Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis

A study on binge eating behavior in urban adolescents

AIM

The study was aimed at studying binge eating behavior in urban adolescents. This was in keeping with the increasing prevalence of obesity and lifestyle disorders amongst Indian population especially in adolescent groups.

METHODS

2000 adolescents English speaking schools in Mumbai were administered the Binge Eating Scale and the Eating Behaviors and Pattern Questionnaire after assent and parental consent. The prevalence of Binge eating behavior was estimated along with the socio-demographic data and other data from scale which was analyzed using the Chi square test and ANOVA where appropriate.

RESULTS

The mean age of the total sample was 15.05 ± 1.65 years. Females reported higher Binge eating behavior than males and majority of the sample belonging to upper and lower middle- class families reported high binge eating behavior. The prevalence of Binge eating behavior was high with 1002 (50.1 %) adolescents reporting moderate binge eating while 736 (36.8 %) reporting severe binge eating. Significantly greater adolescents in the binge eating group reported irregular menses and being overweight and obese. There was a significantly greater proportion of adolescents in the binge eating group that ate out weekly and ate more fried food.

CONCLUSION

There is an increasing trend of obesity and lifestyle disorders in adolescent population that can be linked to Binge eating behavior however, the role of binge eating in context of one of the potential cause of lifestyle disorders and obesity has not been studied in Indian adolescents despite the prevalence of Binge eating and overweight being high in this population, we need further larger studies to corroborate the findings of this study.

Adherence as a predictor of dropout in Internet-based guided self-help for adults with binge-eating disorder and overweight or obesity

OBJECTIVE

Internet-based guided self-help (GSH-I) is an efficacious treatment for adults with binge-eating disorder (BED) and overweight or obesity. Although broadly accessible, high dropout from GSH-I has been reported. However, little is known about the factors explaining dropout from GSH-I, including patients' adherence to treatment.

METHOD

Within a randomized trial on the treatment of BED, adherence to 4-month GSH-I was objectively assessed in N = 89 patients with BED and overweight or obesity. Objective adherence and subjective treatment evaluation were evaluated as predictors of dropout from GSH-I, defined as having accessed 5 or less of 11 modules. Cutoffs with optimal sensitivity and specificity were derived using Receiver Operating Characteristics curves analysis, and baseline sociodemographic and clinical correlates were determined.

RESULTS

According to our definition, n = 22 (24.7%) patients were defined as dropouts. Results of the full logistic regression model accounted for 72% of the variance in dropout and all objective adherence parameters (i.e., number of messages exchanged, days with a completed food diary, and days spent per module), but not patients' subjective GSH-I evaluation significantly predicted dropout. Specifically, not completing the food diary in week 7 had maximized sensitivity and specificity in predicting dropout. Patients' body mass index was positively associated with the number of messages exchanged between patients and coaches. No other associations between baseline variables and objective adherence were found.

DISCUSSION

Patients at risk for dropout from GSH-I can be reliably identified via monitoring of objective adherence and may be provided with additional interventions to prevent dropout.

The effect of trauma and dissociation on the outcome of cognitive behavioural therapy for binge eating disorder: A 6-month prospective study

BACKGROUND

Binge eating disorder (BED) is commonly associated with a history of trauma. Yet, there is little insight into the potential effect that trauma, dissociation, and depressive symptoms may have on the outcome of treatment interventions.

METHODS

A total of 142 treatment-seeking patients admitted with a diagnosis of DSM-5 BED (88% female; mean age = 38.7; SD = 10.8) took part in a 6-month, protocolized, group cognitive behavioural therapy (CBT). Self-report questionnaires were administered to assess lifetime traumatic experiences, dissociation, and depression. Body mass index and the number of binges per week (BPW) were measured throughout treatment. The main outcomes were the percentage reduction in BPW and remission (i.e., less than one BPW; cf. DSM-5).

RESULTS

Most BED patients (91.5%) reported a history of trauma, with two in three patients reporting three or more traumatic experiences. Whereas the number of traumatic experiences was not significantly associated with a reduction in BPW or remission, a higher traumatic impact score significantly decreased the likelihood of obtaining remission at the end of treatment (OR = 0.96; 95% CI [0.92, 0.99]). Higher levels of dissociative symptoms partially mediated this prospective association.

CONCLUSIONS

The impact of traumatic experiences, as opposed to the number of traumatic experiences experienced, negatively predicts remission after 6 months of CBT. These findings highlight the importance of addressing trauma and dissociative features in the CBT treatment of BED.

Dialectical behavior therapy adapted for binge eating compared to cognitive behavior therapy in obese adults with binge eating disorder: a controlled study

BACKGROUND

Current guidelines recommend cognitive behavior therapy (CBT) as the treatment of choice for binge eating disorder (BED). Although CBT is quite effective, a substantial number of patients do not reach abstinence from binge eating. To tackle this problem, various theoretical conceptualizations and treatment models have been proposed. Dialectical behavior therapy (DBT), focusing on emotion regulation, is one such model. Preliminary evidence comparing DBT adapted for BED (DBT-BED) to CBT is promising but the available data do not favor one treatment over the other. The aim of this study is to evaluate outcome of DBT-BED, compared to a more intensive eating disorders-focused form of cognitive behavior therapy (CBT+), in individuals with BED who are overweight and engage in emotional eating.

METHODS

Seventy-four obese patients with BED who reported above average levels of emotional eating were quasi-randomly allocated to one of two manualized 20-session group treatments: DBT-BED (n = 41) or CBT+ (n = 33). Intention-to-treat outcome was examined at post-treatment and at 6-month follow-up using general or generalized linear models with multiple imputation.

RESULTS

Overall, greater improvements were observed in CBT+. Differences in number of objective binge eating episodes at end of treatment, and eating disorder psychopathology (EDE-Q Global score) and self-esteem (EDI-3 Low Self-Esteem) at follow-up reached statistical significance with medium effect sizes (Cohen's d between .46 and .59). Of the patients in the DBT group, 69.9% reached clinically significant change at end of the treatment vs 65.0% at follow-up. Although higher, this was not significantly different from the patients in the CBT+ group (52.9% vs 45.8%).

CONCLUSIONS

The results of this study show that CBT+ produces better outcomes than the less intensive DBT-BED on several measures. Yet, regardless of the dose-difference, the data suggest that DBT-BED and CBT+ lead to comparable levels of clinically meaningful change in global eating disorder psychopathology. Future recommendations include the need for dose-matched comparisons in a sufficiently powered randomized controlled trial, and the need to determine mediators and moderators of treatment outcome.

TRIAL REGISTRATION

Nederlands Trial Register: NL3982 (NTR4154). Date of registration: 2013 August 28, retrospectively registered.

Feeding and eating disorders

Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence-a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.

How are early maladaptive schemas and DSM-5 personality traits associated with the severity of binge eating?

OBJECTIVE

The present study aimed to (a) assess and compare personological traits and early maladaptive schemas (EMSs) of obese women with and without binge eating disorder (BED) and (b) identify the variables associated with the binge severity.

METHOD

One hundred women (55 BED-obese and 45 non-BED-obese) completed psychopathological and personological self-report questionnaires. A forward stepwise linear regression analysis was performed to assess variables associated with binge eating severity.

RESULTS

Not only psychopathological but also personological differences were evident between BED and non-BED-obese women. BED severity was significantly associated with depressivity, emotional deprivation, and defectiveness.

CONCLUSIONS

Our preliminary findings suggest that BED patients exhibit some EMSs that could be linked to the construct of emotional neglect and specific personological traits closely related to depressive dimensions, emotional lability, and impulsivity. In particular, binge severity is associated with the pervasiveness of depressogenic cognitive schemas, as well as those of emotional deprivation and defectiveness.

The influence of oxytocin on eating behaviours and stress in women with bulimia nervosa and binge eating disorder

The current study aimed to test the influence of oxytocin on palatable food intake, 24-h caloric consumption, and stress in women with bulimia nervosa and binge eating disorder. We recruited 25 women with DSM-5 bulimia nervosa or binge eating disorder, and 27 weight-matched comparison women without history of an eating disorder. We employed a double-blind, placebo-controlled crossover design in which each participant attended the lab for two experimental sessions, receiving a divided dose of 64IU intranasal oxytocin in one session and equivalent volume of placebo nasal spray in the opposite session. The order of administration was pseudo-randomised across participants. We hypothesised that a divided dose of 64IU intranasal oxytocin administration would reduce subjective hunger, the immediate consumption of palatable food, 24-h calorie consumption, and the incidence of binge eating when compared to placebo. We also hypothesised that oxytocin administration would be associated with lower levels of stress and salivary cortisol, and that there would be an interaction with participant group such that oxytocin would reduce eating behaviour and stress to a greater degree in women with bulimia nervosa or binge eating disorder, compared to women without history of an eating disorder. We did not find a significant effect of oxytocin on any of the measurements of eating behaviour, subjective stress, or salivary cortisol. We recommend that future studies test the dose-response effect of oxytocin on eating behaviours and stress in human populations with eating disorders to further clarify the moderating factors for oxytocin's effect on eating.

Patients' views on a new treatment for Bulimia nervosa and binge eating disorder combining physical exercise and dietary therapy (the PED-t). A qualitative study

A new group based treatment for patients with bulimia nervosa (BN) and binge eating disorder (BED), combining guided Physical Exercise and Dietary therapy (PED-t), has shown the capacity to alleviate BN and BED symptoms. The PED-t is run by therapists with a professional background in sport sciences and nutrition, which in many clinical settings is an uncommon group of professionals. The symptom reduction effects using the PED-t need validation from patients who have been given this kind of treatment, as negative experiences may impinge further clinical implementation. To explore such experiences, semistructural interviews were conducted with 15 participants. The interviews were transcribed and analyzed using a systematic text condensation approach. Overall, patients experienced the format and content of the PED-t as beneficial and as providing tools to manage BN- and BED symptoms. The patients' experiences of therapist credibility was enhanced by their appreciation of the therapists' professional background. Finally, some treatment modifications were suggested. Overall, the PED-t may thus be offered to patients with BN and BED, by a new set of professionals, and in uncommon settings. This possibility calls for future effectiveness studies integrating both parametric and experiential data.

Combining cognitive bias modification training (CBM) and transcranial direct current stimulation (tDCS) to treat binge eating disorder: study protocol of a randomised controlled feasibility trial

INTRODUCTION

Binge eating disorder (BED) is a common mental disorder, closely associated with obesity. Existing treatments are only moderately effective with high relapse rates, necessitating novel interventions. This paper describes the rationale for, and protocol of, a feasibility randomised controlled trial (RCT), evaluating the combination of transcranial direct current stimulation (tDCS) and a computerised cognitive training, namely approach bias modification training (ABM), in patients with BED who are overweight or obese. The aim of this trial is to obtain information that will guide decision-making and protocol development in relation to a future large-scale RCT of combined tDCS+ABM treatment in this group of patients, and also to assess the preliminary efficacy of this intervention.

METHODS AND ANALYSIS

66 participants with Diagnostic and Statistical Manual-5 diagnosis of BED and a body mass index (BMI) of ≥25 kg/m2 will be randomly allocated to one of three groups: ABM+real tDCS; ABM+sham tDCS or a wait-list control group. Participants in both intervention groups will receive six sessions of ABM+real/sham tDCS over 3 weeks; engaging in the ABM task while simultaneously receiving bilateral tDCS to the dorsolateral prefrontal cortex. ABM is based on an implicit learning paradigm in which participants are trained to enact an avoidance behaviour in response to visual food cues. Assessments will be conducted at baseline, post-treatment (3 weeks) and follow-up (7 weeks post-randomisation). Feasibility outcomes assess recruitment and retention rates, acceptability of random allocation, blinding success (allocation concealment), completion of treatment sessions and research assessments. Other outcomes include eating disorder psychopathology and related neurocognitive outcomes (ie, delay of gratification and inhibitory control), BMI, other psychopathology (ie, mood), approach bias towards food and surrogate endpoints (ie, food cue reactivity, trait food craving and food intake).

ETHICS AND DISSEMINATION

This study has been approved by the North West-Liverpool East Research Ethics Committee. Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN35717198.

Binge eating disorder revisited: what's new, what's different, what's next

Binge eating disorder (BED) is the most common type of eating disorder. According to the most recent data available, the estimated lifetime prevalence of BED among US adults in the general population is 0.85% (men 0.42% and women 1.25%). Among psychiatric treatment populations, prevalence is several-fold higher. Although many people with BED are obese (BMI ≥ 30 kg/m2), roughly half are not. In the DSM-5, BED is defined by recurrent episodes of binge eating (eating in a discrete period of time, an amount of food larger than most people would eat in a similar amount of time under similar circumstances and a sense of lack of control over eating during the episode), occurring on average at least once a week for 3 months, and associated with marked distress. BED often goes unrecognized and thus untreated; in one study, 344 of 22,387 (1.5%) survey respondents met DSM-5 criteria for BED, but only 11 out of the 344 had ever been diagnosed with BED by a health-care provider. Psychiatric comorbidities are very common, with most adults with BED also experiencing anxiety disorders, mood disorders, impulse control disorders, or substance use disorders, suggesting that clinicians have patients in their practice with unrecognized BED. Multiple neurobiological explanations have been suggested for BED, including dysregulation in reward center and impulse control circuitry. Additionally, there is interplay between genetic influences and environmental stressors. Psychological treatments such as cognitive behavioral interventions have been recommended as first line and are supported by meta-analytic reviews; however, access to such treatments may be limited because of local availability and/or cost, and these treatments generally lead to little to no weight loss, although successfully eliminating binge eating can protect against future weight gain. Routine medication treatments for anxiety and depression do not necessarily ameliorate the symptoms of BED, but there are approved and emerging medication options, lisdexamfetamine and dasotraline, respectively, that specifically address the core drivers behind binge eating, namely obsessive thoughts and compulsive behaviors regarding food, resulting in marked decreases in binge eating behaviors as well as weight loss.

Clustered Patterns of Behavioral and Health-Related Variables Among Young Lesbian Women

Lesbian women are at increased risk for a variety of mental and physical health problems compared to heterosexual women. In order to inform treatment and prevention, the purpose of this study was to examine behavioral and health-related patterns among lesbian women and elucidate how these patterns are associated with general discrimination, sexual minority stress, affect, and social support. A sample of self-identified lesbian women (N = 436) completed an online survey from August 2014-March 2015. A latent profile analysis was conducted using measures of body mass index, hazardous alcohol use, binge eating, eating disorder risk, and exercise as indicators. A 5-class solution best fit the data and included two healthy groups: (a) low health risk, moderate exercise (54%), (b) low health risk + high exercise (22%); and three unhealthy risk groups: (c) obese + binge eating (14%); (d) disordered eating + hazardous alcohol use (5%); (e) disordered eating + high exercise (5%). The three unhealthy classes generally reported more general discrimination, sexual minority stress, social anxiety, negative affect, and lower social support compared to the healthy classes. These findings show that behavioral and health-related variables cluster together in several distinct patterns among lesbian women. In addition, general discrimination and sexual minority stress and associated psychosocial functioning may be related to these maladaptive behavioral and health-related patterns and may be important to consider in behavioral interventions.

Mechanisms and moderators in mindfulness- and acceptance-based treatments for binge eating spectrum disorders: A systematic review

OBJECTIVE

Increasing evidence suggests that mindfulness- and acceptance-based psychotherapies (MABTs) for bulimia nervosa (BN) and binge eating disorder (BED) may be efficacious; however, little is known about their active treatment components or for whom they may be most effective.

METHODS

We systematically identified clinical trials testing MABTs for BN or BED through PsychINFO and Google Scholar. Publications were categorized according to analyses of mechanisms of action and moderators of treatment outcome.

RESULTS

Thirty-nine publications met inclusion criteria. Twenty-seven included analyses of therapeutic mechanisms, and five examined moderators of treatment outcome. Changes were largely consistent with hypothesized mechanisms of MABTs, but substandard mediation analyses, inconsistent measurement tools, and infrequent use of mid-treatment assessment points limited our ability to make strong inferences.

DISCUSSION

Analyses of mechanisms of action and moderators of outcome in MABTs for BN and BED appear promising, but the use of more sophisticated statistical analyses and adequate replication is necessary.

Medical Complications of Binge Eating Disorder

Binge eating disorder (BED) is the most common eating disorder and is accompanied by multiple medical comorbidities, many of which are associated with obesity-related diseases. However, the BED itself is likely to confer additional risk factors. BED presents with medical symptoms in virtually every body system and can have devastating consequences on both quality and length of life. This review covers the major comorbidities of BED and highlights areas of ongoing research in this disorder.

General and Eating Disorder Specific Flexibility: Development and Validation of the Eating Disorder Flexibility Index (EDFLIX) Questionnaire

Findings from studies investigating cognitive flexibility in eating disorders (EDs) are inconsistent, and although neuropsychological tests are commonly used to measure these skills, they may not be particularly effective in predicting everyday functioning. Also, extant studies have largely focused on flexibility in anorexia nervosa (AN), with assessments targeting general rather than specific flexibility, and cognitive, rather than behavioral flexibility. Knowledge regarding ED specific flexibility and flexibility in bulimia nervosa (BN) and binge eating disorder (BED) is still scarce. The aim of this study was to develop and validate a novel measure assessing general and ED specific flexibility in a diagnostically diverse sample, and in healthy controls (HCs). A sample of 207 adult individuals with EDs (55% AN, 29% BN, 16% BED) and 288 HCs responded to an online, 51-item, pilot questionnaire on ED specific and general flexibility. In addition, participants completed the shift subscale from the Behavior Rating Inventory of Executive Function Adult version (BRIEF-A), and the Eating Disorder Diagnostic Scale (EDDS). A principal component analysis (PCA) in the clinical sample yielded a 36-item, three-factor solution capturing general flexibility, flexibility related to food and exercise, and flexibility concerning body shape and weight. Results showed that the measure had good to excellent internal consistency, and good convergent validity. A confirmatory factor analysis (CFA) using data from HCs revealed good fit indexes, supporting the original factor solution. A receiver operating characteristics analysis (ROC) demonstrated excellent accuracy in distinguishing scores from those with and without EDs. A cutoff score of 136 yielded the most balanced sensitivity and specificity. Significant differences in general and ED specific flexibility were found between individuals with and without EDs. Overall, HCs achieved the highest flexibility scores, followed by those with BED, BN, and AN. In sum this novel measure, the Eating Disorder Flexibility Index (EDFLIX) questionnaire, was found to be reliable and valid in the assessment of cognitive and behavioral flexibility, with results offering support for the conceptual distinction between general and ED related flexibility. The study also provides strong evidence for the discriminant validity of the EDFLIX with results revealing significant differences in flexibility in people with and without EDs. In addition, significant differences in flexibility also emerged when comparing diagnostic groups, indicating the utility of the assessment instrument for classification purposes.

Obesity

The role of internists in evaluating obesity is to assess the burden of weight-related disease, mitigate secondary causes of weight gain (medications, sleep deprivation), and solicit patient motivation for weight loss. Internists should assess these factors and emphasize the importance of weight loss for the individual patient. All patients wishing to lose weight should be encouraged to monitor their diet and physical activity and should be referred to high-intensity behavioral programs. Some patients with obesity may also benefit from pharmacotherapy or bariatric surgery.

Testing a stepped care model for binge-eating disorder: a two-step randomized controlled trial

BACKGROUND

A stepped care approach involves patients first receiving low-intensity treatment followed by higher intensity treatment. This two-step randomized controlled trial investigated the efficacy of a sequential stepped care approach for the psychological treatment of binge-eating disorder (BED).

METHODS

In the first step, all participants with BED (n = 135) received unguided self-help (USH) based on a cognitive-behavioral therapy model. In the second step, participants who remained in the trial were randomized either to 16 weeks of group psychodynamic-interpersonal psychotherapy (GPIP) (n = 39) or to a no-treatment control condition (n = 46). Outcomes were assessed for USH in step 1, and then for step 2 up to 6-months post-treatment using multilevel regression slope discontinuity models.

RESULTS

In the first step, USH resulted in large and statistically significant reductions in the frequency of binge eating. Statistically significant moderate to large reductions in eating disorder cognitions were also noted. In the second step, there was no difference in change in frequency of binge eating between GPIP and the control condition. Compared with controls, GPIP resulted in significant and large improvement in attachment avoidance and interpersonal problems.

CONCLUSIONS

The findings indicated that a second step of a stepped care approach did not significantly reduce binge-eating symptoms beyond the effects of USH alone. The study provided some evidence for the second step potentially to reduce factors known to maintain binge eating in the long run, such as attachment avoidance and interpersonal problems.

Binge-Eating Disorder

Binge-eating disorder (BED), first included as a diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, is characterized by recurrent episodes of binge eating without regular compensatory behaviors to prevent weight gain. With a complex multifactorial etiology, BED is the most frequent eating disorder co-occuring with significant psychopathology, mental and physical comorbidity, obesity, and life impairment. Despite its significance, BED is not sufficiently diagnosed or treated. Evidence-based treatments for BED include psychotherapy and structured self-help treatment, with cognitive-behavioral therapy as most well-established approach, and pharmacotherapy with lisdexamfetamine as FDA approved medication with a limitation of use.

Early Change Trajectories in Cognitive-Behavioral Therapy for Binge-Eating Disorder

Rapid response is considered the most well-established outcome predictor across treatments of binge-eating disorder (BED), including cognitive-behavioral therapy (CBT). This study sought to identify latent trajectories of early change in CBT and compare them to common rapid response classifications. In a multicenter randomized trial, 86 adults with BED (DSM-IV) or subsyndromal BED provided weekly self-reports of binge eating over the first 4 weeks of CBT, which were analyzed to predict binge eating, depression, and body mass index at posttreatment, 6-, and 18-month follow-up. Using latent growth mixture modeling, three patterns of early change-including moderate and low decreasing-as well as low stable binge eating were identified, which significantly predicted binge-eating remission at 6-month follow-up. Other classifications of rapid response based on Receiver Operating Characteristics curve analyses or on the literature (≥ 10% reduction in binge eating at week 1, ≥ 70% reduction in binge eating at week 4) only predicted posttreatment remission or overall depression, respectively. Latent change trajectories, but not other rapid response classifications, predicted binge-eating frequency over time. A fine-grained analysis of change over the first 4 weeks of CBT for BED revealed different trajectories of early change in binge eating that led to an improved prediction of binge-eating outcome, compared to that of common rapid response classifications. Thorough monitoring of early change trajectories during treatment may have clinical utility.

Meta-analysis of the effects of cognitive-behavioral therapy for binge-eating-type disorders on abstinence rates in nonrandomized effectiveness studies: Comparable outcomes to randomized, controlled trials?

OBJECTIVE

The efficacy of cognitive-behavioral therapy (CBT) for eating disorders is well-established. The extent to which CBT tested in controlled research settings generalizes to real-world circumstances is unknown. We conducted a meta-analysis of nonrandomized studies of CBT for eating disorders, with three aims: (a) to estimate the prevalence of patients who achieve binge-purge abstinence after CBT in routine practice; (b) to compare these estimates with those derived from two recent meta-analyses of randomized controlled trials (RCTs) of CBT for bulimia nervosa (BN) and binge-eating disorder (BED); (c) to examine whether the degree of clinical representativeness of studies was associated with effect sizes.

METHOD

Twenty-seven studies, mainly involving BN, were included. Pooled event rates were calculated using random effects models.

RESULTS

The percentage of treatment completers who achieved abstinence at post-treatment was 42.1% (95% CI = 34.7-50.0). The intention-to-treat (ITT) estimate was lower (34.6% [95% CI = 29.3-40.4]). However, abstinence rates varied across diagnoses, such that the completer and ITT analysis abstinence estimates were larger for BED samples (completer = 50.2%, 95% CI = 29.4-70.9; ITT = 47.2%, 95% CI = 29.8-65.2) than for BN (completer = 37.4%, 95% CI = 29.1-46.5; ITT = 29.8%, 95% CI = 24.9-35.3) and atypical eating disorder samples (completer = 37.8%, 95% CI = 20.2-59.3; ITT = 28.8%, 95% CI = 18.2-42.4). No relationship between the degree of clinical representativeness and the effect size was observed, and our estimates were highly comparable to those observed in recent meta-analyses of RCTs.

DISCUSSION

Findings suggest that CBT for eating disorder can be effectively delivered in real-world settings. This study provides evidence for the generalizability of CBT from controlled research settings to routine clinical services.

Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation

BACKGROUND

Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences.

OBJECTIVES

Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017).

REVIEW METHODS

Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000.

RESULTS

A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit.

LIMITATIONS

Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken.

CONCLUSIONS

Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends.

FUTURE WORK

Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016040190.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.

Therapist adherence and therapeutic alliance in individual cognitive-behavioural therapy for adolescent binge-eating disorder

To evaluate psychological treatments for adolescent binge-eating disorder (BED), reliable information on therapeutic process factors is needed. This study examines therapist adherence and therapeutic alliance and their associations in cognitive-behavioural therapy (CBT) for adolescents with BED. In a randomised-controlled efficacy trial, adherence and alliance were objectively determined based on 247 audio-taped CBT sessions from a sample of N = 64 adolescents with BED. Variability of adherence and alliance, explained by treatment module, patient, and therapist were examined using multilevel modeling. Although adherence and alliance were excellent and unaffected by treatment module and therapist, there was significant between-patient variability for both concepts. Adherence was negatively associated with patient's treatment expectation. Alliance was negatively associated with the number of loss of control eating episodes and positively associated with adherence. Excellent adherence supported the internal validity of CBT for adolescent BED. Associations between process factors and patient characteristics demand adequate supervision in CBT.

A pilot open trial of UNITE-BED: A couple-based intervention for binge-eating disorder

OBJECTIVE

To evaluate the feasibility, acceptability, and preliminary efficacy of a couple-based intervention for binge-eating disorder (BED), called UNiting couples In the Treatment of Eating disorders-BED edition (UNITE-BED).

METHOD

In an open pilot trial, 11 couples in which one or both adult partners had a diagnosis of DSM-5 threshold or sub-threshold BED participated in 22 weekly sessions of UNITE-BED. Patients also received individual treatment, outside of the context of the trial. Couples completed measures on treatment satisfaction, eating disorder symptom severity, depression, anxiety, emotion regulation, and relational functioning at post-treatment and 3-month follow-up. Statistical analyses were conducted to identify change over the course of treatment.

RESULTS

UNITE was feasible and acceptable to the majority of couples (9% dropout; high satisfaction ratings). Objective binge abstinence was 81.8% and subjective binge abstinence was 45.5% by post-treatment. Patient binge-eating symptomatology reduced over the course of treatment with results maintained at follow up. Patients' depression symptoms decreased and patients' emotion regulation improved at both time points.

DISCUSSION

Including partners in treatment for BED may be beneficial. Results support further evaluation of the efficacy of couple-based interventions for BED in larger randomized-controlled trials.

Rates of abstinence following psychological or behavioral treatments for binge-eating disorder: Meta-analysis

OBJECTIVE

Standardized effect sizes reported in previous meta-analyses of binge-eating disorder (BED) treatment are sometimes difficult to interpret and are criticized for not being a useful indicator of the clinical importance of a treatment. Abstinence from binge eating is a clinically relevant component of a definition of a successful treatment outcome. This meta-analysis estimated the prevalence of patients with BED who achieved binge eating abstinence following psychological or behavioral treatments.

METHOD

This meta-analysis included 39 randomized controlled trials, with 65 treatment conditions and 2,349 patients. Most conditions comprised cognitive-behavioral therapy (n = 40). Pooled event rates were calculated at posttreatment and follow-up using random effects models.

RESULTS

The total weighted percentage of treatment-completers who achieved abstinence at posttreatment was 50.9% (95% CI = 43.9, 57.8); this estimate was almost identical at follow-up (50.3%; 95% CI = 43.6, 56.9). The total weighted percentage of patients who achieved abstinence at posttreatment in the intention-to-treat analysis (all randomized patients) was 45.1% (95% CI =40.7, 49.5), and at follow-up it was 42.3% (95% CI =37.5, 47.2). Interpersonal psychotherapy (IPT) produced the highest abstinence rates. Clinician-led group treatments produced significantly higher posttreatment (but not follow-up) abstinence estimates than guided self-help treatments. Neither timeframe for achieving abstinence, assessment type (interview/questionnaire), number of treatment sessions, patient demographics, nor trial quality, moderated the abstinence estimates.

DISCUSSION

The present findings demonstrate that 50% of patients with BED do not fully respond to treatment. Continued efforts toward improving eating disorder treatments are needed.

Psychological, pharmacological, and combined treatments for binge eating disorder: a systematic review and meta-analysis

Objective

To systematically review the efficacy of psychological, pharmacological, and combined treatments for binge eating disorder (BED).

Method

Systematic search and meta-analysis.

Results

We found 45 unique studies with low/medium risk of bias, and moderate support for the efficacy of cognitive behavior therapy (CBT) and CBT guided self-help (with moderate quality of evidence), and modest support for interpersonal psychotherapy (IPT), selective serotonin reuptake inhibitors (SSRI), and lisdexamfetamine (with low quality of evidence) in the treatment of adults with BED in terms of cessation of or reduction in the frequency of binge eating. The results on weight loss were disappointing. Only lisdexamfetamine showed a very modest effect on weight loss (low quality of evidence). While there is limited support for the long-term effect of psychological treatments, we have currently no data to ascertain the long-term effect of drug treatments. Some undesired side effects are more common in drug treatment compared to placebo, while the side effects of psychological treatments are unknown. Direct comparisons between pharmaceutical and psychological treatments are lacking as well as data to generalize these results to adolescents.

Conclusion

We found moderate support for the efficacy of CBT and guided self-help for the treatment of BED. However, IPT, SSRI, and lisdexamfetamine received only modest support in terms of cessation of or reduction in the frequency of binge eating. The lack of long-term follow-ups is alarming, especially with regard to medication. Long-term follow-ups, standardized assessments including measures of quality of life, and the study of underrepresented populations should be a priority for future research.

To deliver or not to deliver cognitive behavioral therapy for eating disorders: Replication and extension of our understanding of why therapists fail to do what they should do

OBJECTIVE

This study investigated the extent to which therapists fail to apply empirically supported treatments in a sample of clinicians in The Netherlands, delivering cognitive behavioral therapy for eating disorders (CBT-ED). It aimed to replicate previous findings, and to extend them by examining other potential intra-individual factors associated with the level of (non-)use of core CBT-ED techniques.

METHOD

Participants were 139 clinicians (127 women; mean age 41.4 years, range = 24-64) who completed an online survey about the level of use of specific techniques, their beliefs (e.g., about the importance of the alliance and use of pretreatment motivational techniques), anxiety (Intolerance of Uncertainty Scale), and personality (Ten Item Personality Inventory).

RESULTS

Despite some differences with Waller's (2012) findings, the present results continue to indicate that therapists are not reliably delivering the CBT-ED techniques that would be expected to provide the best treatment to their patients. This 'non-delivery' appears to be related to clinician anxiety, temporal factors, and clinicians' beliefs about the power of the therapeutic alliance in driving therapy outcomes.

DISCUSSION

Improving treatment delivery will involve working with clinicians' levels of anxiety, clarifying the lack of benefit of pre-therapy motivational enhancement work, and reminding clinicians that the therapeutic alliance is enhanced by behavioral change in CBT-ED, rather than the other way around.

A register-based case-control study of health care utilization and costs in binge-eating disorder

OBJECTIVE

Capturing trends in healthcare utilization may help to improve efficiencies in the detection and diagnosis of illness, to plan service delivery, and to forecast future health expenditures. For binge-eating disorder (BED), issues include lengthy delays in detection and diagnosis, missed opportunities for recognition and treatment, and morbidity. The study objective was to compare healthcare utilization and expenditure in people with and without BED.

METHODS

A case-control design and nationwide registers were used. All individuals diagnosed with BED at eating disorder clinics in Sweden between 2005 and 2009 were included (N = 319, 97% female, M age = 22 years). Ten controls (N = 3190) were matched to each case on age-, sex-, and location of birth. Inpatient, hospital-based outpatient, and prescription medication utilization and expenditure were analyzed up to eight years before and four years after the index date (i.e., date of diagnosis of the BED case).

RESULTS

Cases had significantly higher inpatient, hospital-based outpatient, and prescription medication utilization and expenditure compared with controls many years prior to and after diagnosis of BED. Utilization and expenditure for controls was relatively stable over time, but for cases followed an inverted U-shape and peaked at the index year. Care for somatic conditions normalized after the index year, but care for psychiatric conditions remained significantly higher.

CONCLUSION

Individuals with BED had substantially higher healthcare utilization and costs in the years prior to and after diagnosis of BED. Since previous research shows a delay in diagnosis, findings indicate clear opportunities for earlier detection and clinical management. Training of providers in detection, diagnosis, and management may help curtail morbidity. A reduction in healthcare utilization was observed after BED diagnosis. This suggests that earlier diagnosis and treatment could improve long-term health outcomes and reduce the economic burden associated with BED.

Association between hedonic hunger and body-mass index versus obesity status

Obesity-associated differences in hedonic hunger, while consistently reported, have not been adequately quantified, with most studies failing to demonstrate strong correlations between Body Mass Index (BMI) and hedonic hunger indicators. Here, we quantified and assessed the nature of the relationship between hedonic hunger and BMI, in a cross-sectional study using the Portuguese version of the PFS (P-PFS) to measure hedonic hunger. Data were collected from 1266 participants belonging to non-clinical, clinical (candidates for weight-loss surgery) and population samples. Across samples, significant but weak positive associations were found between P-PFS scores and BMI, in adjusted linear regression models. However, in logistic regression models of data from the clinical and non-clinical samples, the P-PFS Food Available domain score was significantly and robustly associated with belonging to the clinical sample (OR = 1.8, 95%CI: 1.2–2.8; p = 0.008), while in the population sample it was associated to being obese (OR = 2.1, 95%CI: 1.6–2.7; p < 0.001). Thus, hedonic hunger levels are associated with obesity status with the odds of being obese approximately doubling for each unit increase in the P-PFS Food Available score.

Binge eating disorder and depressive symptoms among females of child-bearing age: the Korea Nurses' Health Study

BACKGROUND

Most studies regarding the relationship between binge eating disorder (BED) and depression have targeted obese populations. However, nurses, particularly female nurses, are one of the vocations that face these issues due to various reasons including high stress and shift work. This study investigated the prevalence of BED and the correlation between BED and severity of self-reported depressive symptoms among female nurses in South Korea.

METHODS

Participants were 7,267 female nurses, of which 502 had symptoms of BED. Using the propensity score matching (PSM) technique, 502 nurses with BED and 502 without BED were included in the analyses. Data were analyzed using descriptive statistics, Spearman's correlation, and multivariable ordinal logistic regression analysis.

RESULTS

The proportion of binge eating disorder was 6.90% among the nurses, and 81.3% of nurses displayed some levels of depressive symptoms. Multivariable ordinal logistic regression analysis revealed that age (40 years old and older), alcohol consumption (frequent drinkers), self-rated health, sleep problems, and stress were associated with self-reported depression symptoms. Overall, after adjusting for confounders, nurses with BED had 1.80 times the risk (95% CI = [1.41-2.30]; p-value < 0.001) of experiencing a greater severity of self-reported depression symptoms.

CONCLUSIONS

Korean female nurse showed a higher prevalence of both binge eating disorder and depressive symptoms, and the association between the two factors was proven in the study. Therefore, hospital management and health policy makers should be alarmed and agreed on both examining nurses on such problems and providing organized and systematic assistance.

Study protocol and rationale for a randomized double-blinded crossover trial of phentermine-topiramate ER versus placebo to treat binge eating disorder and bulimia nervosa

INTRODUCTION

Bulimia nervosa (BN) and binge eating disorder (BED) are associated with severe psychological and medical consequences. Current therapies are limited, leaving up to 50% of patients symptomatic despite treatment, underscoring the need for additional treatment options. Qsymia, an FDA-approved medication for obesity, combines phentermine and topiramate ER. Topiramate has demonstrated efficacy for both BED and BN, but limited tolerability. Phentermine is FDA-approved for weight loss. A rationale for combined phentermine/topiramate for BED and BN is improved tolerability and efficacy. While a prior case series exploring Qsymia for BED showed promise, randomized studies are needed to evaluate Qsymia's safety and efficacy when re-purposed in eating disorders. We present a study protocol for a Phase I/IIa single-center, prospective, double-blinded, randomized, crossover trial examining safety and preliminary efficacy of Qsymia for BED and BN.

METHODS

Adults with BED (n=15) or BN (n=15) are randomized 1:1 to receive 12weeks Qsymia (phentermine/topiramate ER, 3.75mg/23mg-15mg/92mg) or placebo, followed by 2-weeks washout and 12-weeks crossover, where those on Qsymia receive placebo and vice versa. Subsequently participants receive 8weeks follow-up off study medications. The primary outcome is the number of binge days/week measured by EDE. Secondary outcomes include average number of binge episodes, percentage abstinence from binge eating, and changes in weight/vitals, eating psychopathology, and mood.

DISCUSSION

To our knowledge this is the first randomized, double-blind protocol investigating the safety and efficacy of phentermine/topiramate in BED and BN. We highlight the background and rationale for this study, including the advantages of a crossover design.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02553824 registered on 9/17/2015. https://clinicaltrials.gov/ct2/show/NCT02553824.

Commissioning guidance for weight assessment and management in adults and children with severe complex obesity

The challenge of managing the epidemic of patients with severe and complex obesity disease in secondary care is largely unmet. In England, the National Institute of Health and Care Excellence and the National Health Service England have published guidance on the provision of specialist (non-surgical) weight management services. We have undertaken a systematic review of 'what evidence exists for what should happen in/commissioning of: primary or secondary care weight assessment and management clinics in patients needing specialist care for severe and complex obesity?' using an accredited methodology to produce a model for organization of multidisciplinary team clinics that could be developed in every healthcare system, as an update to a previous review. Additions to the previous guidance were multidisciplinary team pathways for children/adolescent patients and their transition to adult care, anaesthetic assessment and recommendations for ongoing shared care with general practitioners, as a chronic disease management pathway.

Serotonin transporter density in binge eating disorder and pathological gambling: A PET study with [11C]MADAM

Behavioral addictions, such as pathological gambling (PG) and binge eating disorder (BED), appear to be associated with specific changes in brain dopamine and opioid function, but the role of other neurotransmitter systems is less clear. Given the crucial role of serotonin in a number of psychiatric disorders, we aimed to compare brain serotonergic function among individuals with BED, PG and healthy controls. Seven BED patients, 13 PG patients and 16 healthy controls were scanned with high-resolution positron emission tomography (PET) using the serotonin transporter (SERT) tracer [¹¹C]MADAM. Both region-of-interest and voxel-wise whole brain analyses were performed. Patients with BED showed increased SERT binding in the parieto-occipital cortical regions compared to both PG and healthy controls, with parallel decreases in binding in the nucleus accumbens, inferior temporal gyrus and lateral orbitofrontal cortex. No differences between PG patients and controls were observed. None of the subjects were on SSRI medications at the time of imaging, and there were no differences in the level of depression between PG and BED patients. The results highlight differences in brain SERT binding between individuals with BED and PG and provide further evidence of different neurobiological underpinnings in behavioral addictions that are unrelated to the co-existing mood disorder. The results aid in the conceptualization of behavioral addictions by characterizing the underlying serotonin changes and provide a framework for additional studies to examine syndrome-specific pharmaceutical treatments.

Lisdexamfetamine: A Review in Binge Eating Disorder

Oral lisdexamfetamine dimesylate (Vyvanse^®; lisdexamfetamine), a prodrug of dextroamfetamine, is currently the only drug to be approved in the USA for the treatment of moderate to severe binge eating disorder (BED) in adult patients. Its approval was based on the results of two pivotal short-term (12 weeks) phase III studies, which showed a significantly greater reduction in binge eating days/week at the end of the study with lisdexamfetamine 50-70 mg/day than with placebo. The findings of these studies have been supported and extended by the results of longer-term (≤ 52 weeks) phase III studies, including one with a randomized 26-week withdrawal phase, which showed that lisdexamfetamine markedly reduced the risk of BED relapse relative to placebo. Lisdexamfetamine was generally well tolerated in clinical trials in patients with moderate to severe BED, with a tolerability profile similar to that observed in ADHD patients; most treatment-emergent adverse events (TEAEs) were of mild or moderate intensity. The most common TEAEs in phase III trials included dry mouth, headache and insomnia; TEAEs infrequently led to study drug discontinuation. In conclusion, lisdexamfetamine 50-70 mg/day is an effective and generally well tolerated option for treating moderate to severe BED in adults.

Evidence-based clinical guidelines for eating disorders: international comparison

PURPOSE OF REVIEW

The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.

RECENT FINDINGS

Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines.

SUMMARY

Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.

Disordered eating and obesity: associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities

Binge-eating disorder (BED) and night-eating syndrome (NES) are two forms of disordered eating associated with overweight and obesity. While these disorders also occur in nonobese persons, they seem to be associated with weight gain over time and higher risk of diabetes and other metabolic dysfunction. BED and NES are also associated with higher risk of psychopathology, including mood, anxiety, and sleep problems, than those of similar weight status without disordered eating. Treatments are available, including cognitive behavior therapy (CBT), interpersonal psychotherapy, lisdexamfetamine, and selective serotonin reuptake inhibitors (SSRIs) for BED; and CBT, SSRIs, progressive muscle relaxation, and bright light therapy for NES.

Pilot study of the prevalence of binge eating disorder in non-alcoholic fatty liver disease patients

Background

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the United States. Binge eating disorder (BED) is the most common form of eating disorder. NAFLD and BED have similar risk factors, including obesity, insulin resistance, and metabolic syndrome. The aim of our study was to examine prevalence of BED in NAFLD patients.

Methods

We administered the Binge Eating Scale (BES), a questionnaire validated to screen for BED, to NAFLD patients at our Fatty Liver Center. Demographics were retrieved retrospectively from our electronic medical record.

Results

Of the total 95 NAFLD patients screened, 22 (23.1%) had binge eating tendencies; 6 of the 22 (6.3%) scored 27 or more points, suggestive of severe binge eating. Patient demographics included 59 females and 36 males (14 females and 8 males positive for BED). Liver disease severity and of metabolic syndrome presence were similar in both groups: 45 patients had steatosis, 25 steatohepatitis, and 24 cirrhosis, of which 10 steatosis, 5 steatohepatitis, and 7 cirrhosis patients screened positive for BED. Of the NAFLD patients with BED, 50.0% had insulin resistance, 68.2% hypertension, and 50.0% hyperlipidemia, whereas among non-BED NAFLD patients 58.9% had insulin resistance, 63.0% hypertension, and 67.1% hyperlipidemia.

Conclusions

This pilot study suggests that BED may have a higher prevalence among NAFLD patients than in the general population. Based on these preliminary results, further study into the prevalence of BED is recommended. More data is need to identify effects of BED on the progression of NAFLD and role of BED treatment.

Eating disorders: A 25-year perspective

I founded Eating Disorders: The Journal of Treatment & Prevention 25 years ago, and its character, reputation, and success are highly attributable to Arnold Andersen, John Foreyt, and Margo Maine, the three original senior editors, whose perspectives follow in this article. Having made the decision to retire from the journal, I asked the senior editors to transition to the emeritus board along with me, which I explain further in my own Last Word, "Goodbye, Eating Disorders," in this volume (Cohn, 2017). Over our 25 years of collaboration, the senior editors have acquired unique insights into the evolution of the eating disorders field; so, I asked them to contribute retrospective essays in which they also look forward within their primary areas of expertise-presented here in alphabetical order. - Leigh Cohn, Editor-in-Chief.

Effect of Internet-Based Guided Self-help vs Individual Face-to-Face Treatment on Full or Subsyndromal Binge Eating Disorder in Overweight or Obese Patients: The INTERBED Randomized Clinical Trial

IMPORTANCE

Although cognitive behavioral therapy (CBT) represents the criterion standard for treatment of binge eating disorder (BED), most individuals do not have access to this specialized treatment.

OBJECTIVE

To evaluate the efficacy of internet-based guided self-help (GSH-I) compared with traditional, individual face-to-face CBT.

DESIGN, SETTING, AND PARTICIPANTS

The Internet and Binge Eating Disorder (INTERBED) study is a prospective, multicenter, randomized, noninferiority clinical trial (treatment duration, 4 months; follow-ups, 6 months and 1.5 years). A volunteer sample of 178 adult outpatients with full or subsyndromal BED were recruited from 7 university-based outpatient clinics from August 1, 2010, through December 31, 2011; final follow-up assessment was in April 2014. Data analysis was performed from November 30, 2014, to May 27, 2015.

INTERVENTIONS

Participants received 20 individual face-to-face CBT sessions of 50 minutes each or sequentially completed 11 internet modules and had weekly email contacts.

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference in the number of days with objective binge eating episodes (OBEs) during the previous 28 days between baseline and end of treatment. Secondary outcomes included OBEs at follow-ups, eating disorder and general psychopathologic findings, body mass index, and quality of life.

RESULTS

A total of 586 patients were screened, 178 were randomized, and 169 had at least one postbaseline assessment and constituted the modified intention-to-treat analysis group (mean [SD] age, 43.2 [12.3] years; 148 [87.6%] female); the 1.5-year follow-up was available in 116 patients. The confirmatory analysis using the per-protocol sample (n = 153) failed to show noninferiority of GSH-I (adjusted effect, 1.47; 95% CI, -0.01 to 2.91; P = .05). Using the modified intention-to-treat sample, GSH-I was inferior to CBT in reducing OBE days at the end of treatment (adjusted effect, 1.63; 95% CI, 0.17-3.05; P = .03). Exploratory longitudinal analyses also showed the superiority of CBT over GSH-I by the 6-month (adjusted effect, 0.36; 95% CI, 0.23-0.55; P < .001) but not the 1.5-year follow-up (adjusted effect, 0.91; 95% CI, 0.54-1.50; P = .70). Reductions in eating disorder psychopathologic findings were significantly higher in the CBT group than in the GSH-I group at 6-month follow-up (adjusted effect, -0.4; 95% CI, -0.68 to -0.13; P = .005). No group differences were found for body mass index, general psychopathologic findings, and quality of life.

CONCLUSIONS AND RELEVANCE

Face-to-face CBT leads to quicker and greater reductions in the number of OBE days, abstinence rates, and eating disorder psychopathologic findings and may be a better initial treatment option than GSH-I. Internet-based guided self-help remains a viable, slower-acting, low-threshold treatment alternative compared with CBT for adults with BED.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN40484777 and germanctr.de Identifier: DRKS00000409.

Binge Eating Disorder (BED) in Relation to Addictive Behaviors and Personality Risk Factors

While there is good evidence that binge eating disorder (BED) is linked to higher-than-expected use of a broad range of addictive behaviors, mechanisms underlying this association are not well understood. Using a mediation-analytical approach with three age- and gender-matched groups – overweight/obese adults with (n = 42) and without (n = 104) BED, and normal-weight control participants (n = 73) – we tested the hypothesis that adults with BED would engage in more addictive behaviors and have higher scores on a personality-risk index than the two control groups. We also anticipated that the relationship between BED and addictive behaviors would be mediated by a high-risk personality profile. The predicted mediation effect was strongly supported. Contrary to expectation, BED participants did not engage in more addictive behaviors or have higher personality-risk scores than their weight-matched counterparts. However, both overweight/obese groups did have significantly higher scores than the normal-weight group. The relationships among personality risk, elevated body mass index (BMI), and addictive behaviors have important clinical implications, especially for treatments that target psycho-behavioral intervention for compulsive overeating and substance-use disorders.

Dopamine and Opioid Neurotransmission in Behavioral Addictions: A Comparative PET Study in Pathological Gambling and Binge Eating

Although behavioral addictions share many clinical features with drug addictions, they show strikingly large variation in their behavioral phenotypes (such as in uncontrollable gambling or eating). Neurotransmitter function in behavioral addictions is poorly understood, but has important implications in understanding its relationship with substance use disorders and underlying mechanisms of therapeutic efficacy. Here, we compare opioid and dopamine function between two behavioral addiction phenotypes: pathological gambling (PG) and binge eating disorder (BED). Thirty-nine participants (15 PG, 7 BED, and 17 controls) were scanned with [¹¹C]carfentanil and [¹⁸F]fluorodopa positron emission tomography using a high-resolution scanner. Binding potentials relative to non-displaceable binding (BP_ND) for [¹¹C]carfentanil and influx rate constant (K_i) values for [¹⁸F]fluorodopa were analyzed with region-of-interest and whole-brain voxel-by-voxel analyses. BED subjects showed widespread reductions in [¹¹C]carfentanil BP_ND in multiple subcortical and cortical brain regions and in striatal [¹⁸F]fluorodopa K_i compared with controls. In PG patients, [¹¹C]carfentanil BP_ND was reduced in the anterior cingulate with no differences in [¹⁸F]fluorodopa K_i compared with controls. In the nucleus accumbens, a key region involved in reward processing, [¹¹C]Carfentanil BP_ND was 30-34% lower and [¹⁸F]fluorodopa K_i was 20% lower in BED compared with PG and controls (p<0.002). BED and PG are thus dissociable as a function of dopaminergic and opioidergic neurotransmission. Compared with PG, BED patients show widespread losses of mu-opioid receptor availability together with presynaptic dopaminergic defects. These findings highlight the heterogeneity underlying the subtypes of addiction and indicate differential mechanisms in the expression of pathological behaviors and responses to treatment.