Assessment of binge eating in obese patients

Binge eating disorder: disorder or marker?

OBJECTIVE

To describe the evidence for the constellation of symptoms known as binge eating disorder (BED) and to evaluate the utility of this diagnosis.

METHODS

Examination of the definition, prevalence, psychiatric comorbidity, and treatment of BED through a selective review of the literature.

RESULTS

The objective definition of a binge (its size and duration) remains problematic. Persons with BED have extensive comorbid psychopathology. Pharmacologic treatments effectively reduce binge eating, but only somewhat more than placebos, whereas psychotherapeutic treatments reduce binge eating, but do not produce weight loss. Traditional behavioral weight loss programs produce both weight loss and decreases in binge eating. The course of BED is variable and often remits with nonspecific attention or during wait-list conditions.

CONCLUSIONS

Although there is consensus on the criteria for BED, its great variability limits the implications that can be drawn from its diagnosis, and it may be most useful as a marker of psychopathology.

A test of the continuity perspective across bulimic and binge eating pathology

OBJECTIVE

This article examines the continuity/discontinuity perspective of eating pathology among 375 women seeking treatment.

METHODS

Participants were categorized into five separate groups: obese nonbingers, subthreshold binge eating disorder (BED), BED, subthreshold bulimics, and bulimics. We tested whether differences in core eating pathology (drive for thinness, body dissatisfaction, current body image, body image ideal) and psychiatric symptoms (depression, interoceptive awareness) differentiated the groups quantitatively (supporting the continuity perspective) or qualitatively (supporting the discontinuity perspective).

RESULTS

Our results, overall, supported the continuity perspective of eating pathology. A discriminant function analysis using the eating pathology and psychiatric symptom variables as predictor variables found that one primary factor differentiated the five groups on both core eating pathology and psychiatric variables.

DISCUSSION

The implications of testing this model within a treatment-seeking sample are discussed.

The relationship among binge severity, personality psychopathology, and body mass index

OBJECTIVE

To determine the relationship among binge severity, personality psychopathology, and body mass index (BMI) among individuals with binge eating disorder (BED).

METHOD

Participants were 50 individuals from the community who responded to advertisements for a medication treatment study of compulsive overeating and met BED criteria. Participants completed the Eating Disorder Examination and the Structured Clinical Interview for DSM-IV Personality Disorders.

RESULTS

Binge eating severity was significantly and positively correlated with BMI and personality disorder symptomatology. The frequency of binge eating episodes, but not binge size, was associated with greater levels of personality psychopathology. BMI and personality psychopathology were unrelated. Twelve percent of the participants met full criteria for avoidant personality disorder (APD) and 10% met full criteria for obsessive-compulsive personality disorder (OCPD).

DISCUSSION

Findings suggest that eating pathology, rather than weight, is related to personality psychopathology. APD and OCPD traits may be of particular relevance when considering treatment interventions for individuals with BED.

Overeating among adolescents: prevalence and associations with weight-related characteristics and psychological health

OBJECTIVE

To assess the prevalence of overeating among adolescents and to examine associations between overeating and sociodemographic characteristics, weight status, dieting behaviors, body satisfaction, depressive mood, self-esteem, and suicide.

METHOD

A school-based sample of 4746 boys and girls in public middle and high schools in Minnesota completed the Project EAT (Eating Among Teens) survey and anthropometric measurements of height and weight.

RESULTS

Overall, 17.3% of girls and 7.8% of boys reported objective overeating in the past year. Youths who engaged in overeating were more likely to be overweight or obese, to have dieted in the past year, to be trying to lose weight currently, and to report that weight and shape are very important to their overall feelings about self. Youths who met criteria for binge eating syndrome (high frequency of objective overeating with loss of control and distress regarding the binge eating) scored significantly lower on measures of body satisfaction and self-esteem and higher on a measure of depressive mood than those who reported either subclinical or no binge eating. Overeating was associated with suicide risk; more than one fourth of girls (28.6%) and boys (27.8%) who met criteria for binge eating syndrome reported that they had attempted suicide.

CONCLUSIONS

Overeating among adolescents is associated with a number of adverse behaviors and negative psychological experiences. As the current study is cross-sectional, it is not possible to ascertain cause and effect. Future research should seek to identify whether objective overeating is an early warning sign of additional psychological distress or is a potential consequence of compromised psychological health. Clinical implications are discussed.

Binge eating in obese children and adolescents

OBJECTIVE

The first goal of the current study was to examine the extent to which a population of obese children and adolescents have developed binge eating problems. The second goal was to generate variables that would distinguish obese binge eaters from obese non-binge eaters.

METHOD

A group of 126 children and adolescents seeking residential care because of their obesity was selected. A self-report version of the Eating Disorder Examination was administered.

RESULTS

Binge eating episodes were reported by 36.5% of the obese youngsters. Six percent reported two or more episodes of binge eating a week. Obese binge eaters differed significantly from obese non-binge eaters in self-esteem and in a broad range of eating-related characteristics. Compared with obese non-binge eaters, the obese binge eaters were slightly younger. Obese binge eaters did not differ from obese non-binge eaters in degree of overweight or depression.

DISCUSSION

Results suggest that binge eating is a prevalent problem among obese children and adolescents seeking help for their obesity. The marked difference between obese children with and without binge eating suggests the need for special treatment to focus on the problems of obese binge eaters.

Aspectos psiquiátricos da obesidade

Pesquisas recentes mostram que a obesidade é, em grande parte, o produto da vulnerabilidade genética mediada por um ambiente promotor da doença, o que sugere que os modelos biológicos podem ser mais úteis que os psicológicos para entender seu início e manutenção. No entanto, entre os pacientes que procuram tratamento, a obesidade tem sido associada a outros transtornos psiquiátricos, especialmente à depressão, o que sugere que a comorbidade psiquiátrica deve ser considerada na avaliação e no manejo clínicos. Além disso, embora a obesidade não seja em si mesma um transtorno alimentar, um subgrupo de indivíduos obesos, incluídos aqueles com o transtorno de compulsão alimentar periódica (TCAP) e com a síndrome do comer noturno - SCN (night eating syndrome - NES) sofrem de transtornos alimentares. Os psiquiatras podem e devem ter um papel ativo no tratamento da comorbidade ou de patologias relacionadas à alimentação e no auxílio aos pacientes obesos para que façam escolhas de estilos de vida saudáveis que levem a um maior bem-estar em termos físicos e psicológicos.

Binge-eating disorder in Brazilian women on a weight-loss program

OBJECTIVE

To examine binge-eating disorder (BED) and its association with obesity, weight patterns, and psychopathology in a Brazilian sample of female participants of a weight-loss program in São Paulo, Brazil.

RESEARCH METHODS AND PROCEDURES

Two hundred and seventeen overweight (body mass index >/= 25 kg/m(2)) women, ages 15 to 59 years, enrolled in the Weight Watchers Program were recruited for the study at a program branch meeting after completing the Questionnaire on Eating and Weight Patterns-Revised, Beck Depression Inventory, and the Toronto Alexithymia Scale-20. Participants were categorized into four groups: those who met questionnaire criteria for BED, those who met questionnaire criteria for bulimia nervosa (BN), those that reported binge eating but did not meet all the criteria for any eating disorder (BE), and those with no eating disorder symptoms (No ED). Groups were compared on measures of weight, depressive symptoms, and alexithymia.

RESULTS

Binge eating was frequently reported by women in this study (BED, 16.1%; BN, 4.6%; BE, 22.6%). BED women had significantly higher body mass index, greater highest weight ever, and more frequent weight cycling than the No ED group. BED women also reported more depressive symptoms than BE and No ED women, and were more alexithymic than the No ED group. BE women presented more frequent weigh cycling and were also more depressed and alexithymic than the No ED group.

DISCUSSION

BED is not uncommon in overweight Brazilian women, and similar to North American and European samples, it is associated with overweight and higher levels of psychopathology in this population.

Binge eating disorder in extreme obesity

OBJECTIVE

To determine whether extremely obese binge eating disorder (BED) subjects (BED defined by the Eating Disorder Examination) differ from their extremely obese non-BED counterparts in terms of their eating disturbances, psychiatric morbidity and health status.

DESIGN

Prospective clinical comparison of BED and non-BED subjects undergoing gastric bypass surgery (GBP).

SUBJECTS

Thirty seven extremely obese (defined as BMI > or = 40 kg/m(2)) subjects (31 women, six men), aged 22-58 y.

MEASUREMENTS

Eating Disorder Examination 12th Edition (EDE), Three Factor Eating Questionnaire (TFEQ), Structured Clinical Interview for the Diagnostic and Statistical Manual-IV (SCID-IV), Short-Form Health Status Survey (SF-36), and 24 h Feeding Paradigm.

RESULTS

Twenty-five percent of subjects were classified as BED (11% met full and 14% partial BED criteria) and 75% of subjects were classified as non-BED. BED (full and partial) subjects had higher eating disturbance in terms of eating concern and shape concern (as found by the EDE), higher disinhibition (as found by the TFEQ), and they consumed more liquid meal during the 24 h feeding paradigm. No difference was found in psychiatric morbidity between BED and non-BED in terms of DSM-IV Axis I diagnosis. The health status scores of both BED and non-BED subjects were significantly lower than US norms on all subscales of the SF-36, particularly the BED group.

CONCLUSION

Our findings support the validity of the category of BED within a population of extremely obese individuals before undergoing GBP. BED subjects differed from their non-BED counterparts in that they had a greater disturbance in eating attitudes and behavior, a poorer physical and mental health status, and a suggestion of impaired hunger/satiety control. However, in this population of extremely obese subjects, the stability of BED warrants further study.

Medical and psychiatric morbidity in obese women with and without binge eating

OBJECTIVE

To determine the prevalence of obesity and binge eating in a population-based sample of female twins and to examine whether the presence of binge eating was associated with a greater risk for medical and psychiatric disorders in obese women.

METHOD

A population-based study of twins who were born between 1934 and 1971 and both members responded to a mailed questionnaire (individual response rate was conservatively estimated to be 64%). Data for the present study are from the first and third interview waves. In Wave 1 (1987-1989), we assessed 92% of the eligible individuals (N = 2,163), 90% face-to-face and the remainder by telephone. We assessed lifetime history of psychiatric disorders, major medical disorders, health limitations, health satisfaction, and an array of personality and attitudinal measures.

RESULTS

Obese women with binge eating reported greater health dissatisfaction and higher rates of major medical disorders than obese women without binge eating. Binge eating was also associated with higher lifetime prevalence of major depression, panic disorder, phobias, and alcohol dependence. Obese women with binge eating scored higher on neuroticism and symptom scales measuring depression, anxiety/phobia, and neurovegetative symptoms (i.e., insomnia, agitation, retardation, and obsessive-compulsive traits).

DISCUSSION

The presence of binge eating in obese women is a marker for greater medical and psychiatric morbidity.

Loss of control over eating, adiposity, and psychopathology in overweight children

OBJECTIVE

To investigate the relationship between loss of control over eating, adiposity, and psychological distress in a nontreatment sample of overweight children.

METHOD

Based on self-reports of eating episodes, 112 overweight children, 6-10 years old, were categorized using the Questionnaire of Eating and Weight Patterns-Adolescent Version into those describing episodes of loss of control over eating (LC), and those with no loss of control (NoLC). Groups were compared on measures of adiposity, dieting, and eating behavior, and associated psychological distress.

RESULTS

LC children (33.1%) were heavier and had greater amounts of body fat than NoLC children. They also had higher anxiety, more depressive symptoms, and more body dissatisfaction. 5.3% met questionnaire criteria for BED. Episodes of loss of control occurred infrequently, were often contextual, and involved usual meal foods.

DISCUSSION

As in adults, overweight children reporting loss of control over eating have greater severity of obesity and more psychological distress than those with no such symptoms. It remains unknown whether children who endorse loss of control over eating before adolescence will be those who develop the greatest difficulties with binge eating or obesity in adulthood.

Effects of prolonged and repeated body image exposure in binge-eating disorder

OBJECTIVE

The purpose of the present study was to investigate psychological mechanisms associated with prolonged and repeated body image exposure.

METHOD

In an experimental design, 30 female volunteers diagnosed with binge-eating disorder (BED) (DSM-IV) and 30 non-eating-disordered controls (NC) were exposed to their physical appearance in a mirror. The confrontation procedure was guided by a standardized interview manual and took place on two separate days. Self-reported mood, appearance self-esteem, and frequency of negative cognitions were assessed repeatedly throughout the experiment.

RESULTS

During body image exposure sessions, binge-eating-disordered individuals showed significantly lower mood than controls while appearance self-esteem was diminished in both groups. During the second body image exposure session, higher levels of mood and appearance self-esteem were observed in both groups, and negative cognitions occurred less frequently.

CONCLUSION

Results are discussed with regard to the therapeutic use of body image exposure.

The cognitive-behavioral model of bulimia nervosa: a direct evaluation

OBJECTIVE

This study represented the first attempt to directly evaluate Fairburn et al's (1986) cognitive-behavioral model of bulimia nervosa--the model on which the most widely used treatment for bulimia nervosa is based.

METHOD

The major predictions of the model were tested using structural equation modeling. Data were collected from the responses of 526 subjects to a number of self-report measures.

RESULTS

The factors of self-esteem, overconcern with weight and shape, and dietary restraint accounted for a large proportion of the variance in binge eating and purging. The key pathway in the model was the link between overconcern with weight and shape and the adoption of purgative behaviors, which then fed into a vicious cycle of binge eating and purging. Contrary to Fairburn's hypothesis, high levels of dietary restraint did not predict increased binge eating.

DISCUSSION

The results suggest that the components of Fairburn's model may operate to maintain the bulimic cycle in a slightly different way to that originally proposed.

A study of the attribution style, self-efficacy, and dietary restraint in female binge and non-binge eaters

The purpose of this study was to identify the role that attribution style and self-efficacy expectations have in overweight binge and non-binge eaters. The subjects were women (n=210) enrolled for weight control treatment, who completed a questionnaire to assess attribution style and self efficacy expectations. They were categorized into three binge eating disorder (BED) groups: non-BED, borderline BED and BED. The results of the ANOVA analysis indicated that the borderline and BED groups were significantly similar in terms of all measures of attribution and self-efficacy; and logistic regression analysis that the odds of being borderline BED or BED were greater if an individual had internal attributions, and more likely in the presence of diminished self-efficacy expectations. The subjects with low levels of eating self-efficacy and internal, global, and uncontrollable attributions were also more likely to have borderline BED and BED. The implications of the borderline BED category are discussed in relationship to the DSM-IV BED diagnosis.

Body dissatisfaction and binge eating in obese women: the role of restraint and depression

OBJECTIVE

This study examined the association between body dissatisfaction and binge eating, and the mediating role of restraint and depression among obese women.

RESEARCH METHODS AND PROCEDURES

Participants were obese women taking part in a cognitive-behavioral treatment program who completed self-report measures at baseline (n = 89) and post-treatment follow-up (n = 69).

RESULTS

At baseline, body dissatisfaction was strongly correlated with binge eating score. This was partly a direct effect and partly mediated by depression. No mediating effect of restraint was observed. Over the treatment period, a reduction in body dissatisfaction was associated with a reduction in binge-eating score. As in the cross-sectional data, there was evidence for mediation by change in depression with the greatest improvement in binge eating among those who became more restrained and less depressed.

DISCUSSION

These results suggest that it would be valuable to address psychological well-being, and especially body image, as part of the management of binge-eating behavior in obesity.

Psychosocial variables associated with binge eating in obese males and females

OBJECTIVE

This study tested a psychosocial model of binge eating symptoms in obese men and women. Predictor variables included depression, dietary restraint, self-esteem, weight cycling, history of teasing, body dissatisfaction, and neuroticism.

METHOD

Participants (N = 808) completed a packet of self-report questionnaires.

RESULTS

Weight cycling, teasing about weight and shape, body dissatisfaction, negative affect, and dietary restraint comprised the best fitting models (original and cross-validation) for binge eating in women and men. These variables explained 61-72% of the variance in symptoms of binge eating in the samples of men and 70% of the variance in the samples of women. Although the male and female models were mostly similar, notable differences between them were found.

DISCUSSION

The variables that comprise these etiological models should be considered in the development of prevention programs for obese binge eaters. Longitudinal studies, however, are needed to examine these etiological paths and to test for causal relationships.

Binge-eating disorder and obesity. A combined treatment approach

Patients presenting with both obesity and BED face multiple challenges: normalizing their eating, improving their physical health, and working to enhance their own acceptance of their body image. In an effort to feel better about themselves, they often have become trapped in a cycle of desperately attempting to diet, then losing control, binge eating, and gaining even more weight. Several psychological and pharmacologic treatment approaches have been used in this population. Most suppress binge eating in the short term, and some seem promising in the long term as well. However, sustained weight loss remains a largely unrealized goal. More recently, BED treatment programs have attempted to address these goals sequentially or in combination. In either approach, it is clear that adopting a long-term focus and promoting enhanced self-acceptance, which have so often been missing from these patients' previous attempts at recovery, are important tasks of treatment that are likely to lead to beneficial lifestyle changes and long-term improvements in physical and psychological health.

Measurements of body image in clinical weight loss participants with and without binge-eating traits

This study measured body image disturbances of individuals in a residential weight loss program who were identified as having binge-eating disorder (BED) traits. The study population (N=97) was a convenience sample of 74 men (76%, mean age=51.0) and 23 women (24%, mean age=49.6) in the program who completed the Eating Questionnaire-Revised (EQ-R), the Attitudes About Weight and Dieting (AAWD), the Physical Appearance State and Trait Anxiety Scale (PASTAS): State Version, and the Contour Drawing Rating Scale (CDR). Fifty-five individuals reported having binge traits (57%) while 42 (43%) had no binge traits. Individuals with the binge traits had a significantly higher BMI than nonbinge trait individuals (P=.008). The binge trait group scored higher on the total AAWD (P=.004), the AAWD factor "Fear of Fat" (P=.002), the total PASTA (P=.001), and the PASTA factor "Weight" (P=.001) than the nonbinge trait group. Logistic regression analysis indicated that the odds of having a binge trait were 1.44 times more likely for a person at a given score on the PASTA subscale Weight vs. a person at a score of 5 units less. Feelings of being unable to control eating among individuals seeking weight control is associated with several characteristics related to body image. Individuals showing greater concern about weight and dieting and specifically greater fears of becoming fat were more likely to have a problem with binge eating than those without these concerns. The results of this study suggest that a negative body image is an important factor to consider when treating individuals indicating binge-eating traits.

Body image evaluations in obese females with binge eating disorder

Dimensions of body image in a sample of obese women diagnosed with binge eating disorder (BED; N=42) were compared with a sample of obese women without BED (non-BED; N=42), matched on age and BMI. Additionally, the relationship between BED, body image and several dimensions of treatment response was examined. Results indicated BED women were more likely to negatively evaluate their global physical appearance and have less satisfaction with specific areas of the body than were non-BED women, even after controlling for depression scores. While BED women were significantly more likely to endorse depressive symptoms, depression scores were negatively correlated with body satisfaction in non-BED women only. BED women did not fare worse in formal weight-loss treatment, as measured by length of time in treatment, group-therapy attendance, or BMI at posttreatment. The role of body image in women with BED seeking weight-loss treatment is discussed relevant to the context of potential impact of BED and negative body image on active weight-loss treatment and maintenance.

Binge eating disorder: prevalence and psychopathological features in a clinical sample of obese people in Italy

Binge eating disorder (BED) is a recently conceptualized eating disturbance, and its clinical features and prevalence are still a matter of debate. This study uses interview methodology to estimate the prevalence of BED in Italy in a sample of 66 obese people presenting for treatment, and examines potential related features typical of patients with anorexia and bulimia nervosa. The lifetime and the 6-month prevalences of BED were 18.1 and 12.1%, respectively. Breaking the group down on the basis of the current as well as lifetime presence of BED, we found that the weight and shape primary to self-esteem, and the interpersonal distress related to body image, were associated with lifetime BED (P<0.05). All-or-none thinking about food and dieting was typical of BED patients as a whole, either current (P<0.01) or remitted (P<0.05). We discuss two important findings from our study: (a) the key role of self-esteem depending upon weight and shape in discriminating the eating-disordered obese from non-eating-disordered individuals; and (b) the need to explore the whole lifespan when screening for BED, so pointing to the state-trait issue.

Subthreshold binge eating disorder

OBJECTIVE

To examine the clinical features of subthreshold binge eating disorder (BED).

METHOD

Participants were recruited directly from the community as part of an ongoing study of risk factors for BED. Forty-four women with subthreshold BED were compared with 44 women with BED and 44 healthy controls on demographic characteristics, body mass index (BMI), eating disorder symptomatology, and psychiatric distress. Diagnoses were established using the Eating Disorder Examination (EDE). Participants completed the EDE-Questionnaire, the Brief Symptom Inventory, and were measured and weighed.

RESULTS

Adjusting for significant group differences in BMI, the two eating disorder groups did not differ significantly on measures of weight and shape concern, restraint, psychiatric distress, and history of seeking treatment for an eating or weight problem.

DISCUSSION

Given the importance of diagnostic status for access to treatment, further evaluation of the severity criterion specified for BED is needed.

Using the eating disorder examination to identify the specific psychopathology of binge eating disorder

OBJECTIVE

The clinical features of binge eating disorder (BED) are not well established. Therefore, a comprehensive assessment of the specific psychopathology of BED as compared to anorexia nervosa (AN) and bulimia nervosa (BN) is warranted. This comparison was the aim of the present study.

METHOD

Detailed ratings from an investigator-based interview, the Eating Disorders Examination (EDE), were compared across three groups of female patients: those with BED, AN, and BN, as well as normal-weight and overweight control subjects.

RESULTS

When comparing BED to AN and BN, patients with BED had lower levels of restraint, eating concerns comparable to AN patients but lower than BN patients, and weight and shape concerns comparable to BN patients but higher than AN patients. Significantly more eating disorder psychopathology was found for BED patients as compared to the overweight controls on all bar the EDE restraint subscale. On the majority of individual EDE items, BED patients' scores were similar to those of AN and BN patients, including importance of shape and weight in self-evaluation and preoccupation with shape and weight. No significant relationship was found between BED patients' degree of overweight and eating psychopathology.

DISCUSSION

Our findings support the status of BED as an eating disorder and suggest that the elevated EDE scores reflect the combined impact of being objectively overweight and having disordered cognitions and behaviors about eating, shape, and weight.

Screening for binge eating disorder in obese outpatients

The prevalence of binge eating disorder (BED) in clinical samples of obese patients is controversial, and sensitive diagnostic protocols for use in routine clinical practice need to be further defined. Three hundred forty-four obese (body mass index [BMI] > or =30 kg/m2) patients were studied with the Structured Clinical Interview for DSM-III-R to investigate the lifetime prevalence of mental disorders. The current prevalence of BED was assessed using DSM-IV criteria. Eating attitudes and behavior were investigated with the Bulimic Investigation Test, Edinburgh (BITE) and the Binge Eating Scale (BES). The Beck Depression Inventory (BDI) and Spielberg's State-Trait Anxiety Inventory (STAI) were also applied. The prevalence of BED was 7.5%. Patients with BED had a higher BMI compared with obese patients without BED. Differences in the lifetime prevalence of mental disorders in patients with and without BED were not statistically significant. Using the BES as a screening instrument for BED with a threshold of 17, the sensitivity was 84.8%, specificity 74.6%, positive predictive value 26.2%, and negative predictive value 97.9%. Using the BITE with a threshold of at least 10, the sensitivity was 91%, specificity 51.4%, positive predictive value 71.8%, and negative predictive value 98.2%. The BITE can be a valid alternative to the BES as a screening method for BED in obese patients.

Eating disorder symptoms in a cohort of 11 to 16-year-old black and white girls: the NHLBI growth and health study

OBJECTIVE

This study sought to provide reference data for the Eating Disorder Inventory (EDI) with use of young adolescent black and white girls. Moreover, the study examined the relationship between race, age, socioeconomic status, and adiposity and each of the eight EDI scales.

METHOD

To achieve these aims, data were used that had been collected in Years 3, 5, and 7 as part of the National Heart, Lung, and Blood Institute Growth and Health Study, a longitudinal cohort study of risk factors for obesity in black and white girls. For the present report, data were available from 2,228 girls in Year 3, 2,056 girls in Year 5, and 1,902 girls in Year 7.

RESULTS

EDI scores were found to vary by race, age, socioeonomic status, and body weight of respondents. Black girls scored different from white girls on all EDI subscales. Scores on all but two subscales (Body Dissatisfaction, Drive for Thinness) decreased significantly with increasing age. Significant inverse associations were found between maximum parental education and all EDI subscales except Body Dissatisfaction and Perfectionism. Elevated body weight was associated significantly with Body Dissatisfaction, Drive for Thinness, Bulimia, Interoceptive Awareness, and Ineffectiveness.

DISCUSSION

Our results illustrate the importance of taking into consideration the potentially confounding role of demographic characteristics and body weight when comparing different race or ethnic groups on the EDI.

Sleep-wake cycles in women with binge eating disorder

OBJECTIVE

Binge eating disorder (BED) is a new diagnostic category in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The majority of studies on sleep characteristics in overweight women have used nonbinging obese women. The aim of this study was to evaluate sleep characteristics in obese BED patients in comparison to non-BED obese (OB) and nonbinging normal weight (NW) women.

METHOD

Eighteen females with BED, 13 OB, and 16 NW women were recruited. Sleep-wake patterns were monitored for 1 week using mini-actigraphs and self-report questionnaires.

RESULTS

Their ambulatory sleep data revealed that BED and OB subjects had significantly lower sleep efficiency, had more wake during sleep, and had less zero activity than the NW group. The self-report questionnaires presented significantly more sleep disturbances in the BED and OB groups than in the NW group.

DISCUSSION

The objective results support the subjective sleep disturbances reported by the two obese groups, the BED and the OB. A possible explanation for these findings could be weight-related physical discomfort or the existence of breathing disorders in sleep. Further research, for example, overnight polysomnography recordings and follow-up treatment, is required.

Using a women's health perspective to guide decisions made in quantitative research

Women's health, as an emerging area of nursing scholarship, is based on a set of philosophical assumptions. These assumptions are: (i) women's health can best be understood by examining women's lived experiences within a specific context; (ii) gender bias must be avoided; (iii) the focus should be on health rather than illness; and (iv) non-exploitative relationships should be established between the researcher and research participants. Assumptions from a women's health perspective can be used by researchers to guide decisions made in conducting research with women. In order to strengthen the correspondent validity (i.e., the fit between theory and methods), research decisions need to be consistent with the philosophical assumptions of the inquiry. Examples of quantitative research decisions influenced by a women's health perspective are illustrated using a study of binge eating in women.

Binge eating, body image, depression, and self-efficacy in an obese clinical population

OBJECTIVE

Binge eating disorder appears to be an important factor in obesity treatment. Researchers have proposed that specialized treatment programs be developed to address chronic binge eating behavior. This study was conducted to examine the relationships between binge eating, depression, body image, and self-efficacy. Based on related research, it was hypothesized that depression and negative body image would be greater for binge eaters whereas weight self-efficacy would be lower.

RESEARCH METHODS AND PROCEDURES

Subjects were 159 clinic patients participating in a multidisciplinary weight management program. Baseline measurements of binge eating status, body image and related eating behaviors, depression, and self-efficacy were obtained, whereas follow-up measures consisted of weight loss and attendance. Exploratory factor analyses were performed to obtain factors for items contained in the Eating Habits Questionnaire. Chi-square, t-tests, and logistic regression analyses determined relationships between binge eating, body image, depression, and self-efficacy.

RESULTS

Univariate comparisons indicated that increased perceptions of poor body image were significantly related to binge eating. Higher levels of depression and lower weight self-efficacy were related to binge eating, but the results were qualified after applying corrective statistics for multiple comparisons. A stepwise regression analysis indicated that body image, particularly characterized by a sense of shame and concern with public appearance, had the strongest relationship to binge eating among all the factors examined in this study.

DISCUSSION

These findings extend current understanding of the relationships between binge eating, body image, depression, and self-efficacy. The significance of body image, especially in relation to negative social consciousness, was determined when comparing several psychological and behavioral factors thought to influence binge eating. Further research is needed to determine the causal relationships between binge eating and the other factors examined in this study.

Use of the BULIT bulimia screening questionnaire to assess risk and progress in weight management for overweight women who weight cycle. BULImia Test

A bulimia screening questionnaire was examined for usefulness in assessing risk for bulimia and measuring progress in reducing binge eating in overweight women who weight cycle. In two studies the BULIT test was used to screen for risk for bulimia. Study 1 was a descriptive study of motivations for overeating in normal weight women compared to overweight women who weight cycled. In Study 2, overweight women who weight cycled were examined at baseline, 6, and 12 months for effectiveness of a clinical treatment strategy to reduce binge eating. In Study 1, BULIT scores were statistically significantly higher for overweight compared to normal weight subjects. In Study 2, subjects' BULIT scores were lower after using a long term clinical treatment strategy to gain control of eating. The BULIT test was useful for specifying four categories of eating patterns to assess risk for bulimia and progress in reducing binge eating.

Gender differences among those exhibiting characteristics of binge eating disorder

One hundred and eighty-seven former residential weight control participants exhibiting binge eating traits were assessed for gender differences regarding demographics, diet, exercise, weight control techniques, behavior modification techniques and binge eating characteristics. Data were gathered using a 68-item paper pencil questionnaire. Results indicate that there were no significant differences between males and females regarding demographic variables, and the number and types of weight control programs tried since leaving the residential program. Significant differences did exist between males and females in the number of times they had started dieting in the past year. No significant differences were observed among males and females regarding severity, binge emotions and compensatory behaviors. Statistically significant differences did exist regarding post-binge emotions. Results from this study suggest that males and females differ in regard to the diet/binge cycle and additionally, males appear to have a different or less emotional response subsequent to a binge.

The psychological ramifications of weight management

It has long been believed that food restriction leads to psychological disturbances, including depression, preoccupation with food, and binge eating. However, recent studies suggest that comprehensive weight loss programs that incorporate behavioral treatment, diet change, and encouragement of physical activity in fact can improve the psychological state, including mood. A study conducted on subjects participating in the Weight Watchers program demonstrated positive psychological changes and improved quality of life. These changes may help motivate overweight people to maintain the physical activity and nutritional practices necessary to lose and maintain weight. Programs that include group support, like Weight Watchers, have been associated with psychological benefits independent of the amount of weight lost. Furthermore, dieters who regain lost weight do not appear to experience adverse psychological consequences. The development or exacerbation of bulimia has been linked by some authors to strict dieting, but more moderate weight control programs do not appear to produce disordered eating and may help reduce binge eating among overweight people. Individuals who successfully lose and maintain weight have been shown to experience improved mood, self-confidence, and quality of life. Additionally, decreasing levels of psychological and behavioral symptoms have been associated with increasing duration of weight loss maintenance. It can be concluded that quality of life and other psychological measures improve in individuals on comprehensive weight management programs.

Binge eating before the onset of dieting: a distinct subgroup of bulimia nervosa?

OBJECTIVE

While most individuals with bulimia nervosa begin dieting prior to the onset of binge eating, some individuals begin binge eating prior to dieting. The purpose of this study was to assess the differences between these two groups.

METHODS

Participants (N = 120) in a treatment study for bulimia nervosa were separated into two groups (Binge First vs. Diet First) based on the ages they reported for the onset of binge eating and of dieting and then compared across a number of variables.

RESULTS

Individuals in the Binge First group reported higher weight, higher shape and weight concern, lower age of onset of eating disorder symptoms, and an altered relationship of binge eating to vomiting when compared to individuals in the Diet First group.

DISCUSSION

The differences between the two groups suggest that there may be subgroups of individuals with purging bulimia nervosa and that individuals in the Binge First group more closely resemble individuals with binge eating disorder than do those in the Diet First group.

Natural course of a community sample of women with binge eating disorder

OBJECTIVE

A community sample of women with binge eating disorder (BED) was followed for a period of 6 months, in order to examine the natural course of the disorder.

METHOD

Baseline, 3-, and 6-month assessments were conducted. The following variables were examined: eating disorder symptomatology, importance of weight or shape, psychopathology, social adjustment, childhood sexual abuse, childhood obesity, parental obesity, and parental psychopathology.

RESULTS

After the 3-month follow-up, 10 of the original sample of 31 participants dropped out of the study; drop-outs were more likely to have reported a history of sexual abuse. Of the 21 remaining participants, 11 continued to suffer from full-syndrome BED at 6-month follow-up, while the remaining 10 appeared to be in partial remission. There were no significant baseline predictors of outcome.

CONCLUSION

It appears that for some women with BED, the eating disorder improves with a decrease in binge eating and importance of weight or shape. For others, the eating disorder symptoms remain constant.

The role of dieting in binge eating disorder: etiology and treatment implications

Dieting has been implicated as a potential contributor in the development of binge eating problems in binge eating disorder (BED). If dieting plays a causal role in the etiology of BED, this could have major implications for understanding and treating individuals with the disorder. This article reviews the existing literature on the role of dieting in BED. Retrospective studies of dieting history, research on levels of dietary restraint, and prospective studies investigating the effects of dieting on subsequent eating behavior are explored. Although the literature is inconclusive as to the exact role that dieting plays in the etiology of BED, recommendations for future research and suggestions for treatment are given.

Psychological symptoms are greater among weight cycling women with severe binge eating behavior

OBJECTIVE

To identify psychological characteristics and eating behaviors associated with weight cycling and binge eating behaviors in overweight women (body mass index > 27.3).

DESIGN

Questionnaires measuring self-esteem, self-efficacy, coping strategies, psychological symptoms, depression, binge eating, restrained eating, disinhibition, and hunger were administered to female weight cyclers who were overweight. Psychological characteristics were compared between subjects grouped by binge eating disorder classification and by binge eating severity.

SUBJECTS

A convenience sample of 62 female weight cyclers who were overweight was recruited from the Chicago, Ill, area. Questionnaires were administered individually or in small groups in subjects' homes or other private settings.

STATISTICAL ANALYSES

Student's t tests or Mann-Whitney U tests were used to assess differences in psychological characteristics.

RESULTS

Thirty-six weight cyclers (58%) met the criteria for binge eating disorder and 26 (42%) did not. Weight cyclers with binge eating disorder reported greater severity of binge eating (P < .0005) and disinhibition (P < .0005) and poorer eating self-efficacy (P < .0005) than weight cyclers without binge eating disorder. Weight cyclers with severe binge eating behaviors reported greater psychological distress (P < .0005) and depression (P < .005) and lower self-esteem (P = .0001) and used less healthful coping strategies (P = .0027) than weight cyclers with no binge eating to moderate binge eating problems. Weight cyclers with severe binge eating behavior also reported more hunger (P < .0005) and used less cognitive restraint (P = .0024) than those with no binge eating to moderate binge eating problems.

APPLICATIONS

Operational definitions of weight cycling and binge eating are needed to facilitate research on effective weight-loss treatments. Persons seeking to lose weight (especially weight cyclers) should be assessed for binge eating severity, problematic eating behaviors, and psychological symptoms.

Weight loss education: the challenge of a new paradigm

Health educators and others typically rely on three weight loss strategies to combat obesity. These include (1) medical intervention, (2) caloric restriction, and (3) fat gram restriction. The empirical evidence for these approaches in producing long-term weight loss is weak. However, much media attention has been given to a weight loss paradigm that seemingly does not fall into the aforementioned categories, which has been called the intuitive eating paradigm. Currently there is no empirical evidence to validate this paradigm. The focus of this article is to present an overview of this weight loss paradigm, discuss its potential benefits for health education in relation to current weight loss paradigms, and critically evaluate it in terms of the usefulness and ethical appropriateness for health education.

Nonsurgical factors that influence the outcome of bariatric surgery: a review

OBJECTIVE

Severe obesity (ie, at least 100% overweight or body mass index > or =40 kg/m2) is associated with significant morbidity and increased mortality. It is apparently becoming more common in this country. Conventional weight-loss treatments are usually ineffective for severe obesity and bariatric surgery is recommended as a treatment option. However, longitudinal data on the long-term outcome of bariatric surgery are sparse. Available data indicate that the outcome of bariatric surgery, although usually favorable in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. The objective of this study is to present a review of the outcome of bariatric surgery in three areas: weight loss and improvement in health status, changes in eating behavior, and psychosocial adjustment. The study will also review how eating behavior, energy metabolism, and psychosocial functioning may affect the outcome of bariatric surgery. Suggestions for additional research in these areas are made.

METHOD

Literature review.

RESULTS

On average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty. In about 30% of patients, weight regain occurs at 18 months to 2 years after surgery. Binge eating behavior, which is common among the morbidly obese, may recur after surgery and is associated with weight regain. Energy metabolism may affect the outcome of bariatric surgery, but it has not been systematically studied in this population. Presurgery psychosocial functioning does not seem to affect the outcome of surgery, and psychosocial outcome is generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and suicide.

CONCLUSIONS

Factors leading to poor outcome of bariatric surgery, such as binge eating and lowered energy metabolism, should be studied to improve patient selection and outcome. Long-term outcome data on psychosocial functioning are lacking. Longitudinal studies to examine the long-term outcome of bariatric surgery and the prognostic indicators are needed.

Binge eating disorder: treatment outcome over a 6-year course

Little is known about the long-term course of binge eating disorder (BED). The aim of the study was to assess the 3- and 6-year course and outcome of 68 consecutively treated females with BED. Their mean age was 29.3 years and they were assessed longitudinally at four timepoints: (1) beginning of therapy; (2) end of therapy; (3) 3-year follow-up; and (4) 6-year follow-up. Self rating as well as expert ratings were used for assessment. Symptoms of specific eating disorder as well as general psychopathology were measured. The general pattern of results over time was as follows: substantial improvement during therapy; slight (in most cases nonsignificant) decline during the first 3 years after the end of treatment, and further improvement and stabilization in years 4, 5, and 6 after the end of treatment. At the 6-year follow-up, the majority showed no major DSM-IV eating disorder, 5.9% had BED, 7.4% had shifted to bulimia nervosa (purging type) (DSM-IV), 7.4% were classified as ED-NOS, and one patient died. Based on an operationalized global outcome score for the complete sample, 57.4% had good outcome, 35.3% intermediate outcome, 5.9% poor outcome, and one person (1.4%) died. BED and BNP patients showed very similar intermediate and long-term course in self ratings as well as expert ratings.

Diabetes mellitus and eating disorders: a multicenter study on the comorbidity of the two diseases

Because diet is a key issue in the treatment of diabetes mellitus, it is assumed that these patients are prone to eating disorders. In a multicenter study, we have therefore assessed the prevalence of eating disorders in 662 patients with insulin dependent diabetes mellitus (IDDM) (n = 340) and non-insulin-dependent diabetes mellitus (NIDDM) (n = 322). A two-stage study combining self-rating questionnaires and a standardized interview was carried out. We found a prevalence of eating disorders of 5.9% (lifetime prevalence of 10%), irrespective of gender and type of diabetes; 4.1% of the whole sample reported intentional insulin undertreatment or omission. When patients were stratified according to IDDM and NIDDM, there was no difference in the prevalence of all eating disorders (point prevalence 5.5% vs. 6.5%, lifetime prevalence 10.0% vs. 9.9%). Prevalence of bulimia nervosa (BN) was more frequent in IDDM patients (point prevalence 1.5% vs. 0.3%, lifetime prevalence 3.2% vs. 1.9%) and binge eating (BED) was more frequent in NIDDM patients (point prevalence 1.8% vs. 3.7%, lifetime prevalence 2.6% vs. 5.9%). We conclude that eating disorders seem to be equally frequent in IDDM and NIDDM patients. However, there might be different features of eating disorders in both types of diabetes.

Onset of binge eating and dieting in overweight women: implications for etiology, associated features and treatment

This study investigated differences between overweight binge eating women who reported the onset of binge eating prior to or following the onset of dieting (binged first [BF], or dieted first [DF]). Of overweight binge eating subjects enrolled in a treatment study, 38.7% indicated binge eating first, and 48.1% dieting first. The mean age of onset of binge eating differed significantly between the two groups (11.8 years vs. 25.7 years). More of the BF group (82.5%) satisfied proposed binge eating disorder (BED) criteria than did the DF group (52.0%), although short of significantly. The results suggest that: (a) the leading hypothesis concerning dieting as a cause of binge eating does not apply to a substantial number of individuals who binge eat; (b) there may be an early pattern and a late pattern in the development of binge eating among overweight individuals; and (c) the early or binge first pattern may be more likely to result in BED.

Assessment and treatment of binge-eating disorder

The patient presenting with binge-eating disorder requires a detailed clinical assessment that takes into account behavioral, somatic, and psychological aspects of the disorder. Treatment selection depends on the patient's particular goals. Antidepressant medications and CBT are effective, at least in the short term, in suppressing binge eating and reducing depressive symptoms. Fluoxetine may, in addition, promote short-term weight loss, which is more likely to be maintained if medication is administered in the context of behavior therapy. Preliminary study suggests that behavior therapy may be designed to promote weight loss, even in the absence of medication treatment, without undermining binge cessation. Appetite suppressant medications clearly promote weight loss, but their use in suppressing binge eating has yet to be studied specifically. Further study is needed in several areas including the feasibility and efficacy of treatment approaches that combine medication and psychotherapy, the efficacy of individual versus group psychotherapy, the long-term outcome of various forms of treatment, and the clinical features that predict favorable response to different treatment modalities.

Differences in body image and depression among obese women with and without binge eating disorder

Obese individuals with binge eating disorder (BED) differ from obese non-binge eating (NBE) individuals in a number of clinically relevant ways. This study examined attitudinal responses to various measures of body image in women seeking obesity treatment, by comparing NBE participants (n = 80) to those with BED (n = 48). It was hypothesized that women with BED would demonstrate greater attitudinal disturbance of body image compared to NBE individuals. It was further hypothesized that significant differences between groups would remain after statistically controlling for degree of depression. Consistent with the primary hypothesis, BED participants reported significantly increased attitudinal disturbance in body dissatisfaction and size perception compared to NBE participants. Although shared variance was observed between measures of depression and body image on some items, several aspects of increased body image disturbance remained after statistically controlling for depression. Treatment implications and recommendations for future research are discussed.

The classification of bulimic eating disorders: a community-based cluster analysis study

There is controversy over how best to classify eating disorders in which there is recurrent binge eating. Many patients with recurrent binge eating do not meet diagnostic criteria for other of the two established eating disorders, anorexia nervosa or bulimia nervosa. The present study was designed to derive an empirically based, and clinically meaningful, diagnostic scheme by identifying subgroups from among those with recurrent binge eating, testing the validity of these subgroups and comparing their predictive validity with that of the DSM-IV scheme. A general population sample of 250 young women with recurrent binge eating was recruited using a two-stage design. Four subgroups among the sample were identified using a Ward's cluster analysis. The first subgroup had either objective or subjective bulimic episodes and vomiting or laxative misuse; the second had objective bulimic episodes and low levels of vomiting or laxative misuse; the third had subjective bulimic episodes and low levels of vomiting or laxative misuse; and the fourth was heterogeneous in character. This cluster solution was robust to replication. It had good descriptive and predictive validity and partial construct validity. The results support the concept of bulimia nervosa and its division into purging and non-purging subtypes. They also suggest a possible new binge eating syndrome. Binge eating disorder, listed as an example of Eating Disorder Not Otherwise Specified within DSM-IV, did not emerge from the cluster analysis.

The clinical significance of binge eating in an obese population: support for bed and questions regarding its criteria

The present study examined the prevalence of binge eating disorder (BED) among 192 obese individuals seeking treatment in a university-based eating disorders program. Subjects responded to a self-report questionnaire on the presence and severity of binge eating and were divided into two groups: (a) 48 non-binge eaters and (b) 144 binge eaters, 72 of whom met criteria for BED. Binge eaters reported earlier onset of obesity, higher levels of psychopathology, and less competence in relation to weight control. Comparison between the 72 individuals diagnosed with BED and the 72 binge eaters not meeting BED criteria indicated that the former group evidenced more severe binge eating and a higher level of depression. Given the differences across a range of psychological variables between binge eaters and non-binge eaters, these findings support the clinical and research value of BED as a new diagnostic category. However, they also indicate that severity of binge eating, regardless of frequency and associated behavioral features, is the most important distinguishing characteristic. Further research is needed to determine the most appropriate threshold for BED diagnosis.

Prevalence of binge eating disorder in different populations of French women

OBJECTIVE

The aim of this study was to evaluate the prevalence of binge eating disorder (BED) in nonpatient women in the community and in weight control groups in France and to compare the characteristics of weight history of subjects with and without BED.

METHODS

Eating patterns over the past six months were studied by questionnaires in self-report format. The prevalence of binge eating, BED, and bulimia was studied in 447 nonpatient women and in subjects seeking help for weight control either in private practice (PP, n = 292) or in a hospital department of nutrition (H, n = 85).

RESULTS

BED was common (PP = 9%; H = 15%) among patients attending weight control clinics but very rare in the community (0.7%). The disorder was associated with a history of weight fluctuations. Many subjects with BED referred to regular use of diet pills (29%) or vomiting (39%) but the prevalence of these strategies of weight control fell short for the requirement for the diagnosis of bulimia.

DISCUSSION

BED was common in subjects seeking help for weight control and extremely rare in the community nonpatients.

Psychological factors in the etiology of binge eating

Numerous psychological factors have been hypothesized to play a role in the etiology of binge eating. This chapter proposes that female gender-role socialization puts girls at risk for the development of binge eating. Moreover, it is proposed that an understanding of risk requires an exploration of the developmental tasks of female adolescence. As research of the etiology of binge eating in particular and eating disorders in general begins to move away from testing single-factor causal models and toward testing complex, multifactorial models of causation, research needs to examine the psychological factors discussed in this chapter.

Binge eating onset in obese patients with binge eating disorder

In this study we examined whether obese women with binge eating disorder (BED) reporting earlier onset binge eating differed from those with later onset binge eating on salient clinical parameters. Subjects were 112 women who sought treatment for BED. Subjects with early (< or = age 18) and later onset (> age 18) did not differ in age, weight, body mass index, or severity of binge eating. Participants were interviewed using the Eating Disorder Examination (EDE) and the Structured Clinical Interview for DSM-III-R, and completed a weight and diet history questionnaire. Early-onset binge eaters were more likely than those with later-onset to binge-eat before dieting, to have early onset of obesity and dieting, to have longer binge-free periods, and more paternal obesity and binge eating. Early-onset binge eaters also reported more eating-disorders psychopathology, and they were more likely to report a lifetime history of bulimia nervosa and DSM-III-R mood disorder. These data suggest that there are marked differences among BED patients presenting for treatment. Further research is needed to determine whether these differences reflect a different etiology or have implications for treatment.

The Emotional Eating Scale: the development of a measure to assess coping with negative affect by eating

The development of the Emotional Eating Scale (EES) is described. The factor solution replicated the scale's construction, revealing Anger/Frustration, Anxiety, and Depression subscales. All three subscales correlated highly with measures of binge eating, providing evidence of construct validity. None of the EES subscales correlated significantly with general measures of psychopathology. With few exceptions, changes in EES subscales correlated with treatment-related changes in binge eating. In support of the measure's discriminant efficiency, when compared with obese binge eaters, subscale scores of a sample of anxiety-disordered patients were significantly lower. Lack of correlation between a measure of cognitive restraint and EES subscales suggests that emotional eating may precipitate binge episodes among the obese independent of the level of restraint.