Meal and snack-time eating disorder cognitions predict eating disorder behaviors and vice versa in a treatment seeking sample: A mobile technology based ecological momentary assessment study
Open accessAbstract
Individuals with eating disorders experience high anxiety when eating, which may contribute to the high relapse rates seen in the eating disorders. However, it is unknown if specific cognitions associated with such anxiety (e.g., fears of gaining weight) may lead to engagement in eating disorder behaviors (e.g., weighing oneself). Participants (N = 66) recently treated at a residential eating disorder facility and diagnosed with an eating disorder (primarily anorexia nervosa; n = 40; 60.6%) utilized a mobile application to answer questions about mealtime cognitions, anxiety, and eating disorder behaviors four times a day for one week. Hierarchical linear models using cross-lag analyses identified that there were quasi-causal (and sometimes reciprocal) within-person relationships between specific eating disorder cognitions and subsequent eating disorder behaviors. These cognitions predicted higher anxiety during the next meal and eating disorder pathology at one-month follow-up. Interventions personalized to target these specific cognitions in real time might reduce eating disorder relapse.
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The two studies by Naslund et al. and the one by Levinson et al. were neither randomized nor blinded.
“The two studies by Naslund and colleagues [46, 47] and the one by Levinson and colleagues [48] were neither randomized nor blinded.”
From Mobile Apps for the Management of Comorbid Overweight/Obesity and Depression/Anxiety: A Systematic Review (2020) · cites this paper as [48]
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“According to the diagnostic criteria, between 35% and 44% of individuals with AN are also diagnosed as OCD.15 OCD and AN have common personality traits such as rigidity and perfectionism.16 Also, unwanted intrusive cognitions are common in both OCD and AN.17 In addition, some CONTACT S. Burak Acikel acikel42@gmail.com…”
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Attar, S., Jomaah, J., Khoury, R. E., Cordahi, C. C., Sénèque, M., Courtet, P., Khalil, R. B., & Guillaume, S. (2024) · Journal of Eating Disorders · doi:10.1186/s40337-024-01090-0 · Cited by 3 · see citing works
“From another perspective, yet in accordance with previous epidemiological statements linking ED to OCD, both disorders share similar phenotypes: perfection-ism, rigidity, persistency, and excessive ritual behaviors in an attempt to control long-term anxiety and fear [43].”
ResultRacine, S. E., Riddle, D. R., Durcan, J., Iordache, N., & Paterson, J. (2026) · Clinical Psychology Review · doi:10.1016/j.cpr.2026.102730 · Cited by 2 · see citing works
Mao, W., Schmidt, R., Presseller, E. K., Juarascio, A. S., & Hilbert, A. (2026) · International Journal of Eating Disorders · doi:10.1002/eat.70140 · Cited by 2 · see citing works
“This interpretation is consistent with prior conceptual and empirical work suggesting that EMIs may function as maintenance-oriented extensions of evidence-based ED treatments, by promoting continued engagement and skill application beyond the clinical setting (Levinson et al. 2018).”
Experiential Avoidance During Mealtimes Among Individuals With Eating Disorders
Cusack, C. E., Hunt, R. A., Rae, J., Christian, C., & Levinson, C. A. (2024) · Behavior Therapy · doi:10.1016/j.beth.2024.04.001 · Cited by 1 · see citing works
Self-citationForney, K. J., Jo, J. H., Pucci, G., & France, C. R. (2021) · International Journal of Eating Disorders · doi:10.1002/eat.23637
Brosof, L. C. (2022) · doi:10.18297/etd/3935
Self-citationWons, O. B., Lampe, E. W., Boyajian, L. E., Patarinski, A. G. G., & Juarascio, A. S. (2022) · Springer eBooks · doi:10.1007/978-3-030-67929-3_58-1
Wons, O. B., Lampe, E. W., Boyajian, L. E., Patarinski, A. G. G., & Juarascio, A. S. (2023) · Springer eBooks · doi:10.1007/978-3-031-16691-4_58
Sanders, S. A., Omowale, S. S., Casas, A. D., Kiyanda, A., Smith, A. M., Lai, Y., Wallace, M. L., Rathbun, S. L., Gary‐Webb, T. L., Davis, E. M., et al. (2024) · doi:10.2196/preprints.67081
Sanders, S. A., Omowale, S. S., Casas, A. D., Kiyanda, A., Kosbie, A. S., Lai, Y., Wallace, M. L., Rathbun, S. L., Gary‐Webb, T. L., Davis, E. M., et al. (2025) · JMIR Human Factors · doi:10.2196/67081
“Recent research using EMA to assess dietary behaviors has been conducted in different populations, including children [23,24], adolescents [25,26], mother-child dyads [27-29], individuals with eating disorders [30], and postbariatric surgery patients [31].”
Mealtime Physiological Responses in Individuals With Eating Disorders and Healthy Controls
Schuyteneer, E. D., Quagebeur, R., de Gooijer, F. J., Goris, A. H. C., Simões‐Capela, N., van Kraaij, A., & Vrieze, E. (2025) · European Eating Disorders Review · doi:10.1002/erv.70022 · Cited by 1 · see citing works
Post‐Meal Activity and Eating Disorder Behaviors: An Ecological Momentary Assessment ( EMA ) Study
Stedal, K., Wisting, L., Wonderlich, J. A., Wennersberg, A. L., Skarsbakk, A., Aarmo, I., Lie, S. Ø., & Funderud, I. (2026) · International Journal of Eating Disorders · doi:10.1002/eat.70137
“Levinson et al. (2018) found that meal-related cognitions predicted subsequent ED behaviors and vice versa, highlighting dynamic, reciprocal relationships between cognitive and behavioral processes across meals.”
- Authors
- Levinson, C. A., Sala, M., Fewell, L., Brosof, L. C., Fournier, L., & Lenze, E. J.
- Affiliations
- University of Louisville (US)
- Southern Methodist University (US)
- Washington University in St. Louis (US)
- Corresponding author
- Levinson, Cheri A.
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2018-06
- Volume
- 105
- Pages
- 36-42
- ISSN
- 0005-7967 (ISSN-L)
- PMC
- PMC5924721
- OpenAlex
- W2794575235
- Cited by
- 43
- References
- 66
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 6 · 2023: 1 · 2022: 11 · 2021: 5 · 2020: 7 · 2019: 4 · 2018: 3
- FWCI
- 5.58
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- NIH (T32-DA007261-25)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
- Keywords
- eating disorders, anorexia nervosa, eating disorder behaviors, eating anxiety, relapse, within-person relationships, treatment seeking
- MeSH terms
- Ecological Momentary Assessment, Adolescent, Adult, Anxiety, Feeding and Eating Disorders, Cognition, Eating, Feeding Behavior, Female, Humans, Male, Cell Phone, Young Adult, Snacks
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