An examination of weight bias among treatment-seeking obese patients with and without binge eating disorder

Treatment of Binge-Eating Disorder Across the Lifespan: An Updated Review of the Literature and Considerations for Future Research

PURPOSE OF REVIEW

The present review describes the recent literature on treatment for binge-eating disorder (BED) in adults and youth, with a particular focus on research gaps, emerging treatments, and future research directions.

RECENT FINDINGS

Evidence supports the efficacy of several treatment modalities in adults, including self-help treatment, clinician-led psychotherapy, and pharmacotherapy; the largest effect sizes have been found for psychotherapies, most of which were cognitive-behavioral in orientation. Adapted psychotherapies for youth also show promise but lack a robust body of evidence. Predictors, moderators, and mediators of treatment outcome remain poorly understood; individuals with BED continue to experience significant barriers to treatment; and research is needed to address suboptimal treatment response. Recent work has highlighted the potential of adaptive interventions and investigation of novel mechanisms to address these gaps. Research on BED treatment continues to grow, though critical questions must be answered to improve treatment efficacy across the lifespan.

Preliminary associations of body weight, weight bias, and dietary restriction with eating disorder diagnosis in women experiencing food insecurity

Understanding the co-occurrence of food insecurity and eating disorders is a pressing concern. Several factors have been hypothesized to increase risk for eating disorders in women with food insecurity including dietary restriction, body weight, and weight-related bias, but few studies have tested these factors simultaneously to determine which are associated most strongly with eating disorder status. We tested cross-sectional associations of dietary restriction, current body mass index (BMI), weight suppression (i.e. the difference between current weight and highest weight), and weight bias with eating disorder diagnosis in a sample of 99 self-identified women with current food insecurity (54% White; mean [SD] age = 40.26 [14.33] years). Participants completed two virtual study visits consisting of electronic questionnaires and interviews. A binary logistic regression model was conducted to test relations between the hypothesized correlates and eating disorder diagnostic status in the past 12 months, controlling for age, food insecurity severity, and body dissatisfaction. Higher levels of weight suppression and weight bias, but not current BMI, were significantly associated with the presence of an eating disorder. Contrary to our hypothesis, greater dietary restriction was associated with lower likelihood of eating disorder diagnosis. Results suggest high levels of weight bias and weight suppression characterize women with food insecurity who meet criteria for an eating disorder. Women who experience food insecurity and have lost a relatively great deal of weight and/or hold biases about high weight should be screened for eating pathology in clinical settings.

Raising awareness of anti-fat stigma in healthcare through lived experience education: a continuing professional development pilot study

BACKGROUND

Anti-fat attitudes and weight-based discrimination are prevalent in healthcare settings and among healthcare practitioners and clinical trainees, and can result in immense harm to patients. There is increasing recognition that anti-fat bias in healthcare is a critical issue that must be addressed, but there is a dearth of evidence demonstrating sustained attitude and behavioural change among clinicians, illustrating a need for more innovative educational approaches and rigorous evaluation. We describe the co-design and delivery of a narrative-based continuing professional development curriculum aimed at raising awareness of weight-based bias and stigma.

METHODS

Our research team of lived experience educators, clinicians and researchers collaboratively developed a series of seven podcast episodes comprised of narrative descriptions of lived experiences with and impacts of weight bias, stigma and discrimination in healthcare settings, as well as a post-podcast workshop to facilitate reflection and discussion between participants. The curriculum was piloted among 20 clinicians practicing at a large urban hospital in Mississauga, Canada. We explored feasibility, acceptability and learning impact by analyzing responses to questionnaires completed following each podcast episode and responses shared during the workshops and follow-up feedback sessions.

RESULTS

We observed high acceptability and feasibility of the curriculum. Participants experienced the podcast as a practical and convenient learning format and the workshop as a valuable opportunity to collectively debrief and reflect. The learning impact of the curriculum was strong; participants described a range of emotions elicited by the podcasts, engaged in self-reflection, and expressed a desire to modify clinical approaches. Barriers to the application of learnings identified by participants include pervasiveness of the use of body mass index (BMI) as an indicator of risk and a criterion for referral; discomfort with difficult conversations; prevalent biomedical understandings about the association between weight and health; and clinicians' defensiveness.

CONCLUSION

This pilot study yielded promising findings and demonstrated potential impact on weight bias and stigma among healthcare providers. Necessary next steps include conducting larger scale, rigorous evaluations of the curriculum among broader populations, both health professions trainees and current healthcare providers.

Patient experiences of a 10-weeks weight-neutral treatment program for clinical binge eating disorder in a higher weight population

BACKGROUND

Weight based stigma might drive the development of both higher weight and binge eating disorder (BED). To improve treatment and outcomes, a deeper understanding of how stigma and shame are correlated in clinical encounters is needed. The current study was designed to gain insight into how participating in a 10-weeks weight-neutral treatment program for patients with binge eating disorder and higher weight was experienced.

METHODS

Semi-structured interviews were conducted with 10 patients who had completed the BED treatment. The intervention was group based, addressing stigma and shame, using models of attachment and affect regulation in the presentation of BED. Interviews were analyzed guided by van Manen's hermeneutic-phenomenological approach.

RESULTS

A profound feeling of inferiority due to weight stigma and adverse childhood experiences appeared to have kept the participants stuck in a shame driven carousel  of dieting, weight loss, bingeing, and weight regain. Participants and health care professionals' mutual acknowledgement of driving elements of binge eating appeared to support participants feeling more equal. Feeling equal was described as facilitating increased awareness and tolerance of bodily sensations and emotions, and a deeper understanding and self-caring attitude towards themselves. Feeling less shame was described as important for self-disclosure in family relationships, leading to increased understanding and support from others. Simultaneously, unchanged stigmatizing surroundings were described to relate to challenges with eating patterns and weight after end of treatment.

CONCLUSION

Our findings indicate that relational symmetry, by patients experienced as being met with recognition, compassionate acceptance, and mutual investigation of subjective experience, can contribute to reduction of weight stigma and shame, and the burdensome notion of inferiority experienced by the participants in everyday life, hence improving treatment outcomes. Trail registration The study was approved and registered by the Data Access Committee at Nord-Trøndelag Hospital Trust August 8th, 2019, registration number 2019_2335.

Longitudinal associations of binge eating with internalized weight stigma and eating self-efficacy

INTRODUCTION

Internalized weight stigma (IWS) is linked to binge eating disorder (BED) symptoms and reduced self-efficacy, yet it unknown how changes in these factors may interrelate. The current study examined cross-sectional and longitudinal associations of BED with IWS and eating self-efficacy among treatment-seeking adults with high body weight. Disinhibited eating was explored as a mediator.

METHODS

Seventy-one adults with high weight and elevated IWS were included in this secondary analysis of a clinical trial that provided 26 weeks of behavioral weight loss (BWL) treatment with (versus without) an additional IWS intervention. Participants underwent a BED diagnostic interview at screening and completed validated measures of binge eating, IWS (including weight bias internalization, self-devaluation, and stereotype endorsement), eating self-efficacy, and disinhibited eating at baseline and week-26. Cross-sectional mediation models tested associations of BED with IWS and eating self-efficacy, explained by disinhibited eating. Linear and logistic regression models, controlling for treatment condition, tested if baseline BED predicted changes in IWS, self-efficacy, and disinhibited eating, and if decreased binge episodes were associated with improved outcomes.

RESULTS

At baseline, disinhibited eating mediated the relationship between BED and weight self-devaluation (95 % CI = 0.66,3.58), stereotype endorsement (CI = 0.15,0.56), and eating self-efficacy (CI:-14.40,-4.29). Baseline BED did not predict changes in outcomes. Participants with decreased binge episodes reported greater improvements in weight bias internalization (p = 0.04) and eating self-efficacy (p < 0.001).

CONCLUSION

This study provides novel evidence of longitudinal associations between binge eating, IWS, and eating self-efficacy. IWS warrants further consideration as a treatment target and outcome in studies of BWL and BED.

Examining weight bias before and/or after bariatric surgery: A systematic review

Research examining weight bias in the bariatric population, who may be at greater risk of weight stigma, is scarce. The present study aimed to systematically review the literature for quantitative evidence that explores the medical, psychosocial, and behavioral sequelae associated with experienced, internalized, and/or externalized weight bias in patients seeking or who have undergone bariatric surgery. Five databases were systematically searched for English peer-reviewed quantitative studies, which examined weight bias in a sample of individuals seeking or who had undergone bariatric surgery. Risk of bias was assessed. Twenty-nine studies were included, of which 13 examined internalized weight bias, 12 examined experienced weight bias, 4 examined both, and 0 examined externalized weight bias. Most studies were cross-sectional, and the results showed high risk of bias. The results suggested that both experienced and internalized weight bias were associated with a host of negative psychosocial, behavioral, and medical sequelae. The findings of this review underscore the need for more rigorous research to better understand the relationship between weight bias and bariatric surgery, particularly longitudinally. Future patients may benefit from research developing interventions for reducing weight bias prior to and following bariatric surgery in order to reduce the associated negative correlates and improve outcomes.

Internalized Stigma as a Transdiagnostic Factor for Women with Eating Disorders

This study aimed to examine how internalized weight bias (IWB), body surveillance, and body shame relate to eating pathology in women with diagnosed eating disorders (EDs) across the weight spectrum. Previous research has examined these variables in primarily non-clinical populations, binge eating disorder, and higher weight populations. In a sample of 98 women with diagnosed EDs, the association of IWB, body surveillance, and body shame on the severity of ED symptoms was examined with hierarchical multiple regression analyses. Results indicate that IWB, body surveillance, and body shame significantly predicted global eating pathology, F (4, 93) = 40.74, p < .001. IWB, body surveillance, and body shame related to global eating pathology, even after controlling for previous weight bias experiences. Analyses with specific symptom clusters found that only body surveillance predicted dietary restraint, only IWB and body shame predicted overvaluation of shape/weight, and only IWB predicted body dissatisfaction. The findings in this study provide initial support for internalized stigma variables (IWB, body surveillance, and body shame) related to ED pathology in a transdiagnostic clinical eating disorder sample across the weight spectrum. Results suggest that further examination of internalized stigma is needed within ED treatment.

Internalized weight bias and loss-of-control eating following bariatric surgery

OBJECTIVE

Internalized weight bias (IWB), or negative weight related self-evaluation, is associated with eating-disorder psychopathology and common among patients seeking bariatric surgery, but little is known about the clinical presentation of IWB post-operatively. This study examined IWB and clinical correlates among adult patients with loss-of-control (LOC) eating post-sleeve gastrectomy surgery.

METHODS

Participants (N = 145) were sleeve gastrectomy patients seeking treatment for eating/weight concerns and experiencing regular LOC eating approximately 6 months following surgery. Eating-disorder features were assessed with the Eating Disorder Examination-Bariatric Surgery Version interview (EDE-BSV) and participants completed established measures assessing IWB, depression, and mental and physical components of quality of life.

RESULTS

IWB was not associated significantly with percent excess weight loss, age, or gender, but White participants reported significantly greater IWB than Non-White participants. IWB was significantly associated with greater eating-disorder psychopathology, depression, and lower perceived mental quality of life. Hierarchical regression analysis revealed that IWB significantly predicted variance in eating-disorder psychopathology above and beyond other related variables.

CONCLUSIONS

Findings suggest that IWB is common and associated with a range of heightened eating-disorder and psychosocial difficulties among patients experiencing LOC eating following bariatric surgery. Future research exploring the longitudinal post-operative prognostic significance of IWB is recommended.

Examining Weight Bias and Loss-of-Control Eating among Individuals Seeking Bariatric Surgery

OBJECTIVE

Externalized weight bias (EWB), directed towards others, and internalized weight bias (IWB), directed towards the self, are thought to exacerbate obesity and disordered eating and may be important factors to assess and understand among individuals seeking bariatric surgery. This study examined clinical correlates (pre-surgical BMI, depressive symptoms, weight self-efficacy, and shape/weight overvaluation) of both EWB and IWB among individuals presenting for bariatric surgery with and without regular loss-of-control eating (LOC eating).

METHODS

A total of 316 adults presenting for bariatric surgery completed established self-report measures to assess EWB, IWB, depressive symptoms, weight self-efficacy, and core symptoms of disordered eating including LOC eating and overvaluation of shape/weight.

RESULTS

IWB and EWB were not associated with pre-surgical BMI, age, or sex, but were both significantly higher among White than non-White participants. Adjusting for race, IWB and EWB were significantly associated with greater eating disorder psychopathology and depressive symptoms and with less weight-related self-efficacy. Participants who endorsed regular LOC eating (53.5% of the sample) endorsed significantly lower weight self-efficacy and higher IWB, EWB, depressive symptoms, and overvaluation of shape/weight.

CONCLUSIONS

Findings suggest that regular LOC eating is common among individuals seeking bariatric surgery and associated with a range of heightened eating disorder and psychosocial concerns including both IWB and EWB. Future research exploring the longitudinal significance of the relationship between these two forms of weight bias and LOC eating is indicated.

A bifactor analysis of the Weight Bias Internalization Scale: What are we really measuring?

Internalized weight stigma (IWS) has been linked with disordered eating behavior, both directly, and as a mediator of the relationship between experienced weight stigma and maladaptive coping. However, the construct of IWS is highly correlated with the related constructs of body image and global self-esteem, and the three constructs may better be represented by underlying trait self-judgment. This overlap is not generally accounted for in existing studies. The present study investigated the shared variance between self-esteem, body image, and IWS in an international sample of higher-weight individuals. Bifactor analysis confirmed that the intermediary role of IWS in the relationship between experienced stigma and self-reported eating behavior was largely accounted for by aspects of body image and global self-esteem. Greater conceptual clarity in the study of IWS is needed to understand the mechanisms via which societal weight stigma impacts on individuals' self-directed judgments and downstream health-related behaviors.

Binge eating and binge-eating disorder in Black women: A systematic review

OBJECTIVE

Although several effective behavioral treatments for binge-eating disorder (BED) exist, there are racial disparities in treatment access, with African-Americans and/or Black individuals having some of the lowest rates of access to care. Little is known about the experience and treatment of binge eating (BE) and BED among Black women.

METHOD

This systematic review, conducted according to PRISMA guidelines, synthesizes information related to BE and BED in Black women.

RESULTS

A total of N = 38 studies met our eligibility criteria. We did not identify any systematic risk of bias across studies. The majority of included studies used cross-sectional survey methodology, and relied on interview (EDE) and self-report measures (particularly the Binge Eating Scale, BES) for the assessment of BE. Outcomes were inconsistently measured across trials, and there are limited data on the results of evidence-based treatments for BE/BED in Black women.

DISCUSSION

Although Black women have similar or higher rates of BE than White women, most research on BE and BED has focused on White women, with Black individuals underrepresented in clinical trials. Future research should examine evidence-based treatments to prevent and treat BED in this population.

OBJETIVO

Aunque existen varios tratamientos conductuales que son efectivos para el Trastorno de Atracones (BED, por sus siglas en inglés), existen disparidades raciales en el acceso a tratamiento, con individuos Afroamericanos y/o personas de color teniendo algunas de las tasas más bajas de acceso al cuidado de la salud. Se sabe muy poco acerca de la experiencia y tratamiento del comer en atracones (BE, por sus siglas en inglés) y BED entre mujeres afroamericanas y/o de color. MÉTODO: Esta revisión sistemática, realizada bajo lineamientos de las guías PRISMA, sintetiza información relacionada con BE y BED en mujeres afroamericanas y/o de color.

RESULTADOS

Un total de N = 38 estudios cumplieron con nuestros criterios de elegibilidad. No identificamos ningún riesgo sistemático de sesgo entre los estudios. La mayoría de los estudios incluidos utilizaron una metodología de encuesta transversal y se basaron en la entrevista (EDE) y las medidas de autoinforme (en particular, la Binge Eating Scale, BES) para la evaluación de BE. Los resultados se midieron de manera inconsistente entre los ensayos, y hay datos limitados sobre los resultados de los tratamientos basados en la evidencia para BE/BED en mujeres afroamericanas y/o de color. DISCUSIÓN: Aunque las mujeres afroamericanas y/o de color tienen tasas similares o más altas de BE que las mujeres blancas, la mayoría de las investigaciones sobre BE y BED se han centrado en las mujeres blancas, con individuos afroamericanos y/o de color subrepresentados en ensayos clínicos. La investigación futura debería examinar los tratamientos basados en la evidencia para prevenir y tratar el BED en esta población.

Concept of overweight bias among healthcare professionals: An evolutionary concept analysis

The aim of this concept analysis was to identify the attributes of overweight bias among healthcare providers (HCPs) and create a clear definition to guide the recognition of overweight bias among HCPs. Settings within the healthcare system are not exempt from bias and the stigmatization of persons with obesity. Overweight bias among HCPs may negatively impact health care and health outcomes. Rodger's evolutionary method was used to guide this concept analysis. The databases CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, and PsycINFO were searched. The analysis provided clarification of the concept to facilitate HCP self-awareness of overweight bias. A definition of the concept of overweight bias among HCPs is provided along with its attributes, antecedents, and consequences.

Examining motivational interviewing plus nutrition psychoeducation for weight loss in primary care

OBJECTIVE

Our previous randomized controlled trial found that nutrition psychoeducation (NP), an attention-control condition, produced statistically significantly more weight loss than usual care (UC), whereas motivational interviewing (MI) did not. NP, MI, and UC resulted in medium-large, medium, and negligible effects on weight loss, respectively. To examine whether weight loss could be further improved by combining MI and NP, the current study evaluated the scalable combination (MINP) with accessible web-based materials.

METHODS

31 adults with overweight/obesity, with and without binge-eating disorder (BED), were enrolled in the 3-month MINP treatment in primary care. Participants were assessed at baseline, post, and 3-month follow-up. Mixed-model analyses examined MINP effects over time and the prognostic significance of BED.

RESULTS

Mixed-model analyses revealed that percentage weight loss was statistically significant at post and 3-month follow-up; d'=0.59 and 0.53, respectively. BED status did not predict or moderate weight loss. Twenty-one percent (6 of 28) and 26% (7 of 27) of participants attained 5% weight loss by post-treatment and 3-month follow-up, respectively. Participants with BED had statistically significantly greater improvements in disordered eating and depression (in addition to binge-eating reductions) compared to those without BED.

CONCLUSION

MINP resulted in weight and psychological improvements at post-treatment and through 3-months after treatment completion. There did not appear to be additional benefits to combining basic nutrition information with MI when compared to the previous randomized controlled trial testing nutrition psychoeducation alone.

CLINICAL TRIAL REGISTRATION

NCT02578199.

The role of the "Healthy Weight" discourse in body image and eating concerns: An extension of sociocultural theory

Sociocultural models of body image and eating concerns have highlighted the role of the social discourse in promoting the pursuit of the thin-ideal. Recently, another weight-focused social discourse has gained ground, focused on the goal of maintaining body weight within the boundaries of a weight-range defined as "Healthy." This discourse is somewhat different to the promotion of the thin-ideal; however, it might also be implicated in the development of body image and eating concerns. The present study aimed to extend sociocultural theories of the development of body image and eating concerns by (1) proposing a theoretical model accounting for pressure to maintain a "Healthy Weight", and (2) reviewing the existing evidence for the pathways included in this model. In the proposed model, pressure to maintain a Healthy Weight leads to the internalization of anti-fat attitudes and the need to control weight as well as beliefs in the controllability of weight through diet and exercise. These beliefs may then lead to body preoccupation and disordered eating. The extant literature provides initial support for these relationships; however, empirical testing of this model is necessary to determine its usefulness as an explanatory model and in providing intervention targets for future prevention and intervention efforts.

Diagnosing binge eating disorder in a primary care setting

Binge eating disorder (BED), now recognized as a distinct eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most prevalent eating disorder. Although nearly half of individuals with BED are obese, BED also occurs in nonobese individuals. Despite the relatively high percentage of weight loss treatment-seeking individuals meeting BED criteria, primary care physicians may not be familiar with or have ever diagnosed BED. Many providers may also have difficulty distinguishing BED as a contributory factor in obesity. This review differentiates BED from other causes of obesity by describing how obese individuals with BED differ from obese individuals without BED and from nonobese individuals with BED in areas including psychopathology, behavior, genetics, physiology, quality of life and productivity. The ways in which health-care providers can identify individuals who may have BED are also highlighted so the proper course of treatment is pursued. Overall, obese individuals with BED demonstrate a number of key characteristics that differentiate them from obese individuals without eating disorders, including increased impulsivity in response to food stimuli with loss of control over eating, resulting in the consumption of more calories. They also experience significant guilt and other negative emotions following a meal. In addition, individuals with BED patients have more psychiatric comorbidity, display more psychopathology, exhibit longer binge durations, consume more meals as snacks during the day and have less dietary restraint compared with individuals with BED who are not obese. However, the differences between individuals with BED who are obese versus not obese are not as prominent. Taken together, the evidence appears to support the conclusion that BED is a unique and treatable neurobehavioral disorder associated with distinct behavioral and psychological profiles and distinct medical and functional outcomes, and that it is not merely a subtype of obesity.

Stigma and eating and weight disorders

Although research has consistently documented the prevalence and negative health implications of weight stigma, little is known about the stigma associated with eating disorders. Given that weight stigma is a risk factor associated with disordered eating, it is important to address stigma across the spectrum of eating and weight disorders. The aim of this review is to systematically review studies in the past 3 years evaluating stigma in the context of obesity and eating disorders (including binge eating disorder, bulimia nervosa, and anorexia nervosa). Physical and psychological health consequences of stigma for individuals with obesity and eating disorders are discussed. Recent studies on weight stigma substantiate the unique influence of stigma on psychological maladjustment, eating pathology, and physiological stress. Furthermore, research documents negative stereotypes and social rejection of individuals with eating disorder subtypes, while attributions to personal responsibility promote blame and further stigmatization of these individuals. Future research should examine the association of stigma related to eating disorders and physical and emotional health correlates, as well as its role in health-care utilization and treatment outcomes. Additional longitudinal studies assessing how weight stigma influences emotional health and eating disorders can help identify adaptive coping strategies and improve clinical care of individuals with obesity and eating disorders.