIMH had no further role in study design; in collection; analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. We express our gratitude to all participants in this research.

Footnotes

Conflict of Interest

CMB reports being a grant recipient and Advisory Board member for Shire, a consultant for Idorsia, and a royalty recipient from Pearson. The other authors report no conflicts of interest.

Ethical Statements

The present study, including sampling, recruitment, therapeutic, and assessment protocols were reviewed and approved by the Institutional Review Board at the University of North Carolina, Chapel Hill. UNC-CH IRB # 10-0773

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