NURTURE: A Program for Mothers with Histories of Eating Disorders

A pilot program takes advantage of the Internet.

Parenting can be very challenging for mothers who have had eating disorders, particularly for those with issues around feeding, growth, and development. Infants of mothers with eating disorders also are at increased risk for feeding problems. Often these mothers are concerned about their infants’ health but lack confidence to develop healthy feeding practices and a healthy environment for their infants. With this in mind, a novel pilot program of parenting intervention for mothers with histories of eating disorders was recently developed by researchers at the University of North Carolina, Duke University, Virginia Commonwealth University, and Abo Akademi University, Turku, Finland (Int J Eat Disord 2014; 47:1).

Cristin D. Runfola, PhD, and Cynthia M. Bulik, MD and their colleagues recently reported on the early results of the pilot program, NURTURE (Networking, Uniting, and Reaching Out to Upgrade Relationships and Eating). The 16-week program is designed to be delivered in 90-minute weekly sessions via an internet web conferencing forum. Four modules address laying the foundation for parenting skills, general parenting skills, eating and feeding, and breaking the cycle of risk. The last segments were designed to help mothers develop appropriate vigilance for eating behavior disorder behavior and weight-related concerns, to protect children from social forces and media images that promote unhealthy weight management, and finally to review the skills and to heighten the mother’s awareness of challenges as their children age. The participants were mothers with histories of eating disorders who had children up to 3 years of age. After a brief telephone screening and an in-person interview, 13 mothers were treated in small groups of 3 to 6; the authors reported a 100% retention rate. Women who were still in active treatment for an eating disorder were excluded from the study.

Sessions in a password-protected chat room

According to the authors, the intervention was grounded in Social Cognitive Theory, or SCT, which emphasizes the interaction among environmental, personal, and behavioral factors and is widely used in prevention and health behavior modification. The researchers modified the original planned design, which involved face-to-face sessions, because many mothers reported that time constraints, scheduling conflicts, and challenges finding babysitters made in-person participation very difficult or impossible. Thus, the authors turned to an online web conferencing program (FuzeBox). Using this software program enabled therapists to present all the identical information in web conferencing that they originally planned to present in the in-person sessions.

The group discussions were held in a password-protected chat room, where the participants could communicate with each other and the therapist via both chat and telephone. The mothers could be anonymous if they wished. Assessments were conducted at baseline, post-treatment, and 6-month follow-up and included face-to-face semi-structured interviews and self-report measures at all time points. In addition, two study staff members filmed mothers feeding their children at a typical mealtime either in the home or in a special biobehavioral lab at the University of North Carolina. This lab includes a room equipped with dining room furniture and home equipment, and provides a space for family interactions and feeding sessions, while noninvasive monitoring can be done through 6 in-wall cameras. Various methods were used including observational ratings special questionnaires (Parenting Sense of Competence Scale, the Parent Attribution Test, and Infant Feeding Styles). The mothers also completed the Beck Depression Inventory, The Beck Anxiety Inventory, and the Eating Disorders Examination-Questionnaire.

A few changes were reported

All mothers were white, with a mean age of 32.3 years and mean body mass index (BMI, kg/m²) of 24.4. Most were highly educated; 25% were college graduates and 58.3% had at least one postgraduate degree. Seventy-five percent of the mothers had 1 child; 2 had 2 children, and one had 5 children. About 58% of mothers had a history of anorexia nervosa (AN) 54% had a history of bulimia nervosa (BN), and 9% had a history of AN or BN with an additional period of binge eating disorder. There was no significant change in mother-child feeding relationship, maternal feeding style, maternal self-efficacy and competence with general parenting skills, or martial psychopathology.

The format worked well for mothers with young children

One important positive outcome of the pilot study was related to the feasibility of delivering this form of intervention to mothers with young children. The web conferencing method enabled the mothers to overcome barriers to participation, and 100% of mothers remained in the study. General overall post-treatment feedback on treatment acceptability was very positive.

Because this was a pilot study, the authors did not expect to see significant improvement in outcomes. They did find that, “despite preliminary evidence that mothers with eating disorder histories are anxious during infant feedings and concerned about feeding interactions, the mothers in this study had scores in the normal range.” The mothers scored highest on the responsive feeding style, showing appropriate response to infant fullness and receptiveness cues and generally good feeding practices even before receiving any education about infant feeding. The authors also reported that they observed changes suggesting improvement in self-reported maternal self-efficacy and competence with parenting.