Liviu A. Fodor1,2, Ana Cosmoiu3, Ioana R. Podina3,4*
1 International Institute for The Advanced Studies of Psychotherapy and Applied Mental Health,
Babeș-Bolyai University, Cluj-Napoca, Romania
2 Evidence Based Psychological Assessment and Interventions Doctoral School, Babeș-Bolyai University, Cluj-Napoca, Romania
3 Laboratory of cognitive clinical sciences, Department of Psychology, University of Bucharest, Bucharest, Romania
4 Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
Background and aims: Cognitive bias modification (CBM) interventions for attention to and approach of appetitive food stimuli, especially approach-avoidance training (AAT) and attention bias modifications (ABM), have received a lot of attention lately. However, as far as we know the effect of these interventions has not been investigated so far by means of a quantitative meta-analysis.
Methods: We included randomized controlled trials (RCTs) on AAT/ABM interventions for attention to and approach of appetitive food stimuli. A random-effects model was used for pooling the effect sizes, which were calculated for bias scores and food consumption/craving (FC/C) outcomes at post-intervention, and we also examined risk of bias, publication bias, and possible other moderators.
Results: We included 15 RCTs, of which seven RCTs employed an AAT intervention and eight RCTs employed an ABM intervention. At post-intervention, there were significant effects sizes favoring CBM in terms of bias scores (g = 0.57; 95% CI: 0.35 to 0.79) and FC/C outcomes (g = 0.25; 95% CI: 0.12 to 0.38). The type of bias intervention and the type of control group were significant moderators of the effect size for the bias scores outcome. The risk of bias was uncertain in most of the trials and we found no evidence of publication bias.
Conclusions: Overall, these findings indicate that CBM interventions are showing promise in the overweight/obese and maladaptive eating domains. However, the quality of the RCTs entails a more cautious interpretation of these effect sizes. Other limitations and possible implications are discussed.
Keywords: cognitive bias modification, approach avoidance, attentional bias, maladaptive eating
Published online: 2017/09/01
Published print: 2017/09/01
References marked with an asterisk are included in the meta-analysis
Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & Van Ijzendoorn, M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study.
Becker, D., Jostmann, N. B., & Holland, R. W. (2017). Does approach bias modification really work in the eating domain? A commentary on Kakoschke et al.(2017). Addictive Behaviors.
*Becker, D., Jostmann, N. B., Wiers, R. W., & Holland, R. W. (2015). Approach avoidance training in the eating domain: Testing the effectiveness across three single session studies. Appetite, 85, 58–65. https://doi.org/10.1016/j.appet.2014.11.017
Belsky, J., & Pluess, M. (2009). Beyond diathesis stress: Differential susceptibility to environmental influences. Psychological bulletin, 135(6), 885.
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Introduction to Meta-Analysis. John Wiley & Sons, Ltd.
*Boutelle, K. N., Kuckertz, J. M., Carlson, J., & Amir, N. (2014). A pilot study evaluating a one-session attention modification training to decrease overeating in obese children. Appetite, 76, 180–185. https://doi.org/10.1016/j.appet.2014.01.075
Brooks, S., Prince, A., Stahl, D., Campbell, I. C., & Treasure, J. (2011). A systematic review and meta-analysis of cognitive bias to food stimuli in people with disordered eating behaviour. Clinical psychology review, 31(1), 37-51.
Christiansen P., Schoenmakers T.M., Field M. (2015). Less than meets the eye: Reappraising the clinical relevance of attentional bias in addiction. Addict Behav. 2015;44: 43–50. pmid:25453782
Cisler, J. M., & Koster, E. H. (2010). Mechanisms of attentional biases towards threat in anxiety disorders: An integrative review. Clinical psychology review, 30(2), 203-216.
Cox WM, Fadardi JS, Intriligator JM, Klinger E. Attentional bias modification for addictive behaviors: clinical implications. CNS Spectr. 2014;19: 215–224. pmid:24642267
Cristea, I. A., Kok, R. N., & Cuijpers, P. (2015). Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis. The British Journal of Psychiatry, 206(1), 7-16.
Cristea, I. A., Kok, R. N., & Cuijpers, P. (2016). The effectiveness of cognitive bias modification interventions for substance addictions: a meta-analysis. PloS one, 11(9), e0162226.
*Dickson, H., Kavanagh, D. J., & MacLeod, C. (2016). The pulling power of chocolate: Effects of approach-avoidance training on approach bias and consumption. Appetite, 99, 46–51. https://doi.org/10.1016/j.appet.2015.12.026
Duval, S., & Tweedie, R. (2000). Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics, 56(2), 455–463.
Field, M., & Cox, W. M. (2008). Attentional bias in addictive behaviors: a review of its development, causes, and consequences. Drug and alcohol dependence, 97(1), 1-20.
Field, M., Werthmann, J., Franken, I., Hofmann, W., Hogarth, L., & Roefs, A. (2016). The role of attentional bias in obesity and addiction. Health Psychology, 35(8), 767.
Fleming, K. A., & Bartholow, B. D. (2014). Alcohol cues, approach bias, and inhibitory control: Applying a dual process model of addiction to alcohol sensitivity. Psychology of Addictive Behaviors, 28(1), 85.
Gatineau, M., & Dent, M. (2011). Obesity and mental health. National Obesity Observatory: Oxford, UK.
Graham, R., Hoover, A., Ceballos, N. A., & Komogortsev, O. (2011). Body mass index moderates gaze orienting biases and pupil diameter to high and low calorie food images. Appetite, 56(3), 577-586.
Hakamata, Y., Lissek, S., Bar-Haim, Y., Britton, J. C., Fox, N. A., Leibenluft, E., … & Pine, D. S. (2010). Attention bias modification treatment: a meta-analysis toward the establishment of novel treatment for anxiety. Biological psychiatry, 68(11), 982-990.
Hardman, C. A., Rogers, P. J., Etchells, K. A., Houstoun, K. V., & Munafò, M. R. (2013). The effects of food-related attentional bias training on appetite and food intake. Appetite, 71, 295-300.
Hedges, L. V., & Olkin, I. (1985). Statistical Methods for Meta-Analysis. Academic Press.
Hendrikse, J. J., Cachia, R. L., Kothe, E. J., McPhie, S., Skouteris, H., & Hayden, M. J. (2015). Attentional biases for food cues in overweight and individuals with obesity: a systematic review of the literature. Obesity reviews, 16(5), 424-432.
Higgins, J. P. T., Altman, D. G., Gøtzsche, P. C., Jüni, P., Moher, D., Oxman, A. D., … Cochrane Statistical Methods Group. (2011). The Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials. BMJ (Clinical Research Ed.), 343, d5928.
Jones, A., Hardman, C. A., Lawrence, N., & Field, M. (2017). Cognitive training as a potential treatment for overweight and obesity: A critical review of the evidence. Appetite. https://doi.org/10.1016/j.appet.2017.05.032
*Kakoschke, N., Kemps, E., & Tiggemann, M. (2014). Attentional bias modification encourages healthy eating. Eating behaviors, 15(1), 120-124.
Kakoschke, N., Kemps, E., & Tiggemann, M. (2017). Approach bias modification training and consumption: A review of the literature. Addictive Behaviors, 64, 21–28. https://doi.org/10.1016/j.addbeh.2016.08.007
*Kakoschke, N., Kemps, E., & Tiggemann, M. (2017). The effect of combined avoidance and control training on implicit food evaluation and choice. Journal of Behavior Therapy and Experimental Psychiatry, 55, 99–105. https://doi.org/10.1016/j.jbtep.2017.01.002
*Kemps, E., Tiggemann, M., & Elford, J. (2015). Sustained effects of attentional re-training on chocolate consumption. Journal of Behavior Therapy and Experimental Psychiatry, 49(Pt A), 94–100. https://doi.org/10.1016/j.jbtep.2014.12.001
*Kemps, E., Tiggemann, M., & Hollitt, S. (2014). Biased attentional processing of food cues and modification in obese individuals. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 33(11), 1391–1401. https://doi.org/10.1037/hea0000069
*Kemps, E., Tiggemann, M., & Hollitt, S. (2016). Longevity of attentional bias modification effects for food cues in overweight and obese individuals. Psychology & Health, 31(1), 115–129. https://doi.org/10.1080/08870446.2015.1077251
*Kemps, E., Tiggemann, M., Martin, R., & Elliott, M. (2013). Implicit approach-avoidance associations for craved food cues. Journal of Experimental Psychology. Applied, 19(1), 30–38. https://doi.org/10.1037/a0031626
*Kemps, E., Tiggemann, M., Orr, J., & Grear, J. (2014). Attentional retraining can reduce chocolate consumption. Journal of Experimental Psychology. Applied, 20(1), 94–102. https://doi.org/10.1037/xap0000005
Kiefer, F. (2012). Impairment of inhibitory control in response to food-associated cues and attentional bias of obese participants and normal-weight controls. International journal of obesity, 36(10), 1334.
Loeber, S., Grosshans, M., Korucuoglu, O., Vollmert, C., Vollstädt-Klein, S., Schneider, S., … &
MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in emotional disorders. Journal of abnormal psychology, 95(1), 15.
McGough, J. J., & Faraone, S. V. (2009). Estimating the size of treatment effects: moving beyond p values. Psychiatry (Edgmont), 6(10), 21.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Journal of Clinical Epidemiology, 62(10), 1006–1012. doi:10.1016/j.jclinepi.2009.06.005
Neumann, R., & Strack, F. (2000). Approach and avoidance: the influence of proprioceptive and exteroceptive cues on encoding of affective information. Journal of personality and social psychology, 79(1), 39.
Nijs, I. M., & Franken, I. H. (2012). Attentional processing of food cues in overweight and obese individuals. Current obesity reports, 1(2), 106-113.
Orsini, N., Bottai, M., Higgins, J., & Buchan, I. (2006). HETEROGI: Stata module to quantify heterogeneity in a meta-analysis. Retrieved from http://econpapers.repec.org/software/bocbocode/s449201.htm
Rodin, J. (1976). The role of perception of internal and external signals on the regulation of feeding in overweight and nonobese individuals. Appetite and food intake, 265.
Schachter, S. (1971). Some extraordinary facts about obese humans and rats. American Psychologist, 26(2), 129.
Schulz, K. F., Altman, D. G., & Moher, D. (2010). CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMC medicine, 8(1), 18.
*Schumacher, S. E., Kemps, E., & Tiggemann, M. (2016). Bias modification training can alter approach bias and chocolate consumption. Appetite, 96, 219–224. https://doi.org/10.1016/j.appet.2015.09.014
Turton, R., Bruidegom, K., Cardi, V., Hirsch, C. R., & Treasure, J. (2016). Novel methods to help develop healthier eating habits for eating and weight disorders: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 61, 132–155. https://doi.org/10.1016/j.neubiorev.2015.12.008
*Werthmann, J., Field, M., Roefs, A., Nederkoorn, C., & Jansen, A. (2014). Attention bias for chocolate increases chocolate consumption–an attention bias modification study. Journal of Behavior Therapy and Experimental Psychiatry, 45(1), 136–143. https://doi.org/10.1016/j.jbtep.2013.09.009
World Health Organization. (2014). Global Health Observatory. Obesity: Situation and trends. (http://www.who.int/gho/ncd/risk_factors/obesity_text/en/). Retrieved on 04.08.2017