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Binge Eating and Obesity Treatment
Örebro Studies in Medicine 29
Joakim de man Lapidoth
Binge Eating and Obesity Treatment
– Prevalence, Measurement and Long-term Outcome
© Joakim de Man Lapidoth, 2009
Title: Binge Eating and Obesity Treatment
– Prevalence, Measurement and Long-term Outcome
Publisher: Örebro University 2009
www.publications.oru.se
Editor: Heinz Merten
[email protected]
Printer: intellecta infolog, V Frölunda 04/2009
issn 1652-4063
isbn 978-91-7668-663-8
Abstract
de Man Lapidoth, Joakim (2009): Binge Eating and Obesity Treatment – Prevalence, measurement and long-term outcome. Örebro Studies in Medicine 29; 68 pp.
Background: Overweight and obesity has increased markedly during the last decades. In
addition to personal suffering, obesity is negatively associated to physical health, physical
aspects of health related quality of life (HRQL), and mortality. Among weight loss treatment
applicants, eating disorders and binge eating are common problems that are associated with
psychopathology and low HRQL. Binge eating is also associated with weight gain, why an
assessment of eating behaviour is recommended before weight loss treatments. Information
is insufficient about the association between binge eating and weight loss treatment outcome,
largely depending on methodological and diagnostic differences and difficulties in previous
studies.
Method: Study I was a naturalistic study measuring the point prevalence of eating disorders
and binge eating in 194 behavioural weight loss treatment applicants. Studies II–IV were
all based on a cohort of surgical and behavioural weight loss treatment patients that were
followed, from before treatment to three years after treatment. Study II investigated the
psychometric properties of a new self-reporting questionnaire (Eating Disorders in Obesity)
by comparing results from assessments of eating disorders and binge eating, to assessments
made with the Eating Disorder Examination. In Study III the prevalence of eating disorders
and binge eating was compared between patients applying for bariatric surgery or behavioural
weight loss treatment. Study IV used long-term data to investigate whether binge eating before
or after bariatric treatment was associated with BMI outcome, and whether binge eating after
bariatric treatment was associated with psychopathology and HRQL.
Results: Study I showed that 9.8% of the behavioural weight loss treatment applicants had
an eating disorder, while an additional 7.2% were classified as binge eaters. Eating disorders
and binge eating was associated with lower HRQL and more psychopathology. In Study II the
reliability and validity of the Eating Disorder in Obesity (EDO) questionnaire was shown to
be good for assessments of eating disorders (=0.67) and binge eating (=0.63). Study III found
that while binge eating as a symptom was equally common in participants before surgical
and behavioural weight loss treatment, surgical treatment participants indicated more eating
disorders. Surgical treatment participants also indicated higher levels of psychopathology than
behavioural treatment participants. Study IV found that those that were classified as binge
eaters before of after bariatric surgery did not differ in long-term BMI outcome, compared
to those with no binge eating. However, binge eating after bariatric surgery was common
and associated to less successful treatment outcome regarding HRQL and psychopathology.
Discussion: Results show that binge eating was common before surgical and non-surgical
weight loss treatments. Binge eating three years after surgical treatment was also common,
but neither pre- nor post-treatment binge eating was associated to long-term BMI outcome.
Binge eating after surgical treatment though was associated to low HRQL and high psychopathology, why the overall treatment outcome for these binge eating patients can be considered to be poor. This indicates a need for assessing and treating binge eating in weight loss
treatments. The mixed results from previous research on binge eating in weight loss treatment
settings also show that there is a need of more research on this issue.
Keywords: Eating disorders, obesity, binge eating, long-term outcome, weight loss
List of Papers
This thesis is based on the following original papers:
I
de Man Lapidoth, J., Ghaderi, A. & Norring, C. (2006). Eating disorders
and disordered eating among patients seeking non-surgical weight-loss
treatment in Sweden. Eating Behaviors 7: 15-26.
II
de Man Lapidoth, J., Ghaderi, A., Halvarsson, K. & Norring, C. (2007).
Psychometric properties of the Eating Disorders in Obesity questionnaire:
validating against the Eating Disorder Examination interview. Eating and
Weight Disorders 12:168-75
III
de Man Lapidoth, J., Ghaderi, A. & Norring, C. (2008). A comparison of
Eating Disorders among patients receiving surgical vs. non-surgical weightloss treatments. Obesity Surgery 18: 715-720.
IV
de Man Lapidoth, J., Ghaderi, A., Norring, C. Binge eating in surgical
weight-loss treatments – Long-term associations with weight loss, health
related quality of life (HRQL) and psychopathology. International Journal
of Obesity (Submitted).
The studies presented have been reprinted with the kind permission of the
publishers concerned.
A bbreviations
AN
BED
BMI
BN
CPRS-S-A
DSM
EDE
EDE-Q
EDO
EDNOS
SF-36
-PF
-RP
-BP
-GH
-VT
-SF
-RE
-MH
Anorexia Nervosa
Binge Eating Disorder
Body Mass Index
Bulimia Nervosa
Comprehensive Psychopathological Rating Scale – Self-rating scale
for Affective Syndromes
Diagnostic and Statistical Manual of mental disorders
Eating Disorder Examination
Eating Disorder Examination – Questionnaire
Eating Disorders in Obesity
Eating Disorders Not Otherwise Specified
Short Form 36
Physical Functioning
Role Physical
Bodily Pain
General Health
Vitality
Social Functioning
Role Emotional
Mental Health
Table of Contents
BACKGROUND .................................................................................. 13
Obesity ............................................................................................... 13
Weight loss treatments ......................................................................... 14
Bariatric surgery ............................................................................... 14
Behavioural weight-loss treatments ..................................................... 15
Obesity and mental health .................................................................... 15
Eating disorders in weight loss treatments .............................................. 15
Associated features in weight loss treatments ...................................... 17
Binge eating and weight loss treatment outcome ..................................... 18
Eating disorders and binge eating in the clinical weight loss ..................... 19
treatment practice
Diagnostic and methodological issues of concern .................................... 19
BED frequency and duration criterion .................................................. 20
Large amounts criterion and subjective binge eating ............................. 20
Shape and weight concern ................................................................. 21
BED vs. EDNOS .............................................................................. 21
Instruments for assessing eating behaviour in weight loss treatments......... 21
AIMS ................................................................................................. 23
METHODS AND MATERIAL ............................................................... 25
Participants ......................................................................................... 25
Instruments ......................................................................................... 27
Procedure ........................................................................................... 28
Definitions .......................................................................................... 29
Analyses ............................................................................................. 30
Ethical considerations........................................................................... 31
RESULTS........................................................................................... 33
Study I: Eating disorders and disordered eating among patients seeking ..... 33
non-surgical weight-loss treatment in Sweden
Study II: Psychometric properties of the Eating Disorders ......................... 33
in Obesity questionnaire: validating against the Eating Disorder
Examination interview
Study III: A comparison of eating disorders among patients receiving ......... 34
surgical vs. non-surgical weight loss treatments.
Study IV: Binge eating in surgical weight-loss treatments – long-term......... 34
associations with weight loss, health related quality of life (HRQL)
and psychopathology
Summary of the main findings ............................................................... 35
DISCUSSION ..................................................................................... 37
Major findings...................................................................................... 37
Clinical considerations .......................................................................... 39
Diagnostic and methodological considertions .......................................... 40
Research considerations and future research........................................... 41
CONCLUSIONS ................................................................................. 45
SAMMANFATTNING PÅ SVENSKA (SUMMARY IN SWEDISH) .............. 47
TACK (Acknowledgements) ................................................................ 49
APPENDICES .................................................................................... 51
REFERENCES ................................................................................... 55
BACKGROUND
Eating disorders and binge eating symptoms are common in weight loss
treatments. More knowledge about these eating behaviours and about their
association to treatment outcome is of clinical importance to establish how these
patients are to be addressed in weight loss treatments. Due to methodological
difficulties and differences results from previous research are mixed and thus
most inconclusive, which has led to great differences in the clinical weight loss
treatment practice.
Obesity
The global increase in obesity in the westernized world, has been discussed
intensively during the last decades, and in June of 1997 obesity was declared a
worldwide epidemic at the World Health Organisation Consultation on Obesity.
Through the documented negative effects of obesity on a wide range of health
factors, obesity is now considered to be one of the major risks to global health.
The increased medical cost brought by obesity 3, 46 is a matter of great concern and
is an increasing challenge for all health care systems. In the wake of globalization,
what used to be a problem in the industrialized world has now also become a
major health problem in the less developed areas of the world 69.
Obesity has repeatedly been shown to have a significant negative impact on
somatic health, as well as on psychosocial well-being, mortality 112, and quality of
life 45. Undoubtedly obesity brings health problems, but these negative effects are
shown to be reduced if weight is lost. Long-term weight loss has been shown to be
beneficial for a number of obesity-related comorbidities, such as Diabetes,
Dyslipidemia, Hypertension and Sleep Apnea 71, but also by decreased mortality 13,
112
. Results show that obese persons that manage to loose as little as 5–10% of
their weight 50, besides the above mentioned health benefits, show improvements
in quality of life 126, as well as in most psychological and psychosocial endpoints 2,
13, 36, 60, 79
.
In Sweden the prevalence of adult obesity (Body Mass Index (BMI)>30) has risen
in the last decades, from approximately 5% in 1980 to more than 10% in 2005
93
. A corresponding increase in overweight (BMI>25) has led to an overweight
prevalence of approximately 50% for men and 35% for women. The increase in
the rates of overweight and obesity are alarming, but the rates are relatively low in
an international comparison. According to the Center for Disease Control and
Prevention in 2007 21, all states but one in the United States, had an obesity
prevalence of more than 20%, and in more than 30 states the prevalence rate was
equal to or greater than 25%.
The global increase, increased health care costs, and individual negative
consequences of obesity, have all contributed to bring attention not only to the
global, but also to the local health care situations for obesity. Most regions in
Sweden now have, or are in the progress of developing health policies that cover
obesity, as well as strategies for how to manage obesity in e.g. local health care,
child care and schools. Publicly financed surgical and behavioural weight loss
14
Binge Eating and Obesity Treatment joakim de man lapidoth I 13
treatments are today offered in a large number of hospital-based clinics and
health centres in Sweden, but the availability of these treatments fail to reach the
needs by far.
Weight loss treatment
Clinical weight loss treatments are often categorized as being either behavioural1
or surgical (i.e. bariatric surgery). In general, results show that behavioural
treatments provide only short-term weight-loss and are effective in the long term
for only a limited percentage of the patients 126, 129. Bariatric surgery on the other
hand has been shown to produce long-term weight loss, with subsequent longterm health benefits and reductions in mortality 112.
Bariatric surgery
Bariatric surgical procedures have been performed since the 1950’s. Since then,
this has become a common surgical procedure, and the forms of bariatric surgery
have been modified substantially. New procedures that have been introduced
during the last decades have led to improvements in weight loss while
complication rates and mortality have dropped 71. Many of the bariatric
procedures are now done laparoscopically which has further reduced the
morbidity associated to the surgical procedure, and has improved recovery after
surgery 44.
The primary strategies of surgically induced weight loss are gastric restriction,
intestinal malabsorption, or a combination of them. 44. The restrictive procedures,
(such as vertical banded gastroplasty or adjustable gastric banding) cause early
satiety by the creation of a small gastric pouch, and prolonged satiety by a small
outlet from this gastric pouch. The malabsorptive procedures (such as
biliopancreatic diversion or jejunoileal bypass) primarily depend on a surgical
bypass of a substantial part of the small intestine. This causes a markedly reduced
area for the absorption of nutrients. In procedures that combine the restrictive
and malabsorptive strategies, improved long-term weight-loss results are
produced through the initial restrictive effect being complemented by the
malabsorptive effect of the procedure, when the restrictive effect starts to decrease
after approximately 1–2 year post-surgery 71. Gastric bypass (GBP) and gastric
sleeve with duodenal switch are examples of combination procedures, where GBP
is the most commonly performed procedure in bariatric surgery in Sweden today.
In addition to the restrictive and malabsorptive effects of GBP, other aspects have
been ascribed as contributing to the success of the procedure. One of these is the
“dumping syndrome”, where eating large amounts of sweet and/or foods with
high fat contents causes a most unpleasant sensation that consequently motivates
changes in the choice of food. Changes have also been shown in plasma levels of
certain gut hormones after gastric bypass surgery. These hormones are shown to
be associated to decreased dietary intake, and to influence hedonic feeding 71.
These aspects of bariatric surgery lay beyond the scope of this thesis.
1
Behavioural weight loss treatments are also described as a non-surgical weight loss treatments.
14 I joakim de man lapidoth Binge Eating and Obesity Treatment
Behavioural weight-loss treatments
Behavioural weight loss treatments represent a wide variety of non-surgical weight
loss treatments, typically administered on a group basis 144. The main objective of
these treatments is the (non-surgical) modification of people’s behaviour and
lifestyle, by helping the patient to identify behaviour and attitudes that are related
to weight. This consequently helps the patient to make changes that will affect
energy intake and expenditure (i.e. exercise and food). These lifestyle changes are
promoted by a wide variety of cognitive, behavioural, psycho-educative, and/or
other therapeutic techniques. The behavioural treatments that are offered differ
widely in regard to aspects like treatment length and intensity.
Hospital-based behavioural treatments are sometimes combined with
pharmacological treatment. In Sweden only Orlistat and Sibutramine are accepted
for pharmacological weight-loss treatment. These anti-obesity drugs have both
shown to cause a significant (but limited) increase in weight loss when they are
combined with behavioural treatment 9. Sibutramine has also shown to reduce
binge eating in patients with Binge Eating Disorder (BED) 8, but the effects of
pharmacotherapy will not be addressed in this thesis.
Also liquid Low (or Very-low) Calorie Diets ((V)LCDs) 128 are occasionally
combined with behavioural weight loss treatments. This commonly means that
the patient starts the first weeks of treatment by substituting all or some meals for
a liquid high protein supplement of 800–1200 kcal/day, which brings a fast initial
weight loss. After the period of meal replacement sizable weight regain is typical,
why these treatments cannot be shown to offer any long-term benefits over
traditional diets 127.
Obesity and mental health
Obesity and measures of psychiatric symptomatology have in some studies been
shown to be unrelated 125, while conflicting studies have found obesity to be
related to e.g. mood disorders 84. In specific weight loss treatment samples though,
it is indisputable that rates of both eating pathology and other psychopathology
are raised 60, 94, 105, 132. Obesity in the general population is in general associated
with impaired physical functioning, but not with impaired mental and social
functioning 110.
Eating disorders in weight loss treatments
Eating disorders and the associated symptoms of binge eating have repeatedly
been shown to be common in behavioural 100, 101, 114, 149 and surgical weight loss
treatments 22, 91. Binge eating is the core criteria of BED and the primary symptom
in most other eating disorders in obese patients 5. Binge eating is defined by the
DSM-IV as eating amounts of food that are larger than most others would have
eaten in similar circumstances, while feeling a loss of control over eating 5. Besides
being a common symptom in weight loss treatment patients, the importance of
binge eating has been emphasized through studies showing binge eating to be
associated to overweight and weight gain 29, 43, 58, and binge cessation to be
associated with weight stabilization 29.
Binge Eating and Obesity Treatment joakim de man lapidoth I 15
According to the Statistical and Diagnostic Manual of Mental Disorders (DSMIV) 5, there are three main categories of eating disorders; Anorexia Nervosa (AN),
Bulimia Nervosa (BN) and Eating Disorders Not Otherwise Specified (EDNOS)
where BED is included. The criteria for AN, BN, EDNOS and BED are presented
in Appendix A. The use of these diagnoses in weight loss treatment settings are
presented briefly below.
The diagnosis of AN requires that the patient is below 85% of expected weight 5
which is not applicable to patients in weight loss treatment setting. In theory this
diagnose could be applicable to weight loss patients post-treatment, but to my
knowledge strict cases of AN have not been reported. Problems of post-treatment
anorectic symptoms or behaviours though, have been documented in rare cases
109
.
The criteria for BN indicate that this is a valid diagnose in a weight loss treatment
setting even if purging BN is rarely seen in patients with severe obesity 43. Since
BED was introduced in the DSM-IV in 1994, BN has shown to represent only a
smaller part of the eating disordered in weight loss treatments 62, 63.
Overall, EDNOS is by far the largest diagnostic category representing
approximately 60% or more of the eating disordered 39, 78. Six examples of
EDNOS are stated in the DSM 5. The first two examples are similar to AN. Even
though these patients show severe weight loss, they do not meet either the
amenorrhea criteria, or are not below 85% of expected weight, why these EDNOS
examples are applicable only for weight-loss patients after treatment. In the third
example, patients are required to meet criteria for BN, except for not reaching the
binge eating or compensatory frequency. This has been frequently reported in the
weight loss literature 41. The fourth example describes compensatory behaviour
by an individual of normal body weight after eating only small amounts of food,
and the fifth example describes compensatory behaviour after chewing and
spitting out food or after eating small amount of food. These two behaviours
have to my knowledge never been reported in weight loss treatment subjects. The
last example is Binge Eating Disorder (BED) which according to Wade et al. 133
accounts for a sizeable portion of EDNOS.
BED was included in the DSM in 1994, after the first clinical reports were
presented on binge eating in the obese 50 years ago 117. After that a number of
large studies in the beginning of the nineties 113, 114 led to Binge Eating Disorder
(BED) being included in the DSM-IV 5, as a disorder in need of further study. The
essential features of BED are recurrent episodes of binge eating, and a number of
associated features in the absence of regular use of inappropriate compensatory
behaviours5.
Since BED was presented in the DSM, it has been used in many studies of eating
behaviour in weight loss treatment settings 25, 30, 43, 91. Studies based on selfreported data have shown large differences in the prevalence of BED in different
populations, from 2–5% in community samples to 10–30% in weight loss
treatment samples 25, 30. Studies that also have included sub-clinical symptoms of
16 I joakim de man lapidoth Binge Eating and Obesity Treatment
binge eating, have shown rates of binge eating of more than 50% 56. More current
studies though have reported lower levels of BED, probably owing to more careful
methodology and better definitions of this behaviour 85. The gender imbalance
shown in other eating disorders is less pronounced in BED, where women are
approximately 1.5 times more likely to have BED than men 113, 114.
Associated features in weight loss treatments
BED and binge eating in obesity have been shown to be associated to more
psychopathology, compared to those without these symptoms 16, 19, 56, 87, 116, 140, 149.
The rates of frequently reported comorbidities, such as depression and anxiety,
are lower in the specific group of obese binge eaters than in BN though 7, 17, 42, 152.
There are reports that individuals with high psychopathology may be at risk for
attrition from behavioural weight loss treatments and that the may show earlier
weight regain 81, but others conclude that baseline psychiatric status, particularly
depression, cannot predict postoperative weight loss 131 and that there is little
evidence that psychiatric treatment or psychiatric evaluation can improve patient
selection for surgical treatments 70. The high rates of psychopathology that has
been shown in weight loss treatment settings is thought to be attributable to the
severity of binge eating rather than to the degree of obesity 85, 99, 152. In addition to
psychopathology, interpersonal distress and Health Related Quality of Life
(HRQL) is more impaired in obese individuals with eating disorders or binge
eating, compared to those with no such problems 26, 27, 34, 68, 80, 99. Binge eating and
the associated features of psychopathology and HRQL are regarded as aspects of
life that could cause, affect, maintain, or complicate obesity, why it is generally
recommended that weight loss patients are assessed for these issues pre-treatment
52, 104
.
In the DSM-IV criteria for BED 5 no distinction has been made between obese and
non-obese binge eaters. Even though the diagnosis is not limited to overweight or
obese individuals, BED has been shown to be associated to overweight and
obesity 43, 140, through most BED patients having varying degrees of obesity 25, 33,
114
. While some have shown that a higher degree of obesity leads to more binge
eating or BED 149, most conclude that weight has little, or no impact on the
severity of eating disorders 11, 20, 31, 82, 85, 137, 152.
In one of the few studies that have compared applicants to different types of
weight loss treatments, Bancheri and colleagues 10 found no difference in eating
behaviour between those seeking bariatric treatment and psychotherapy plus
dieting. Those seeking surgical treatment showed lower psychopathology scores
in two of the subscales of the Minnesota Multiphasic Personality Inventory-2
though. In the Swedish Obese Subjects study, the only difference found between
surgical and non-surgical weight loss participant, was that patients applying for
surgery had lower HRQL than behavioural weight loss treatment applicants 64.
Binge Eating and Obesity Treatment joakim de man lapidoth I 17
Binge eating and weight loss treatment outcome
The association between weight loss outcome and eating disorders/binge eating is
an issue of clinical concern for establishing if eating disorders or binge eating
should be addressed in the context of weight loss treatments. The studies that
have addressed this issue show mixed results, both regarding weight loss and
eating behaviour 91. A number of studies have found less weight-loss after
bariatric surgery for those with disordered eating 63, 103, but conflicting studies
show no such effect 14, 15, 75 or even show more weight loss in those with binge
eating 79. In behavioural weight loss treatments, patients with eating disorders or
binge eating have not had more problems in loosing weight 51, 61 but there is some
evidence that these individuals are more likely to drop out of weight loss
treatment 81. Thus binge eating cannot be shown to be a predictor for weight loss
or weight regain after treatment 85 which has been further confirmed by recent
prospective findings 22, 91. Some conclude though that binge eating pre-treatment
could pose a risk of future weight regain 38.
Instead of focusing on binge eating as a predictor of weight loss treatment
outcome, there has been an increased emphasis on the importance of posttreatment binge eating for the outcome of bariatric treatments (no corresponding
studies from post-behavioural treatments have been found). A number of these
studies have shown that binge eating that remains, or re-emerges post-treatment
has a negative effect on weight-loss treatment outcome 22, 62, 86, 91.
In addition to weight loss, changes in eating behaviour have also been reported as
possible consequences of the calorie restriction that is caused in weight loss
treatments 57, 108, 109, 136. Restraint theory postulates that overeating results from
the disruption of restraint in vulnerable individuals 85. According to this theory
binge eating starts in response to dieting behaviour, and severe dietary restriction
(like in bariatric surgery and (Very) Low Calorie Diets) could worsen binge eating.
Binge eating though, has shown not only to follow on dieting, but also to precede
dieting 1, 130, which would question the restraint theory in weight loss treatment
patients. Weight loss treatments in general does not worsen binge eating 151, 153.
Most studies of larger surgical cohorts have also described the prevalence of
eating disorders and binge eating to be less after bariatric surgery 2, 65, 73, 75, but
there are clinical reports and case studies that show that eating disorders
sometimes start in response to weight loss treatments 57, 97, 108, 109, 136.
In behavioural weight loss treatments, negative outcome regarding eating
behaviour has been described only in treatments with Low, or Very Low Calorie
Diets. Results from these treatments show that while some develop binge eating
after these treatments 151, (V)LCD programs in general do not lead to emergence
of binge eating 130. Weight loss treatments most often lead to reductions in binge
eating 72, and caloric restriction does not appear to be associated with the
development of binge eating in individuals who never reported problems with
binge eating 130.
Besides weight loss and binge eating, weight loss treatment studies have not only
focused on longevity, but also on other more qualitative measures of outcome
18 I joakim de man lapidoth Binge Eating and Obesity Treatment
such as Health Related Quality of Life 60, 67, 70 and different measures of
psychopathology 2, 60, 65. The great majority of these studies show that successful
weight loss is associated with improvements in HRQL and psychopathology. The
generality of this association can be questioned though, by the number of case
studies that have shown disturbed eating patterns (such as anorectic behaviour)
after bariatric treatment 28, 108. For these patients, the weight loss that has been
achieved, has been a result of pathological eating patterns, why the overall
treatment outcome for these patients is unlikely to be considered as successful 105.
Eating disorders and binge eating in the clinical weight loss treatment practice
Due to insufficient research data, there is a lack of agreement about how binge
eating patients should be managed in weight loss treatments 85. Patients are
therefore managed differently in different clinics in regard to eating disorders and
binge eating, which includes differences in pre-treatment assessments, which
patients are admitted for treatment, and if eating behaviour and other
psychological issues are addressed in treatment or follow-up. Devlin and
colleagues 30 examined the current practice of bariatric surgeons and found that
eating disorders and binge eating in most cases was routinely screened for, but
there were large differences in how to proceed with these patients. While 20% of
the surgeons would proceed with surgery, 30% would postpone or recommend
against surgery, and as many as 50% reported that they varied in their decision.
The current practice was also studied by Zimmerman and colleagues 154, who
showed that 18% of the bariatric patients that were examined were not cleared
for surgery after a psychiatric evaluation. The study concluded that the reliability
of these decisions was good (i.e. a consensus within the clinic), but demonstrated
no relationship between these decisions and treatment outcome.
D iagnostic and m ethodological issues of concern
Since BED was introduced in the DSM-IV 5, research on BED has dominated
research in the field of eating behaviour in the obese 43. Research has shown BED
patients to differ from other obese patients through their high rates of
psychopathology 16, 19, 150 and psychological distress 99. Patients with BED show
similarities to patients with other eating disorders regarding weight and shape
concerns, psychopathology, functional impairment and healthcare utilization 16, 33,
137, 140
. In contrast to earlier reports, BED has been shown to be a stable, chronic
disorder with long duration and similar placebo responsiveness as the other
eating disorders 137. Despite these similarities BED patients are unique compared
to patients with other eating disorders, regarding e.g. demographic profile, risk
factors and obesity. Research on BED has suggested that BED is a valid and
clinically significant disorder that in a revised version most likely will be included
as an officially recognized diagnosis in the DSM-V 137.
The BED criteria that were formed in 1994 were not primarily based on empirical
research but on expert consensus 55, 137. In addition to a general debate about the
diagnostic validity of BED 24, 140, 147, critique has also been raised regarding the use
of BED in weight loss treatments, as no differences have been shown regarding
weight-loss between persons with sub-threshold symptoms of binge eating and
those with BED 6, 103. There have been suggestions that the current categorical
Binge Eating and Obesity Treatment joakim de man lapidoth I 19
classification in eating disorders most likely has been limiting to the development
of more empirically based knowledge in the area. According to these suggestions,
a dimensional approach would most likely convey richer and more complete
information, which would have the ability to capture variations in
symptomatology, and could through this further expand knowledge 137 in the
area.
A number of diagnostic and methodological concerns have been raised in the area
of eating disorders and obesity. Those relevant to this specific research area are
briefly addressed below.
BED frequency and duration criterion
Few differences have been shown between patients that were diagnosed with a
strict definition of BED and those diagnosed with a modified binge eating
frequency of once per week (compared to twice per week) 76, 115, 137, 145. This has
questioned the utility of the frequency requirement of the DSM, which was not
primarily based on empirical evidence but chosen to match the BN frequency
criterion 85. There is also limited empirical support for the 6 months duration
required for a diagnosis of BED (compared to the BN criteria of 3 months), why it
has been suggested that also the BED duration criteria be set at 3 months 24. In
line with this, research shows only few differences between those diagnosed with
ED and binge eaters that indicate sub-clinical states 103, 116, 148, which may question
the general procedure of classifying eating disorders as distinct entities 137, 148. A
higher intensity and frequency of binge eating has been shown to be associated
with more co-morbid symptoms and more distress 85, 135, why it has been
suggested that binge eating should be assessed as a continuous symptoms.
Large amounts criterion and subjective binge eating
The DSM-IV definition of binge eating 5 states that the amount of food eaten in a
binge eating episode should be definitely larger than most people would eat in a
similar period of time under similar circumstances, while experiencing a lack of
control over eating. Research has failed to show any differences between those
having subjective or objective binge eating episodes 98, 148, why the feelings of loss
of control instead have been emphasized. Feelings of loss of control have been
known to be closely associated with psychological distress 23. Together with
difficulties in operationalizing what should be considered as a large amount 137,
this has led researchers to focus on the loss of control, over eating both
objectively or subjectively large amounts of food 22, 88, 105, 106, 137. A binge eating
definition that also includes subjectively large amounts of food is also of great
importance in the assessments of binge eating after bariatric treatment 91, when
large amounts of food can no longer be eaten. In accordance to this, the limited
time of approximately two hours for a binge eating episode has also been
criticized for not being empirically based 85, 137. This two hour limit, for example,
fails to include grazing 22, 106 (eating small amounts continuously while feeling a
loss of control) as a binge eating behaviour.
20 I joakim de man lapidoth Binge Eating and Obesity Treatment
Shape and weight concern
Almost half of all patients with BED have a tendency to evaluate self-worth in
terms of weight and shape, which has been shown to be an indicator of disease in
BED patients 89, 99. Shape and weight concern has therefore been suggested to be
included as a core feature of BED 54, 83, 99, 100, 115, 137, 139. According to Wilfley and
colleagues 137 an inclusion of weight and shape concerns instead of the associated
features and “marked distress”, is motivated to simplify the BED diagnosis and
bring it in line with AN and BN 5.
BED vs. EDNOS
As shown above, diagnostic shortcomings have been found in the preliminary
BED diagnosis. Fichter and colleagues 43 described that BED has been used with
two different definitions, one through the BED research criteria, and the other
through the general EDNOS-criteria. The difference between these alternatives is
mainly that EDNOS does not require “marked distress” to be present, which the
BED-criteria does. This means that using the EDNOS-definition (without adding
the criterion of “marked distress”) increases the probability that milder cases of
binge eating are included in the sample 43, 85. Fichter and colleagues 43 reported that
those that also indicated “marked distress” did not do as well over time as those
without distress, and that these BED patients emerge as having severe disorders
that are comparable in severity to BN.
Instruments for assessing eating behaviour in weight loss treatments
In addition to the above described difficulties in defining binge eating and eating
disorders in weight loss treatment samples, a large number of different
instruments have been used that may account for some of the variations that have
been found in previous research. During the last decades eating disorders and
binge eating in weight loss treatments have been assessed with a large number of
different questionnaires such as; Bulimic Investigatory Test, Edinburgh (BITE 59);
Binge Eating Scale (BES 51), Three Factor Eating Questionnaire (TFEQ 118) Eating
Disorder Inventory (EDI 47) Questionnaire of Eating and Weight Patterns-R
(QEWP-R 114) and the Eating disorder Examination-Questionnaire (EDE-Q 12). It
has been shown that the use of different instruments can generate different
estimates within the same patient group, and that rates of disorders are reported
to be lower when using a structured diagnostic interview and formal criteria,
compared to when unstructured clinical interviews or self-report measures are
used 37. In general, interviews are considered to be the most valid method of
assessment of eating disorders 66, but in weight loss treatments settings
assessments are commonly done by self-reported questionnaires 40, despite their
questionable validity 35, 40, 53, 66.
In summary, research has established that binge eating and eating disorders are
common in weight loss treatments. In spite of the efforts to describe the clinically
important associations between eating disorders/binge eating and treatment
outcome, methodological variations and diagnostic difficulties have led to
inconclusive results, which has failed to provide sufficient scientific support for
how eating disorders and binge eating is associated to weight loss treatment
outcome 91, 105, 124.
Binge Eating and Obesity Treatment joakim de man lapidoth I 21
AIMS
The overall aim of this thesis has been to study eating disorders and binge eating
in weight loss treatments, and the association of binge eating to weight loss
treatment outcome. The specific aims in the four articles of the thesis are presented
below.
Study I
The aim of Study I was to estimate the prevalence of eating disorders and
symptoms of binge eating among obese men and women seeking non-surgical
weight-loss treatment in Sweden. A secondary aim was to delineate the possible
differences between 1) Eating Disordered, 2) Binge Eaters and 3) Non Binge
Eaters, regarding co-morbid psychopathology, health related quality of life and
anthropometric data.
Study II
The aim of Study II was to assess the psychometric properties of the Eating
Disorders in Obesity (EDO) questionnaire, by comparing it with assessments of
binge eating and eating disorders made with the interviewer-based Eating
Disorder Examination (EDE).
Study III
The main aim of Study III was to investigate whether there was a difference
between patients allocated to surgical compared to non-surgical weight loss
treatment, regarding eating disorder diagnoses and binge eating as a symptom. A
secondary aim was to investigate whether there were any group differences
regarding general psychopathology and Health Related Quality of Life.
Study IV
The objective of the present study was to investigate the long-term associations
between binge eating and outcome in bariatric surgery. Our specific research
questions were:
a) Is pre- or post-treatment binge eating associated with long-term weight loss?
b) Is post-treatment binge eating associated with long-term health related quality
of life and general psychopathology?
Binge Eating and Obesity Treatment joakim de man lapidoth I 23
METHODS AND MATERIALS
The studies in this thesis were based on material from two separate groups of
weight loss treatment patients. Study I was based on a group of behavioural2
weight loss treatment applicants that were studied cross-sectionally. Studies II-IV
were all based on a cohort of 252 behavioural and surgical weight loss treatment
patients that were included within the same project, and followed longitudinally
from pre-treatment to three years after weight loss treatment. A methodological
overview of the four studies is presented below in Table 1.
Table 1. Overview of the papers presented in this thesis
Study
I
Participants
Design
Instruments (and points of measurement)
n=194, from one
behavioural weight
loss treatment unit
Crosssectional
Self-report questionnaires:
-Eating disorders & binge eating = SEDs (pre)
-Psychopathology = CPRS-S-A (pre)
-HRQL = SF-36 (pre)
II
n=97, from one
surgical and one
behavioural weight
loss treatment unit*
Crosssectional
Semi-structured interview:
-Eating disorders & binge eating = EDE (pre)
Self-report questionnaires:
-Eating disorders & binge eating = EDO (pre)
III
n=100, from one
surgical and one
behavioural weight
loss treatment unit*
Crosssectional
Self-report questionnaires:
-Eating disorders & binge eating = EDO (pre)
-Psychopathology = CPRS-S-A (pre)
IV
n=130, from four
surgical weight loss
treatment units*
3-year
follow-up
Self-report questionnaires:
-Binge eating = EDO (pre)
-Binge eating = EDE-Q (post)
-Psychopathology = CPRS-S-A (pre & post)
-HRQL = SF-36 (pre & post)
*See Figure 1, Flow-chart
Participants
The participants of Study I were 194 behavioural weight loss treatment
applicants, 131 females and 63 males. The mean age of these participants was
46.8 years (SD=12.9). Participants had a mean Body Mass Index (BMI) of 39.8
kg/m2 (SD=5.8) and mean waist-hip ratio (WHR=waist circumference/hip
circumference) of 0.96 (SD=0.09).
2
Behavioural treatments were described as non-surgical treatments in studies I, II and III.
Binge Eating and Obesity Treatment joakim de man lapidoth I 25
Figure 1 shows an overview of the three different sub-samples that constituted the
participants of Studies II, III, and IV. These participants had all been accepted for
weight loss treatment at either of the four surgical and the only behavioural
weight loss clinics. Participants of the cohort were assessed longitudinally, from
before treatment to three years after treatment. The participation from each clinic
was different in the three studies. The reason for these differences were that not all
participants in the long-term cohort were interviewed in Study II, and not all
surgical treatment participants in the long-term cohort received treatment in time
for being included in the long-term follow-up of Study IV.
Figure 1. Flow-chart showing the inclusions of participants from the five weight loss
treatment units (n=252), to studies II, III and IV, and dropouts of each study.
Behavioural
Treatment
n=52
Dropout
n=28
Study 2
n=125
25
Surgical
Treatment
(A) n=57
39
23
19
Dropout
n=9
19
Surgical
Treatment
(B) n=65
52
57
Surgical
Treatment
(C) n=33
Study 3
n=109
Study 3
n=100
52
Dropout
n=43
48
29
Surgical
Treatment
(D) n=45
Study 2
n=97
44
Study 4
n=173
Study 4
n=130
The participants of Study II were 97 surgical and non-surgical/behavioural weight
loss treatment patients (70 women and 27 men) from all five weight loss clinics in
the cohort above. Out of these 97 participants, 48 were included for confirming
the binge eating definition presented in the EDO (see the appendix 1 of Study II)
while 49 denied fulfilling the criteria of the definition. Twenty of the participants
(five men) were included at the non-surgical/behavioural clinic and 77 (15 men) at
the surgical weight loss clinics. The mean age of the participants was 41.1 years
(SD=10.6), ranging from 19 to 62 years. Mean BMI was 44.2 kg/m2 (SD=7.7)
ranging from 31.0 to 76.8 kg/m2.
26 I joakim de man lapidoth Binge Eating and Obesity Treatment
The participants of Study III consisted of 100 patients from the only nonsurgical/behavioural weight loss clinic (n=46) and one of the surgical (n=54)
clinics (clinic A in Figure 1). Of the 100 participants 28 were men. Thirteen of the
men applied for surgical treatment and 15 for non-surgical/behavioural weight
loss treatment. Participants had a mean age of 42.6 years (SD=10.8) and a mean
BMI of 43.3 kg/m2 (SD=6.2).
Participants of Study IV were 130 bariatric surgery patients from the four
surgical clinics (clinics A, B, C, and D in Figure 1 above) in the cohort. These
participants were followed from before treatment to three years after treatment.
When included, these participants were on an average 40.6 years old (SD=9.2)
with a mean BMI of 45.8 kg/m2 (SD=6.7). Twenty-eight (21.5%) of the
participants were male. The surgical procedures performed were 100 Gastric
Bypass (76.9%), 18 Gastric Banding (13.8%), seven Vertical Banded Gastroplasty
(5.4%) and five Biliopancreatic Diversion with Duodenal Switch (3.8%).
Instruments
Survey of Eating Disorders (SEDs), short version
The SEDs was used in Study I for measuring self-reported eating disorder
symptoms 48. The questionnaire is based on the DSM-criteria, and was adjusted,
with the purpose of detecting eating disorder symptoms in patients seeking
weight-loss treatment. Questions referring only to issues of underweight were
excluded, leading to a total of 11 questions. The SEDs has been shown to have
high sensitivity and high positive predictive value 48.
Short Form – 36 (SF-36)
The SF-36 is a well-validated self-reporting questionnaire 120 that was used in
Studies I, III and IV to measure Health Related Quality of Life (HRQL). The SF36 consists of eight dimensions, ranging from mainly physical to mainly
psychological; Physical Functioning (PF), Role-Physical (RP), Bodily Pain (BP),
General Health (GH), Vitality (VT), Social Functioning (SF), Role-emotional (RE)
and Mental Health (MH). The sum of the SF-36 item scores within each
dimension is transformed into a scale ranging from 0 (poor health) to 100 (good
health). The good psychometric properties of the SF-36 have been repeatedly
been confirmed 95, 119, 121.
Comprehensive Psychopathological Rating Scale – Self-rating scale
for Affective Syndromes (CPRS-S-A)
The CPRS-S-A was used in Studies I, III and IV for measuring self-reported
psychopathology in three scales and a total score. A total of 19 items are given a
score of 0-3, leading to a score for each of the three scales (depression, anxiety
and obsessive-compulsive symptoms) as well as a total score. The CPRS-S-A was
constructed by re-phrasing the items from the interview-based Comprehensive
Psychopathological Rating Scale (CPRS), covering depression, anxiety and
obsessive-compulsive symptoms. The depression and anxiety scales show a high
degree of concordance with the interview-based CPRS rating 122.
Binge Eating and Obesity Treatment joakim de man lapidoth I 27
Eating Disorders in Obesity (EDO, see appendix 1 in Study II)
The EDO is a short self-reporting questionnaire that was constructed from the
SEDs 48 to be used for assessing the full range of eating disorders and binge
eating in the studies of this thesis. The questionnaire was constructed to be used
in the specific group of obese patients why questions that refer to states of
underweight were excluded. Some modifications of the diagnostic segments of the
SEDs were also done to avoid ambiguities that were found in some questions.
The psychometric properties of the EDO were studied in Study II. The EDO was
also used in Studies III and IV to assess pre-treatment binge eating (and eating
disorders in Study III), according to DSM-IV criteria. Binge eating is explicitly
defined in the questionnaire in accordance to the DSM-IV definition.
Eating Disorder Examination (EDE)
The EDE 40 was used in Study II to assess binge eating and eating disorders in
bariatric weight loss treatment patients before bariatric surgery. The EDE is an
interview-based assessment that is considered to be the “gold standard” for the
assessment of eating disorders. The interview requires an interviewer with good
knowledge of eating disorders. In this study only the diagnostic questions of the
EDE were used, and questions that only refer to the diagnosis of AN were
excluded. Questions about the associated features of BED that are described in
the DSM-IV were added to the interview, in accordance to the DSM-IV criteria 5.
Eating Disorder Examination-Questionnaire (EDE-Q)
The EDE-Q 12 is a 36-item self-report measure that was used in Study IV to assess
binge eating after weight loss surgery. The EDE-Q was derived from the Eating
Disorder Examination Interview and assesses the specific psychopathology of
eating disorders over the previous 28 days. Several forms of overeating are
assessed by the EDE-Q in accordance with the DSM-IV definition; objective binge
episodes, subjective binge episodes and objective overeating. Research supports
the validity of the EDE-Q in the assessment of binge eating 88, 90.
Procedure
In Study I all participants were asked to fill out the self-report questionnaires
SEDs, CPRS-S-A and SF-36, as a part of the routine clinical assessment of
behavioural weight loss treatment applicants. The SEDs was used for measuring
both eating disorders and binge eating pre-treatment.
In Studies II, III, and IV, all patients that accepted to participate in this long-term
study were assessed regarding pre-treatment binge eating, by completing the
EDO. In Studies II and III also pre-treatment eating disorders were assessed by
the EDO. All participants were also asked to complete the CPRS-S-A and SF-36
at home and return these questionnaires before treatment. Participants were
assessed at inclusion and three years after treatment, regarding eating behaviour,
HRQL and psychopathology. Specific procedures of the three studies are
described below.
In Study II the participants of the long-term cohort were asked about also
participating in an interview study, where results from the self-reported EDO-
28 I joakim de man lapidoth Binge Eating and Obesity Treatment
questionnaire and the EDE interview were compared regarding eating disorders
and binge eating. The EDO was also completed once again for test-retest
purposes. The interview and EDO-retest were completed approximately two
weeks after inclusion. The interviews took 20 to 60 minutes, and were conducted
by either of two interviewers, at the weight loss clinic, or at a suitable location of
the patient’s choice.
In Study III pre-treatment eating disorders and binge eating (EDO) were
compared between surgical and behavioural weight loss treatment participants.
Also differences in HRQL (SF-36) and psychopathology (CPRS-S-A) were
compared between the treatment groups.
In Study IV, pre-treatment binge eating was assessed with the EDO. Posttreatment binge eating (EDE-Q), psychopathology (CPRS-S-A) and HRQL (SF36), were assessed by sending these questionnaires to all participants three years
after surgical weight loss treatment. At this time participants were also sent
structured follow-up questions asking the patients for their self-reported weight.
Those not returning the questionnaires of the three-year follow-up where
reminded two to five months after the three-year follow-up, and were at that time
also sent the EDE-Q and the structured follow-up questions again.
Definitions
Eating disorders and binge eating
In Study I binge eating was present in participants that reported repeated episodes
of eating objectively large amounts of food while feeling out of control over eating
(during the last three months), without fulfilling all criteria for an eating disorder
diagnosis (see appendix A).
An eating disorder was present in those that fulfilled strict DSM criteria 5 for BN,
the Oxford criteria for BED (requiring a minimum of one binge eating episode
per week for the last three months), or EDNOS. In EDNOS, a minimum
requirement of binge eating was set at once monthly during the last three
months, while indicating marked distress.
In Studies II, III and IV, pre-treatment binge eating, according to the EDO, was
present in participants that confirmed the DSM binge eating definition that was
presented in the EDO, but who also confirmed eating objectively large amounts of
food, and feeling out of control over eating in two additional questions.
An eating disorder (according to the EDO) was present in Studies II and III, if
strict DSM criteria for BN or BED were met pre-treatment. In Study III, those
fulfilling the Oxford definition of BED (binging at least once per week during the
last three months) were also classified as BED, while these participants were
classified as EDNOS in Study II. Both these definitions therefore classified these
participants as eating disordered, but through either the diagnosis of BED or
EDNOS. In Study II the minimum requirement for an EDNOS diagnosis was set
at binging at least once a week during the last three months. Study III required
EDNOS participant to binge only once every month during the last three months,
but also required these participant to indicate marked distress.
Binge Eating and Obesity Treatment joakim de man lapidoth I 29
In Study IV subjective and objective binge eating after bariatric treatment was also
assessed. This was done by means of the EDE-Q. Subjective binge eating
participants were required to indicate feelings of loss of control over eating either
objectively or subjectively large amounts of food during the last 28 days.
Body Mass Index
In all four studies calculations of pre-treatment Body Mass Index (BMI=weight/
length2 (kg/m2)) were obtained through length and weight that were extracted
from patient records.
In Study IV BMI three years after treatment was calculated through length from
patient records, and weight mainly through self-reporting data from the 3-year
follow-up questions. The choice of deviating from the original plans of using only
clinical data was based on the insufficient number of clinical data that were found
one year after treatment. Self-reported data were complemented by data from
patient records for increased statistical power. Mixing these data was shown not
to affect results significantly.
A nalyses
Statistix, version 8, was used to analyse data in all four studies. An alpha level of
p<0.05 was considered as significant throughout these studies.
In Study I differences between the three eating behaviour groups, regarding comorbid Psychopathology, Body Mass Index, Waist-Hip Ratio and Age were
analysed using the one-way ANOVA. Subsequent to the ANOVAs, post-hoc tests
were conducted with Tukey’s multiple comparison procedure. For categorical
comparisons regarding sex, marital status and occupation Chi-square tests was
used. HRQL (SF-36) was analysed by the non-parametrical tests, Kruskal-Wallis
and Mann-Whitney, as the three groups showed unequal variances, different
sample sizes, and a number of outliers.
In Study II, validity and reliability of the EDO were tested using Cohen’s Kappa.
For group comparisons of categorical data (sex, occurrence and non-occurrence
of eating disorders and binge eating), Chi-square tests were used. Group
comparisons of continuous data (level of obesity and age) were analyzed by
means of the Student’s t-test. Because of small sample sizes Chi-square tests of the
differences between men and women in the classifications of eating disorders and
binge eating (EDE vs. EDO, and EDO vs. EDO-retest) were performed to address
the sex issue, instead of doing separate analyses for men and women.
In Study III, possible group differences of sex and eating pathology were analysed
by Chi-square. Differences in age and level of obesity were tested by means of the
student’s t-test. The Mann-Whitney test was used for analyzing CPRS-S-A and
SF-36 scales, as they were found to have unequal distributions with a number of
outliers, also including the corresponding effect sizes measured by Cohen’s d. In
analyzing the results of group differences in SF-36, Bonferroni-Holms method
was used for a statistical correction for multiple testing.
30 I joakim de man lapidoth Binge Eating and Obesity Treatment
As data did not meet requirements for running parametric data, the KruskalWallis test was used to compare the CPRS-S-A-scores in three equally large BMI
strata. To investigate whether differences between treatment groups regarding
CPRS-S-A were associated with differences in the occurrence of eating disorders,
the three treatment groups were compared again after excluding the participants
with eating disorders, and these result was compared with the one including the
participant with eating disorders.
The association between eating disorders and level of obesity was investigated by
comparing mean scores of BMI in the three eating disorder group, by means of
the one way ANOVA. For the post-hoc comparison Tukey’s test was used.
In Study IV the overall changes in BMI, pre-to post-treatment, were analysed by
paired t-test.
Differences in post-treatment BMI, between those with or without objective binge
eating (before or after treatment), and with or without subjective binge eating
after bariatric surgery, were analysed by means of ANCOVA, with the
corresponding effect sizes measured by Cohen’s d. In these analyses pre-treatment
BMI was used as a covariate.
Differences in long-term HRQL and psychopathology were compared between
those with and without subjective binge eating by means of ANCOVA, with the
corresponding effect sizes measured by Cohen’s d. Pre-treatment scores were used
as covariates.
Besides the main sample of 130 participants, two different sub-samples were used
in the different analyses, due to the accumulated dropout from each measure. In
each of these sub-samples, comparisons between those analysed and those not
analysed were done by means of student’s t-test for continuous data (BMI and
age) and by Chi-square for categorical data (eating disorders, binge eating, and
sex).
Ethical considerations
The sample in Study I consisted of a clinical population that was studied using the
standard clinical instruments and routines that were used at the clinic at that time.
The participants had previously signed a consent form, stating that their
treatment data could be used for research purposes. Participants had been
informed verbally as well as in writing about research confidentiality, and that
their participation in research was strictly voluntary.
Participants in Studies II, III and IV were all recruited within the same research
project. The project was approved by the appropriate ethical committees. All
participants were informed verbally as well as in writing about confidentiality,
that participation was strictly voluntary, and that failure to participate would not
affect the treatment decisions.
Binge Eating and Obesity Treatment joakim de man lapidoth I 31
RESULTS
The results of each of the four studies are briefly presented below.
Study I: Eating disorders and disordered eating among patients seeking non-surgical
weight-loss treatment in Sweden
No differences were found between the three eating behaviour groups (Eating
Disorders (ED), Binge Eating (BE), Non Binge Eating (NBE)), regarding sex,
marital status, occupation, age, Body Mass Index or Waist-Hip Ratio. Of the total
sample, 9.8% were classified as ED. Of these ED participants, 52.6% were
classified as BED, but this rate increased to 73.9% (while the rate of EDNOS
decreased) if the Oxford criterion for BED was used instead. In addition to the ED
participants, 7.2% reported binge eating (BE) (without fulfilling eating disorder
criteria) which indicated that, in total, 17.0% had symptoms of binge eating.
Differences between the three groups regarding psychopathology (CPRS-S-A) and
HRQL (SF-36) are shown in Table 2 below.
Table 2
Significant differences (p<0.05) between the eating behavior
groups, regarding the CPRS-S-A and SF-36 subscales.
NBE<ED*
NBE<BE*
BE<ED*
CPRS-S-A
Total
X
X
Dep
X
X
Anx
X
X
OCD
X
X
SF-36
NBE>ED*
NBE>BE*
BE>ED*
PF
RP
X
BP
X
X
GH
VT
X
SF
X
X
X
RE
X
X
MH
X
X
*In the CPRS-S-A more psychopathology is indicated by higher
scores, while higher scores in the SF-36 indicate better HRQL
Study II: Psychometric properties of the Eating Disorders in Obesity questionnaire:
validating against the Eating Disorder Examination interview
Validity and reliability of the EDO was tested for assessments of both eating
disorders and binge eating as a distinct symptom. Validity was measured as the
concordance between the self-reported EDO questionnaire and the EDE-interview.
Binge Eating and Obesity Treatment joakim de man lapidoth I 33
This comparison indicated a good validity in the assessment of both eating
disorders (=0.67) and binge eating (=0.63).
Of the 48 participants that confirmed the binge eating definition in the first
question, 39 fulfilled criteria for binge eating according to the EDO. All eating
disordered participants according to the EDE (n=12), were a subgroup of these
39 participants. Results further show that none of the 49 participants that denied
fulfilling the binge eating definition, were subsequently classified as a binge eater
(or as eating disordered) by the EDE.
The test-retest reliability of the EDO regarding assessments of eating disorders
(=0.65) and binge eating (=0.65) showed good agreements between the two
assessments.
Study III: A comparison of eating disorders among patients receiving surgical vs. nonsurgical weight loss treatments
Results indicated that there was a difference in eating related pathology between
the surgical and non-surgical weight loss treatment participants (2 (1)=6.4,
p=0.04). While binge eating was equally common in surgical (31.5%), and nonsurgical (30.4%) weight loss treatments, eating disorders were more common in
participants that were accepted for surgical weight loss treatment (18.5%),
compared to those accepted for non-surgical (4.3%) weight loss treatment (2
(1)=4.7, p=0.03).
Differences were shown between treatment groups, where surgical participants
had higher scores than the non-surgical participants, regarding all three CPRS-SA categories (depression, anxiety and obsessive-compulsive symptoms) as well as
the total scale. These differences were not associated with differences in the
occurrence of eating disorders or in differences in BMI. After correcting for
multiple testing, patients accepted for surgical weight loss treatment did not differ
in HRQL from the non-surgical patients.
Study IV: Binge eating in surgical weight-loss treatments – Long-term association
with weight loss, health related quality of life (HRQL), and psychopathology
Objective binge eating before bariatric surgery was indicated by 18.5% of the 130
participants. Participants who reported objective binge eating before bariatric
treatment did not differ from participants without these symptoms in regard to
long-term BMI after correcting for pre-treatment BMI.
Results further showed that 28.4% of the 102 participants that were analysed
regarding binge eating after bariatric surgery indicated subjective binge eating
episodes. There was no difference in BMI outcome between those with or without
subjective or objective binge eating after bariatric surgery. Subjective binge eating
after surgical treatment was associated to significantly more psychopathology and
lower HRQL post-treatment, than in those with no binge eating.
34 I joakim de man lapidoth Binge Eating and Obesity Treatment
Summary of the main findings
• Eating disorders and binge eating was common in patients that were
accepted for non-surgical/behavioural weight loss treatment.
• Eating disorders and binge eating before non-surgical/behavioural weight
loss treatment, was associated with lower pre-treatment HRQL and higher
pre-treatment psychopathology, than in those with no eating disorders or
binge eating.
• The EDO indicated good validity and reliability in the assessments of binge
eating and eating disorders before weight loss treatment.
• All those failing to agree with the presented binge eating definition,
confirmed in the interview that they had no symptoms of binge eating.
• Surgical weight loss treatment participants had more eating disorders
before treatment, than non-surgical/behavioural weight loss treatment
participants.
• The prevalence of binge eating as a symptom was equally common in
surgical and non-surgical/behavioural weight loss treatment participants.
• Surgical weight loss treatment participants displayed more co-morbid
psychopathology than non-surgical/behavioural weight loss treatment
participants.
• Objective binge eating was common before bariatric treatment, but this did
not predict the long-term BMI-outcome.
• Subjective binge eating was common after bariatric treatment, but this did
not predict the long-term BMI-outcome.
• Participants with subjective binge eating after bariatric treatment were
shown to have less successful long-term treatment outcome through
indicating more co-morbid psychopathology and lower HRQL than
participants without subjective binge eating.
Binge Eating and Obesity Treatment joakim de man lapidoth I 35
DISCUSSION
Since BED was introduced as a preliminary diagnose in the DSM, research in the
field of eating behaviour in weight loss treatments has increased considerably.
This research has indicated that BED could represent a meaningful category of the
eating disordered 16, 33, 137, 140. There is only limited empirical support for some of
the criteria in BED (e.g. the frequency and the duration criteria 88, 137, 148) why there
has perhaps been too much focus on the use of BED in weight loss treatment
settings 103. This focus has most likely limited research on other diagnostic aspects
than BED, therefore failing to adequately challenge, explore and further expand
knowledge, beyond this specific scope 137. After 15 years of eating disorder
research in weight loss treatments, there is still insufficient scientific support for
how binge eating and eating disordered patients are to be addressed and managed
in weight loss treatments.
Major findings
The prevalence of eating disorders and binge eating pre-treatment has been a
specific aim only in Study I, but the other three studies also confirm the
undisputed evidence that eating disorders and binge eating is highly prevalent in
patients before weight loss treatments 4, 25, 97, 100, 107. The rates of binge eating and
eating disorders that were displayed in Study I were lower than in many previous
studies 141 which could perhaps be explained by the EDO defining binge eating in
the questionnaire, and through this does not include other aspects of overeating
than objective binge eating. Of greater importance than the exact prevalence rates
though, are the issues of a more clinical concern, such as which the
implications/associations of these problems are, and if eating disorders or binge
eating is associated with treatment outcome. Of major interest in the search for
answers to these questions are also questions of how to relevantly define and
validly assess binge eating and eating disorders in weight loss treatment patients.
In Study I differences in prevalence rates were shown when using different
definitions of BED and eating disorders. The rate of BED was shown to increase
by almost 50% when the Oxford definition was used 24, instead of the strict
DSM-definition. When the focus of eating disorders was limited to strict BED,
almost 50% of all eating disordered participants were excluded. This shows the
importance of how eating disorders are defined. There is so far no empirical
support 6, 103 for using BED instead of the whole spectrum of eating disorder in
weight loss treatment settings. In the coming DSM-V the present categorical
approach to eating disorders (and BED) has been suggested to be replaced by a
more dimensional approach 137, 148. This approach would most likely help provide
more knowledge in the research area which may also help to develop future
guidelines of how binge eating in weight loss treatments is to be addressed.
There have been many previous attempts to predict long-term weight loss through
eating behaviour 18, 32, 77, 103, 111, 134. The results of these studies however, have been
most inconclusive 14, 15, 63, 74, 79, 103, 131, which has many to the conclusion that longterm weight loss may not be predicted through pre-treatment eating behaviour 91.
This was also confirmed through the results from Study IV, where no association
Binge Eating and Obesity Treatment joakim de man lapidoth I 37
between pre-treatment binge eating and long-term weight loss was shown. This
questions the procedure of excluding binge eating or eating disordered patients
from e.g. bariatric treatments, if this exclusion is based on a risk of less long-term
weight loss. Also patients with pre-treatment eating disorders or binge eating have
successful weight losses, and therefore have large health benefits from this
procedure 112. Being the most effective weight loss treatment, bariatric surgery will
lead to severe improvements of physical health for most binge eating patients.
Exclusions from treatments with such positive health effects should only be
motivated by indisputable evidence. There is no such evidence regarding the effect
on long-term weight loss today.
Considering data from Study IV, there may be reasons other than weight loss
outcome for why e.g. binge eating should be considered in weight loss treatments.
Addressing these issues throughout treatment may help to expand knowledge in
the area through collecting more information. This is most relevant in the specific
weight loss treatment research area, where many methodological shortcomings
have been reported 79, 91, 105. A pre-treatment assessment of binge eating and other
psychopathology may also be used in a discussion with the patient about possible
treatment options, and how to proceed with treatment considering these specific
comorbidities. Knowing that eating disorders and other psychopathological
problems are common, these symptoms should perhaps be addressed not as a
problem in treatment, but as one (of many) associated symptoms to consider in
the decisions about treatment. With an open clinical approach of finding the best
available treatment and optimal time for treatment (also considering
comorbidities) there is less risk of the patient concealing psychopathological
problems. This also gives the opportunity for the patient to discuss which of the
problems that the patient is most motivated to address, and with which approach.
This open dialogue will most likely lead to more motivated patients who expect to
receive help in accordance with their needs.
The previously reported negative changes in eating pathology in weight loss
treatments 28, 108, 109 provide good reasons for assessing these issues from pretreatment and continuously in treatment. In Study IV binge eating after bariatric
surgery was shown to be common, and also to be associated to low HRQL and
high psychopathology. Thus evidence shows that the commonly reported success
of bariatric surgery on a wide range of outcome measures 112, can be questioned in
patients that indicate binge eating post-treatment. In contrast to Hsu et al. 63 these
binge eating participants were not shown to have less successful weight loss
outcome. Even if there are few long-term studies, binge eating post-treatment has
in one study been shown to be associated to weight gain beyond three years 86. We
can therefore speculate whether the low quality of life and high psychopathology
that was found in Study IV indicates a risk for future weight regain beyond three
years. Perhaps the time span of three years that was used in Study IV was too
short for getting a good picture of possible post-bariatric changes regarding binge
eating psychopathology and weight loss. For this reason not only weight loss, but
also other measures of outcome are needed to help establish what should be
considered to be positive outcome.
38 I joakim de man lapidoth Binge Eating and Obesity Treatment
In Study IV, the EDO-questionnaire that was used pre-treatment was exchanged
for the EDE-Q in the post-treatment assessments. Through this change of
questionnaire, pre- and post-treatment binge eating was unfortunately not
possible to compare by sufficiently valid measures. Considering that both
instruments are DSM-based and both assess binge eating in a similar manner, an
investigation pre- to post-treatment changes still managed to provide some
indication of possible changes. Most prominent was that only approximately
20% of the post-treatment binge eaters indicated binge eating pre-treatment and
that only one third of the pre-treatment binge eaters reported binge eating
problems post-treatment. Despite the large uncertainty of these data, results can at
the least indicate that some of the patients who binge eat after bariatric treatment,
have not done so previously. Previous studies have shown post-treatment binge
eating to be associated to pre-treatment eating behaviour 63, 86, but results from
Study IV show that this conclusion can be questioned. In these studies only regain
of binge eating, and remaining binge eating was assessed. Study IV indicates that
there are patients that binge eat after, but not before weight loss treatments, why
also these patients should be included in an analysis of long-term weight losses.
For more conclusive results this must be further studied with adequate methods.
Clinical considerations
In some surgical weight loss clinics, eating disorders are explicitly stated as
something that excludes patients from treatment. Therefore it is considered that
weight loss applicants may minimize their eating problems prior to surgery,
because they want to be approved for this procedure 49. This is probably true in a
setting where no treatment alternatives are offered, and when binge eating and
other psychopathology are assessed to investigate if treatment applicants fulfill the
inclusion criteria. My experience from a large number of interviews for Study II is
that these patients honestly reveal binge eating and other psychopathology when
this information will not affect whether treatment is offered or not. If the goal of
the assessment instead was to inquire how this patient can be helped, the issues of
binge eating and other psychopathology could most likely be explored openly.
Such an open approach could help the clinic and patient to decide whether this
treatment targets the patients´ most essential problems (such as obesity, binge
eating or perhaps depression), and if these problems should be addressed in e.g.
psychiatric treatment. This open approach towards psychopathology may be
difficult to carry out though, through the lack of psychiatric expertise in most
Swedish weight loss clinics. During the last decades bariatric surgery has gained
large positive attention in Sweden for its good weight loss and its associated
improvements in somatic health and HRQL. This has led to long waiting lists for
receiving publicly financed bariatric treatments, why an increased focus on
psychiatric and psychosocial aspects of bariatric surgery may perhaps not be
prioritized.
An important concern when eating behaviours in weight loss programs are
studied, is having a long-term approach that can assess changes in both
psychopathology and weight 63. In spite of the convincing support for a long-term
approach in clinical treatment and research, many outcome studies have a followup duration of twelve months or less 61, 102, 123, 142. The long-term approach is also
important if one wants to learn more about which participants drop out of
Binge Eating and Obesity Treatment joakim de man lapidoth I 39
treatment, and out of research. A long-term study is difficult to carry out though,
which was shown in the long-term analyses of participants in the cohort, where
only a relatively low number of surgical participants attended follow-up according
to the treatment plan. Unpublished results of the follow-up of behavioural weight
loss treatment participants in the large cohort shows that less than 50% of the 52
non-surgical behavioural participants had completed the two-year weight loss
program. This emphasizes the importance of having a long-term focus that can
report temporal changes in several measures, but that also considers those that
drop out of treatment.
Diagnostic and methodological considerations
In the effort to learn more about how eating behaviour is associated to outcome
in weight loss treatments 137 a wide definition of eating disturbance has been used
in the studies of this thesis; all eating disorders as well as binge eating symptoms.
The strict DSM-classifications of BED has been questioned, why the Oxford
definition (that was used in Studies I and III) of BED has been promoted in
research. As shown above, there are perhaps reasons for not assessing these
features as dimensional at all, but as continuous. Also in the specific area of
assessing binge eating after bariatric treatment, the strict DSM-based definition of
binge eating has been questioned. Research has revealed problems in defining
binge eating as objectively large, and suggestions have been presented of how
binge eating after bariatric treatment should be assessed.
In spite of the critique raised regarding eating disorder diagnostics, strict DSMbased definitions were used in validating the EDO (in Study II). The main
differences this brought, compared to Study I and III, was mainly that less cases of
BED were found when the strict definition of BED was used. Many of the
potential BED cases (those fulfilling the Oxford, but not full BED definition)
though were classified as eating disordered, through the diagnosis of EDNOS.
There was a difference in regard to how EDNOS was classified though. While the
classification of EDNOS in Study II relied on a binge eating frequency of once per
week, Study III required a frequency of only once per months but also that
“marked distress” should be present. During the last decade studies have
suggested that “shape and weight concern”, should be included in the BED
criteria (instead of “marked distress”) 54, 83, 99, 100, 115, 137, 139. This could perhaps be
used as a requirement for all eating disordered patients (also for EDNOS), to
include some degree of severity as a diagnostic requirement, like in AN and BN 5.
A general shortcoming in the research area is that a large number of different
instruments and assessment methods have been used over the years 37, 79, 91, 105. In
these assessments, a variety of methods have been used, from clinical standardised
interviews to self-made, un-validated self-reporting instrument, that have
measured a wide span of different symptoms, using different definitions. As
previously shown this diversity can produce different estimates in otherwise
comparable samples 37, and makes comparisons difficult. To address the problem
of this diversity the EDO was developed and validated in Study II. The EDO was
found to have reliability and good concurrent validity in assessments of both
binge eating and eating disorders pre-treatment. The overestimation of prevalence
rates that previously has been shown in self-reported measures 47, 146, was not
40 I joakim de man lapidoth Binge Eating and Obesity Treatment
reported when using the EDO. An explanation to this may be that the binge
eating definition is explicitly defined in the questionnaire, and that objectively
large amounts and loss of control is further confirmed in separate questions. This
has helped to discriminate between different forms of overeating and thus helped
to avoid false-positive results 96, 143. Results from more recent research 23, 91, 106
have provided results that questions the use of EDO (and other instruments that
make use of the objective binge eating definition) in post-bariatric samples. To
address this, changes could perhaps be made to the EDO by defining binge eating
as eating large (not objectively large) amounts of food while feeling out of control,
with separate indications of subjective and objective large amounts. In this way
more can be learned about these symptoms, not only post-, but perhaps also pretreatment. Recent research 22 have also showed reports of grazing and
uncontrolled eating before bariatric treatment (i.e. subjective binge eating). The
importance of pre-treatment subjective eating can be questioned through Study II
though. There it was shown that only one participant (out of 97) indicated
subjective binge eating pre-treatment in the EDE, and that this participant
indicated objective as well as subjective binge eating in the EDO.
Research considerations and future research
From this thesis there are at least three main issues of importance to address in
future research of eating behaviour in weight loss treatment settings. First is the
question if and how eating pathology changes over time in weight loss treatments.
For valid assessments of these changes, diagnostic interviews are most likely
required to assess all kinds of overeating, and to be able to address these issues
more precisely. The influence of possible changes in psychopathology is also of
major importance in future studies, as binge eating and psychopathology
commonly occur together and seem to shift in regard to when, and perhaps what
treatment is received. For a proper investigation of these issues a longitudinal
study (of at least three years) is required, that continuously can monitor temporal
changes in weight, eating behaviour and psychopathology.
In addition to this, information is insufficient about other measures of outcome
(than weight) in weight loss treatments. In Study IV both psychopathology and
HRQL were used as outcome measures, but due to dropout, the conclusions were
drawn from results of relatively small samples. Beyond the scope of this thesis,
data from the large cohort (of 252 participants) will be used for examining
outcome in relation to psychopathology and HRQL.
A third point of importance for future research is the difficult question of how
obese binge eaters should be treated for their obesity, for their eating disorder or
for a combination of these. There is little evidence that successful treatment of
binge eating brings about significant weight loss 85. We here also show that
successful treatment for weight loss most likely does not lead to long-term
improvements in binge eating (Study IV). There is also limited evidence to suggest
that specific eating disorder approaches are superior, or significantly add to
outcome of standard weight control approaches 85.
Binge Eating and Obesity Treatment joakim de man lapidoth I 41
Strengths
A strength of the studies in this thesis is the clinical and naturalistic approach,
where eating behaviour was studied in the current practice of weight loss clinics in
Sweden. This was a reflection of the every-day clinical practice where all different
types of weight loss treatment patients were included. By including patients that
already were accepted for treatment the patients were also more likely to admit to
behaviours that, if revealed before the treatment decision, may have excluded
them from treatment. A strength was also that the participants of Study IV were
studied prospectively and long-term, which allowed the assessment of long-term
changes in weight, HRQL and psychopathology.
The wider scope of eating behaviours that was assessed, compared to studies that
only have assessed BED, is a strength of the studies in this thesis. In the
assessments of Studies I, II and III, both eating disorders and binge eating as a
symptom have been assessed, while only binge eating was assessed in Study IV.
This wider scope has perhaps made comparisons to other studies more difficult,
but this approach was chosen in response to empirical data. The inclusion of
subjective binge eating in the definition of binge eating after bariatric treatment is
also supported by previous research data.
Data is inconclusive regarding the association of binge eating to outcome in
weight loss treatments. In Study IV, besides weight and eating behaviour, also
measures of HRQL and psychopathology have been included, which has given a
more complete picture of weight loss outcome in weight loss treatment patients.
Limitations
One of the shortcomings in three of the four studies (Study I, III, and IV) of this
thesis is the reliance on self-report measures for assessing eating pathology (EDO
and EDE-Q). This is a shortcoming of all self-reported questionnaires that also
was a motivation to develop the EDO and to investigate the psychometric
properties of the questionnaire. Self-reporting measures have previously been
shown to overestimate the numbers of binge eaters, compared to interviews 53, 138.
The validation of the EDO though showed no such overestimation. Also selfreporting measures were used in the assessment of long-term BMI in Study IV. It
is known that self-reported weight differs from clinically assessed weight 92, but
this possible difference was shown to be of no major importance for the results of
the analyses of weight data.
As described above, two different self-rating instruments of eating disorder
symptoms were used for assessing pre- (EDO) or post-treatment binge eating
(EDE-Q). The EDO was exchanged for the EDE-Q in the post-bariatric follow-up,
in response to the documented importance of also including subjective binge
eating in assessments of binge eating after bariatric treatment. This change of
instrument has made pre- and post-treatment comparisons difficult, but has most
likely increased the validity of the post-bariatric assessments. Some preliminary
and most careful conclusions have been drawn from a comparison pre-to posttreatment, but these data must be interpreted with caution.
42 I joakim de man lapidoth Binge Eating and Obesity Treatment
The third limitation to be addressed is the small sample sizes of some of the
analyses. In spite of a large cohort of 252 participants being included in the
sample (in studies II, III, and IV), many of these participants never started the
assigned weight loss treatment, or dropped out of (behavioural) treatment. There
has also been drop-out of research data, which was most evident in the long-term
follow-up when several measures are assessed together. The drop-out analyses
have shown no differences between those analysed and those excluded, but small
samples lead to a loss of statistical power and cause uncertainty regarding how
representative the remaining sample.
Binge Eating and Obesity Treatment joakim de man lapidoth I 43
CONCLUSIONS
Eating disorders and binge eating is common in patients that are enrolled in both
surgical and behavioural/non-surgical weight loss treatments. These patients
display higher psychopathology and lower HRQL than patients without eating
disorders or binge eating. The rates of these eating disturbances depend on how
they are defined, but results show that also sub-clinical binge eaters show high
psychopathology and low HRQL, why also these patients should be considered in
weight loss research and practice.
The Eating Disorder in Obesity questionnaire was shown to indicate good
concurrent validity and good reliability in the assessments of binge eating and
eating disorders before weight loss treatment. In contrast to many self-reporting
questionnaires the rate of binge eating and eating disorders was not overestimated
by the EDO. The EDO can be used as a first preliminary assessment of binge
eating in weight loss treatment, as it was shown that all patients that were
identified as binge eaters by the EDE confirmed the binge eating classification in
the EDO.
Approximately 30% of both surgical and non-surgical weight loss treatment
participants indicated symptoms of binge eating before treatment. Surgical weight
loss treatment participants were shown to have significantly more eating disorders
and co-morbid psychopathology than non-surgical/behavioural weight loss
treatment participants before treatment.
Objective binge eating was shown to be common before bariatric surgery, but did
not predict the degree of long-term (three-year) BMI-outcome. Also subjective
binge eating after bariatric surgery was common and failed to predict long-term
BMI-outcome. In spite of an average weight loss that was comparable to those
with no binge eating, participants with binge eating after bariatric surgery had less
successful treatment outcome in terms of co-morbid psychopathology and
HRQL.
Results show that binge eating is common in both surgical and nonsurgical/behavioural weight loss treatments, and that binge eating after bariatric
treatment has a negative impact on long-term quality of life and psychological
well-being. This shows that binge eating should be assessed within the context of
weight loss treatments.
Binge Eating and Obesity Treatment joakim de man lapidoth I 45
SAMMANFATTNING PÅ SVENSKA (SUMMARY IN SWEDISH)
Under de senaste decennierna har förekomsten av fetma och övervikt ökat i
Sverige liksom i övriga världen. Utöver ett personligt lidande, har fetma visat sig
vara associerat med sämre fysisk livskvalitet, sämre fysisk hälsa, samt högre
mortalitet. Den ökning av följdsjukdomarna som är associerad till fetma har även
inneburit ökade sjukvårdskostnader för samhället. Patienter som söker viktreducerande behandlingar har visat sig ha en ökad förekomst av ätstörningar och
hetsätning, vilka är kopplade till sämre psykisk hälsa och sämre livskvalitet.
Hetsätning är det primära symptomkriteriet på ätstörningar hos patienter med
fetma vilket innebär att personen äter stora mängder mat och upplever att
han/hon saknar kontroll över detta ätande. Då hetsätning är förknippat med
viktuppgång, med vidmakthållande av en hög vikt, samt med svårigheter att gå
ned i vikt, har detta beteende ansetts vara viktigt att identifiera inför viktreducerande behandlingar. Många kirurgiska kliniker avråder dessutom patienter
med ätstörningar från kirurgiska viktreduktionsbehandlingar, då hetsätning
anses vara en indikation på svårigheter att tillgodogöra sig behandlingen,
alternativt att behandlingen anses riskera att förvärra ätstörningssymtomen.
Ännu saknas dock tillförlitliga data om associationen mellan ätbeteende och
behandlingsutfall i viktreduktionsbehandlingar, delvis på grund av
metodologiska och diagnostiska olikheter och problem i sådana studier.
I syfte att öka denna kunskap undersöktes ätbeteende, vikt, livskvalitet och
psykisk hälsa i två olika grupper av patienter. I första studien undersöktes detta
hos 194 patienter som sökte icke-kirurgisk/beteendeförändrande viktreduktionsbehandling, och i de följande tre studierna hos en annan grupp av 252 patienter
som hade accepterats för kirurgiska eller icke-kirurgisk/beteendeförändrande
viktreduktionsbehandlingar. De 252 deltagarna i den andra gruppen följdes från
före behandlingen till tre år efter behandlingsstart, med avseende på ovanstående
parametrar. Av de 252 deltagare som följdes intervjuades 97 av dem för en
jämförelse mellan ett nykonstruerat frågeformulär, Eating Disorders in Obesity
(EDO), och ätstörningsintervjun Eating Disorder Examination (EDE).
Resultaten från de fyra studierna i avhandlingen presenteras kort nedan:
I Studie I undersöktes förekomsten av ätstörningar och hetsätning bland
patienter som hade accepterats till icke-kirurgisk/beteendeförändrande viktreduktionsbehandling. Resultaten visar att 17% av patienterna hade ett återkommande hetsätningsbeteende, och att drygt hälften av dessa patienter även
uppfyllde kriterierna för en ätstörning. Ätstörningar och hetsätning var associerat
med sämre psykisk hälsa samt sämre livskvalitet.
I Studie II undersöktes de psykometriska egenskaperna hos ett kort ätstörningsformulär, Eating Disorders in Obesity (EDO). Instrumentet utvecklades för att
bedöma ätstörningar och hetsätning bland patienter som söker viktreduktionsbehandling. I en jämförelse mellan EDO och ätstörningsintervjun EDE uppvisade
instrumenten en god samstämmighet i bedömningen av förekomsten av ätstörningar och hetsätning.
Binge Eating and Obesity Treatment joakim de man lapidoth I 47
I Studie III jämfördes patienter från kirurgiska och icke-kirurgiska/beteendeförändrande viktreduktionsbehandlingar, med avseende på ätstörningar, hetsätning, psykisk hälsa och livskvalitet. Resultaten visade att förekomsten av
ätstörningar var betydligt högre bland de som sökte kirurgisk behandling, men
att förekomsten av hetsätning var lika stor i de båda grupperna. De kirurgiska
viktreduktionsdeltagarna uppvisade även en högre grad av psykopatologi, än de
icke-kirurgiska deltagarna, men grupperna skilde sig inte åt avseende livskvalitet.
I Studie IV undersöktes hur förekomsten av hetsätning var associerat med vikt
(BMI) efter kirurgisk viktreduktionsbehandling. Förekomsten av hetsätning före
eller efter kirurgisk behandling, visade sig inte vara associerat med BMI efter tre
år. Det fanns dock en relevant förekomst av hetsätning tre år efter behandlingen,
som visade sig vara associerat med en betydligt sämre psykisk hälsa och sämre
livskvalitet.
N yckelord:
Ätstörning, fetma, hetsätning, longitudinell, viktreduktion
48 I joakim de man lapidoth Binge Eating and Obesity Treatment
T A C K (ACKNOWLEDGEMENTS))
Först och främst vill jag tacka mina två handledare, Claes Norring och Ata
Ghaderi. Claes, som med entusiasm och stor tillit erbjöd mig att göra min
avhandling för det som då hette Nationellt Kunskapscentrum för Ätstörningar i
Örebro, och som genomgående under dessa år har varit tillgänglig för att erbjuda
vetenskapligt och mänskligt stöd, uppmuntran och vänskap. Ata, för tålamod
och stor generositet i att erbjuda metodologiskt, statistiskt och
allmänvetenskapligt stöd, samt för förmågan att kunna väcka frågor hos mig som
har burit vidare mot nya funderingar och lösningar.
Jag vill också tacka;
Alla deltagare i studien som tålmodigt under fyra år har lämnat bidrag till denna
forskning.
Chefer och personal på klinikerna där jag har fått möjligheten att utföra dessa
studier.
Ingemar Engström och alla andra på Psykiatriskt forskningscentrum, för
förmånen att få göra min avhandling i den trivsamma, utvecklande och kreativa
forskningsmiljön som råder där.
Tabita Björk för all hjälp med avhandlingen.
Henrik Nilsson för hjälp med formuleringar i kirurgiska frågor.
Min bror och min far för noggrann korrekturläsning och hjälp med översättningar.
Johan Söderquist som jag gjorde mina examensuppsatser tillsammans med för
mer än tio år sedan, och som genom diskussioner, vänskap och många skratt
gjorde detta till ett positivt första intåg i forskningens värld.
Klaas Wijma för sin uppmuntran och sitt stöd under mina examensuppsatser
med Johan, men också för att tidigt ha väckt forskningstankar hos mig.
Margareta Landin för tålmodigt och ovärderligt stöd med referensbiblioteket.
Min älskade familj Caroline, Lova, Jonatan och Alma
Binge Eating and Obesity Treatment joakim de man lapidoth I 49
APPENDICES
Appendix A
DSM-IV Diagnostic criteria for Eating Disorders
3 0 7 .1
A norexia Nervosa (A N)
A. Refusal to maintain body weight at or above a minimally normal weight for the
age and height (e.g. weight loss leading to maintenance of body weight less than
85% of that expected; or failure to make expected weight gain during period of
growth, leading to a body weight less than 85% of that expected).
B. Intense fear of gaining weight or getting fat, even though underweight.
C. Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or denial of the
seriousness of the current body weight.
D. In post menarcheal females, amenorrhea, i.e. the absence of at least three
consecutive menstrual cycles. (A woman is considered to have amenorrhea if her
periods occur only following hormone, e.g. oestrogen administration.)
Specify type:
Restrictive Type: during the current episode of Anorexia Nervosa,
the person has not regularly engaged in binge eating or purging
behaviour (i.e. self-induced vomiting or the misuse of laxatives,
diuretics, or enemas)
Binge eating/Purging Type; during the current episode of Anorexia
Nervosa, the person has regularly engaged in binge eating or purging
behaviour (i.e. self-induced vomiting or the misuse of laxatives,
diuretics, or enemas)
Binge Eating and Obesity Treatment joakim de man lapidoth I 51
3 07.51
Bulimia Nervosa (BN)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized
by both the following:
(1) eating, in a discrete period of time (e.g. within any 2-hour period),
an amount of food that is definitely larger than most people would
eat during a similar period of time and under similar circumstances
(2) a sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop what or how much one is eating)
B. Recurrent inappropriate compensatory behaviour in order to prevent weight
gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or
other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviours occur, on
average, at least twice a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight
E. The disturbance does not occur exclusively during episodes of Anorexia
Nervosa
Specify type:
Purging type: during the current episode of Bulimia Nervosa, the
Person has regularly engaged in self-induced vomiting or the misuse
of Laxatives, diuretics or enemas.
Non-purging type: during the current episode of Bulimia Nervosa the
Person has used other inappropriate compensatory behaviours, such
as fasting or excessive exercise but has not regularly engaged in selfinduced vomiting or the misuse of laxatives, diuretics or enemas.
307.50
Eating Disorders Not Otherwise Specified (EDNOS)
1. For females, all of the criteria for Anorexia Nervosa are met except that the
individual has regular menses.
2. All of the criteria for Anorexia Nervosa are met except that, despite
significant weight loss, the individual’s current weight is in the normal
range.
3. All of the criteria for Bulimia Nervosa are met except that, despite
significant weight loss, the individual’s current weight is in the normal
range.
4. The regular use of inappropriate compensatory behaviour by an individual
of normal body weight after eating small amounts of food (e.g. selfinduced vomiting after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of
food.
6. Binge eating disorder: recurrent episodes of binge eating in the absence of
the regular use of inappropriate compensatory behaviours characteristic of
Bulimia Nervosa.
52 I joakim de man lapidoth Binge Eating and Obesity Treatment
DSM-IV Binge eating Disorder criteria
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
1. eating in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than most people would
eat in a similar period of time under similar circumstances
2. a sense of lack of control over eating during the episode (e.g. a
feeling that one cannot stop eating or control what or how much
one is eating)
B. The binge eating episodes are associated with three (or more) of the
following:
1.
2.
3.
4.
eating much more rapidly than normal
eating until feeling uncomfortably full
eating large amounts of food when not feeling physically hungry
eating alone because of being embarrassed by how much one is
eating
5. feeling disgusted with oneself, depressed, or very guilty after
overeating
C. Marked distress regarding binge eating is present
D. The binge eating occurs, on average, at least 2 days a week for six
months
Note: The method of determining frequency threshold is counting the
number of days on which binges occur or in counting the number of
episodes of binge eating.
E. The binge eating is not associated with regular use of inappropriate
compensatory behaviors (e.g., purging, fasting, excessive exercise) and does
not occur exclusively during the course of anorexia nervosa or bulimia
nervosa
Binge Eating and Obesity Treatment joakim de man lapidoth I 53
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