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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 REFERENCES 1. Abbott DW, de Zwaan M, Mussell MP, Raymond NC, Seim HC, Crow SJ, Crosby RD, Mitchell JE. Onset of binge eating and dieting in overweight women: implications for etiology, associated features and treatment. Journal of Psychosomatic Research 1998;44(3-4):367-74. 2. Adami GF, Gandolfo P, Meneghelli A, Scopinaro N. Binge eating in obesity: a longitudinal study following biliopancreatic diversion. International Journal of Eating Disorders 1996;20(4):405-13. 3. Agren G, Narbro K, Jonsson E, Naslund I, Sjostrom L, Peltonen M. Cost of in-patient care over 7 years among surgically and conventionally treated obese patients. Obesity Research 2002;10(12):1276-83. 4. Allison KC, Wadden TA, Sarwer DB, Fabricatore AN, Crerand CE, Gibbons LM, Stack RM, Stunkard AJ, Williams NN. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Obesity (Silver Spring) 2006;14 Suppl 2:77S-82S. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington D.C.: American Psychiatric Press; 1994. 6. Antoniou M, Tasca GA, Wood J, Bissada H. Binge eating disorder versus overeating: a failure to replicate and common factors in severely obese treatment seeking women. Eating and Weight Disorders : EWD 2003;8(2):145-9. 7. Antony MM, Johnson WG, Carr-Nangle RE, Abel JL. Psychopathology correlates of binge eating and binge eating disorder. Comprehensive Psychiatry 1994;35(5):386-92. 8. Appolinario JC, McElroy SL. Pharmacological approaches in the treatment of binge eating disorder. Current Drug Targets 2004;5(3):301-7. 9. Aronne LJ. Eating Disorders and Obesity. In: Fairburn CG, Brownell KD, editors. Current Pharmacological Treatments for Obesity. New York: The Guilford Press; 2002. p. 551-6. 10. Bancheri L, Patrizi B, Kotzalidis GD, Mosticoni S, Gargano T, Angrisani P, Tatarelli R, Girardi P. Treatment choice and psychometric characteristics: differences between patients who choose bariatric surgical treatment and those who do not. Obesity Surgery 2006;16(12):1630-7. Binge Eating and Obesity Treatment joakim de man lapidoth I 55 11. Barry DT, Grilo CM, Masheb RM. Comparison of patients with bulimia nervosa, obese patients with binge eating disorder, and nonobese patients with binge eating disorder. Journal of Nervous and Mental Disease 2003;191(9):589-94. 12. Beglin SJ, Fairburn CG. Evaluation of a new instrument for the detection of eating disorders in community samples. Psychiatry Research 1992;44(3):191-201. 13. Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. Journal of Psychosomatic Research 2002;52(3):155-65. 14. Buddeberg-Fischer B, Klaghofer R, Krug L, Buddeberg C, Muller MK, Schoeb O, Weber M. Physical and psychosocial outcome in morbidly obese patients with and without bariatric surgery: a 4 1/2-year follow-up. Obesity Surgery 2006;16(3):321-30. 15. Bueter M, Thalheimer A, Lager C, Schowalter M, Illert B, Fein M. Who benefits from gastric banding? Obesity Surgery 2007;17(12):1608-13. 16. Bulik CM, Sullivan PF, Kendler KS. An empirical study of the classification of eating disorders. American Journal of Psychiatry 2000;157(6):886-95. 17. Bulik CM, Sullivan PF, Kendler KS. Medical and psychiatric morbidity in obese women with and without binge eating. International Journal of Eating Disorders 2002;32(1):72-8. 18. Burgmer R, Grigutsch K, Zipfel S, Wolf AM, de Zwaan M, Husemann B, Albus C, Senf W, Herpertz S. The influence of eating behavior and eating pathology on weight loss after gastric restriction operations. Obesity Surgery 2005;15(5):684-91. 19. Cargill BR, Clark MM, Pera V, Niaura RS, Abrams DB. Binge eating, body image, depression, and self-efficacy in an obese clinical population. Obesity Research 1999;7(4):379-86. 20. Castellini G, Lapi F, Ravaldi C, Vannacci A, Rotella CM, Faravelli C, Ricca V. Eating disorder psychopathology does not predict the overweight severity in subjects seeking weight loss treatment. Comprehensive Psychiatry 2008;49(4):359-63. 21. Centers for Disease Control and Prevention. Overweight and Obesity – U.S. Obesity Trends 1985–2007 [Internet]. 2007 [cited 2009 March 19]. Available from: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/. 56 I joakim de man lapidoth Binge Eating and Obesity Treatment 22. Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity (Silver Spring) 2008;16(3):615-22. 23. Colles SL, Dixon JB, O’Brien PE. Loss of control is central to psychological disturbance associated with binge eating disorder. Obesity (Silver Spring) 2008;16(3):608-14. 24. Cooper Z, Fairburn CG. Refining the definition of binge eating disorder and nonpurging bulimia nervosa. International Journal of Eating Disorders 2003;34 Suppl:S89-95. 25. de Zwaan M. Binge eating disorder and obesity. International Journal of Obesity and Related Metabolic Disorders 2001;25 Suppl 1:S51-5. 26. de Zwaan M, Lancaster KL, Mitchell JE, Howell LM, Monson N, Roerig JL, Crosby RD. Health-related quality of life in morbidly obese patients: effect of gastric bypass surgery. Obesity Surgery 2002;12(6):773-80. 27. de Zwaan M, Mitchell JE, Howell LM, Monson N, Swan-Kremeier L, Crosby RD, Seim HC. Characteristics of morbidly obese patients before gastric bypass surgery. Comprehensive Psychiatry 2003;44(5):428-34. 28. Deitel M. Anorexia nervosa following bariatric surgery. Obesity Surgery 2002;12(6):729-30. 29. Devlin MJ. Is there a place for obesity in DSM-V? International Journal of Eating Disorders 2007;40 Suppl:S83-8. 30. Devlin MJ, Goldfein JA, Flancbaum L, Bessler M, Eisenstadt R. Surgical management of obese patients with eating disorders: a survey of current practice. Obesity Surgery 2004;14(9):1252-7. 31. Didie ER, Fitzgibbon M. Binge eating and psychological distress: is the degree of obesity a factor? Eating Behaviors 2005;6(1):35-41. 32. DiGioacchino R, Sargent R, Rankin HJ, Sharpe P, Miller P, Hussey JR, Tafakoli AS. Factors associated with weight change among clients of a residential weight control program indicating binge and nonbinge traits. Addictive Behaviors 1997;22(3):293-303. 33. Dingemans AE, Bruna MJ, van Furth EF. Binge eating disorder: a review. International Journal of Obesity and Related Metabolic Disorders 2002;26(3):299-307. Binge Eating and Obesity Treatment joakim de man lapidoth I 57 34. Doll HA, Petersen SE, Stewart-Brown SL. Obesity and physical and emotional well-being: associations between body mass index, chronic illness, and the physical and mental components of the SF-36 questionnaire. Obesity Research 2000;8(2):160-70. 35. Dymek-Valentine M, Rienecke-Hoste R, Alverdy J. Assessment of binge eating disorder in morbidly obese patients evaluated for gastric bypass: SCID versus QEWP-R. Eating and Weight Disorders : EWD 2004;9(3):211-6. 36. Dymek MP, le Grange D, Neven K, Alverdy J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obesity Surgery 2001;11(1):32-9. 37. Elder KA, Grilo CM, Masheb RM, Rothschild BS, Burke-Martindale CH, Brody ML. Comparison of two self-report instruments for assessing binge eating in bariatric surgery candidates. Behaviour Research and Therapy 2006;44(4):545-60. 38. Elfhag K, Rossner S. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obesity Reviews 2005;6(1):67-85. 39. Fairburn CG, Bohn K. Eating disorder NOS (EDNOS): an example of the troublesome "not otherwise specified" (NOS) category in DSM-IV. Behaviour Research and Therapy 2005;43(6):691-701. 40. Fairburn CG, Cooper Z. Binge eating: nature assessment and treatment In: Fairburn CG, Wilson GT, editors. The Eating Disorder Examination. 12th ed. New York: Guilford Press; 1993. p. 317-31. 41. Fairburn CG, Cooper Z. The eating disorder examination. In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment and treatment. 12th ed. New York: Guilford Press; 1993. p. 317-31. 42. Fichter MM, Quadflieg N, Brandl B. Recurrent overeating: an empirical comparison of binge eating disorder, bulimia nervosa, and obesity. International Journal of Eating Disorders 1993;14(1):1-16. 43. Fichter MM, Quadflieg N, Hedlund S. Long-term course of binge eating disorder and bulimia nervosa: relevance for nosology and diagnostic criteria. International Journal of Eating Disorders 2008;41(7):577-86. 44. Fisher BL, Schauer P. Medical and surgical options in the treatment of severe obesity. American Journal of Surgery 2002;184(6B):9S-16S. 58 I joakim de man lapidoth Binge Eating and Obesity Treatment 45. Fontaine KR, Barofsky I. Obesity and health-related quality of life. Obesity Reviews 2001;2(3):173-82. 46. Foreyt JP, Poston WS, 2nd, Goodrick GK. Future directions in obesity and eating disorders. Addictive Behaviors 1996;21(6):767-78. 47. Garner D, Olmstead M, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. International Journal of Eating Disorders 1983;2(3):15-34. 48. Ghaderi A, Scott B. The preliminary reliability and validity of the Survey for Eating Disorders (SEDs): A self-report questionnaire for diagnosing eating disorders. European Eating Disorders Review 2002;10(1):61-76. 49. Glinski J, Wetzler S, Goodman E. The psychology of gastric bypass surgery. Obesity Surgery 2001;11(5):581-8. 50. Goldstein DJ. Beneficial health effects of modest weight loss. International Journal of Obesity and Related Metabolic Disorders 1992;16(6):397-415. 51. Gormally J, Black S, Daston S, Rardin D. The assessment of binge eating severity among obese persons. Addictive Behaviors 1982;7(1):47-55. 52. Greenberg I, Perna F, Kaplan M, Sullivan MA. Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. Obesity Research 2005;13(2):244-9. 53. Greeno CG, Marcus MD, Wing RR. Diagnosis of binge eating disorder: discrepancies between a questionnaire and clinical interview. International Journal of Eating Disorders 1995;17(2):153-60. 54. Grilo CM, Hrabosky JI, White MA, Allison KC, Stunkard AJ, Masheb RM. Overvaluation of shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic construct. Journal of Abnormal Psychology 2008;117(2):414-9. 55. Grilo CM, Masheb RM, Lozano-Blanco C, Barry DT. Reliability of the Eating Disorder Examination in patients with Binge Eating Disorder. International Journal of Eating Disorders 2004;35(1):80-5. 56. Grissett NI, Fitzgibbon ML. The clinical significance of binge eating in an obese population: support for bed and questions regarding its criteria. Addictive Behaviors 1996;21(1):57-66. Binge Eating and Obesity Treatment joakim de man lapidoth I 59 57. Guisado JA, Vaz FJ, Lopez-Ibor JJ, Lopez-Ibor MI, del Rio J, Rubio MA. Gastric surgery and restraint from food as triggering factors of eating disorders in morbid obesity. International Journal of Eating Disorders 2002;31(1):97-100. 58. Hasler G, Pine DS, Gamma A, Milos G, Ajdacic V, Eich D, Rossler W, Angst J. The associations between psychopathology and being overweight: a 20-year prospective study. Psychological Medicine 2004;34(6):1047-57. 59. Henderson M, Freeman CP. A self-rating scale for bulimia. The 'BITE'. British Journal of Psychiatry 1987;150:18-24. 60. Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. International Journal of Obesity and Related Metabolic Disorders 2003;27(11):1300-14. 61. Ho KS, Nichaman MZ, Taylor WC, Lee ES, Foreyt JP. Binge eating disorder, retention, and dropout in an adult obesity program. International Journal of Eating Disorders 1995;18(3):291-4. 62. Hsu LK, Benotti PN, Dwyer J, Roberts SB, Saltzman E, Shikora S, Rolls BJ, Rand W. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosomatic Medicine 1998;60(3):338-46. 63. Hsu LK, Betancourt S, Sullivan SP. Eating disturbances before and after vertical banded gastroplasty: a pilot study. International Journal of Eating Disorders 1996;19(1):23-34. 64. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Binge eating in bariatric surgery patients. International Journal of Eating Disorders 1998;23(1):8992. 65. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Effects of bariatric surgery on binge eating and related psychopathology. Eating and Weight Disorders : EWD 1999;4(1):1-5. 66. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Assessment of eating disorders in bariatric surgery candidates: self-report questionnaire versus interview. International Journal of Eating Disorders 2000;28(4):465-9. 67. Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects (SOS)–an intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesity. International Journal of Obesity and Related Metabolic Disorders 1998;22(2):113-26. 60 I joakim de man lapidoth Binge Eating and Obesity Treatment 68. Kolotkin RL, Westman EC, Ostbye T, Crosby RD, Eisenson HJ, Binks M. Does binge eating disorder impact weight-related quality of life? Obesity Research 2004;12(6):999-1005. 69. Kopelman PG. Obesity as a medical problem. Nature 2000;404(6778):635-43. 70. Kral JG. Patient selection for treatment of obesity. Surgery for Obesity and Related Diseases 2005;1(2):126-32. 71. Kral JG, Naslund E. Surgical treatment of obesity. Nature Clinical Practice. Endocrinology & Metabolism 2007;3(8):574-83. 72. LaPorte DJ. Treatment response in obese binge eaters: preliminary results using a very low calorie diet (VLCD) and behavior therapy. Addictive Behaviors 1992;17(3):247-57. 73. Larsen JK, van Ramshorst B, Geenen R, Brand N, Stroebe W, van Doornen LJ. Binge eating and its relationship to outcome after laparoscopic adjustable gastric banding. Obesity Surgery 2004;14(8):1111-7. 74. Latner JD, Clyne C. The diagnostic validity of the criteria for binge eating disorder. International Journal of Eating Disorders 2008;41(1):1-14. 75. Latner JD, Wetzler S, Goodman ER, Glinski J. Gastric bypass in a lowincome, inner-city population: eating disturbances and weight loss. Obesity Research 2004;12(6):956-61. 76. le Grange D, Binford RB, Peterson CB, Crow SJ, Crosby RD, Klein MH, Bardone-Cone AM, Joiner TE, Mitchell JE, Wonderlich SA. DSM-IV threshold versus subthreshold bulimia nervosa. International Journal of Eating Disorders 2006;39(6):462-7. 77. Leombruni P, Piero A, Dosio D, Novelli A, Abbate-Daga G, Morino M, Toppino M, Fassino S. Psychological predictors of outcome in vertical banded gastroplasty: a 6 months prospective pilot study. Obesity Surgery 2007;17(7):941-8. 78. Machado PP, Machado BC, Goncalves S, Hoek HW. The prevalence of eating disorders not otherwise specified. International Journal of Eating Disorders 2007;40(3):212-7. Binge Eating and Obesity Treatment joakim de man lapidoth I 61 79. Malone M, Alger-Mayer S. Binge status and quality of life after gastric bypass surgery: a one-year study. Obesity Research 2004;12(3):473-81. 80. Mannucci E, Ricca V, Barciulli E, Di Bernardo M, Travaglini R, Cabras PL, Rotella CM. Quality of life and overweight: the obesity related well-being (Orwell 97) questionnaire. Addictive Behaviors 1999;24(3):345-57. 81. Marcus MD, Wing RR, Hopkins J. Obese binge eaters: affect, cognitions, and response to behavioural weight control. Journal of Consulting and Clinical Psychology 1988;56(3):433-9. 82. Marshall HM, Allison KC, O'Reardon JP, Birketvedt G, Stunkard AJ. Night eating syndrome among nonobese persons. International Journal of Eating Disorders 2004;35(2):217-22. 83. Masheb RM, Grilo CM. The nature of body image disturbance in patients with binge eating disorder. International Journal of Eating Disorders 2003;33(3):333-41. 84. McElroy SL, Kotwal R, Malhotra S, Nelson EB, Keck PE, Nemeroff CB. Are mood disorders and obesity related? A review for the mental health professional. Journal of Clinical Psychiatry 2004;65(5):634-51, quiz 730. 85. Mitchell JE, Devlin MJ, de Zwaan M, Crow SJ, Peterson CB. Binge-Eating Disorder – clinical foundations and treatment. New York: The Guilford Press; 2007. 86. Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD, Crosby RD, Wonderlich SA, Gosnell BA. Long-term follow-up of patients' status after gastric bypass. Obesity Surgery 2001;11(4):464-8. 87. Mitchell JE, Mussell MP. Comorbidity and binge eating disorder. Addictive Behaviors 1995;20(6):725-32. 88. Mond J, Hay P, Rodgers B, Owen C, Crosby R, Mitchell J. Use of extreme weight control behaviors with and without binge eating in a community sample: implications for the classification of bulimic-type eating disorders. International Journal of Eating Disorders 2006;39(4):294-302. 89. Mond JM, Hay PJ, Rodgers B, Owen C. Recurrent binge eating with and without the “undue influence of weight or shape on self-evaluation”: implications for the diagnosis of binge eating disorder. Behaviour Research and Therapy 2007;45(5):929-38. 62 I joakim de man lapidoth Binge Eating and Obesity Treatment 90. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ. Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behaviour Research and Therapy 2004;42(5):551-67. 91. Niego SH, Kofman MD, Weiss JJ, Geliebter A. Binge eating in the bariatric surgery population: a review of the literature. International Journal of Eating Disorders 2007;40(4):349-59. 92. Nyholm M, Gullberg B, Merlo J, Lundqvist-Persson C, Rastam L, Lindblad U. The validity of obesity based on self-reported weight and height: Implications for population studies. Obesity (Silver Spring) 2007;15(1):197-208. 93. Official Statistics of Sweden. Every tenth Swede is obese [Internet]. 2006 [cited 2009 March 19]. Available from: http://www.scb.se/statistik/_publikationer/BE0801_2007K01_TI_05_A05 ST0701.pdf. 94. Onyike CU, Crum RM, Lee HB, Lyketsos CG, Eaton WW. Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. American Journal of Epidemiology 2003;158(12):1139-47. 95. Persson LO, Karlsson J, Bengtsson C, Steen B, Sullivan M. The Swedish SF36 Health Survey II. Evaluation of clinical validity: results from population studies of elderly and women in Gothenborg. Journal of Clinical Epidemiology 1998;51(11):1095-103. 96. Peterson CB, Miller KB, Crow SJ, Thuras P, Mitchell JE. Subtypes of binge eating disorder based on psychiatric history. International Journal of Eating Disorders 2005;38(3):273-6. 97. Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: a prospective study. International Journal of Eating Disorders 1999;25(3):293-300. 98. Pratt EM, Niego SH, Agras WS. Does the size of a binge matter? International Journal of Eating Disorders 1998;24(3):307-12. 99. Ramacciotti CE, Coli E, Bondi E, Burgalassi A, Massimetti G, Dell’Osso L. Shared psychopathology in obese subjects with and without binge-eating disorder. International Journal of Eating Disorders 2008;41(7):643-9. Binge Eating and Obesity Treatment joakim de man lapidoth I 63 100. Ramacciotti CE, Coli E, Passaglia C, Lacorte M, Pea E, Dell’Osso L. Binge eating disorder: prevalence and psychopathological features in a clinical sample of obese people in Italy. Psychiatry Research 2000;94(2):131-8. 101. Ricca V, Mannucci E, Moretti S, Di Bernardo M, Zucchi T, Cabras PL, Rotella CM. Screening for binge eating disorder in obese outpatients. Comprehensive Psychiatry 2000;41(2):111-5. 102. Safer DL, Lively TJ, Telch CF, Agras WS. Predictors of relapse following successful dialectical behavior therapy for binge eating disorder. International Journal of Eating Disorders 2002;32(2):155-63. 103. Sallet PC, Sallet JA, Dixon JB, Collis E, Pisani CE, Levy A, Bonaldi FL, Cordas TA. Eating behavior as a prognostic factor for weight loss after gastric bypass. Obesity Surgery 2007;17(4):445-51. 104. Sarwer DB, Cohn NI, Gibbons LM, Magee L, Crerand CE, Raper SE, Rosato EF, Williams NN, Wadden TA. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obesity Surgery 2004;14(9):1148-56. 105. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obesity Research 2005;13(4):639-48. 106. Saunders R. “Grazing”: a high-risk behavior. Obesity Surgery 2004;14(1):98-102. 107. Saunders R, Johnson L, Teschner J. Prevalence of eating disorders among bariatric surgery patients. Eating Disorders: The Journal of Treatment & Prevention 1998;6(4):309-17. 108. Scioscia TN, Bulik CM, Levenson J, Kirby DF. Anorexia nervosa in a 38year-old woman 2 years after gastric bypass surgery. Psychosomatics 1999;40(1):86-8. 109. Segal A, Kinoshita Kussunoki D, Larino MA. Post-surgical refusal to eat: anorexia nervosa, bulimia nervosa or a new eating disorder? A case series. Obesity Surgery 2004;14(3):353-60. 110. Seidell J, Tijhuis M. Obesity and quality of life. In: Fairburn C, Brownell K, editors. Eating disorders and obesity. New York: The Giulford Press; 1994. p. 388-92. 111. Sherwood NE, Jeffery RW, Wing RR. Binge status as a predictor of weight loss treatment outcome. International Journal of Obesity and Related Metabolic Disorders 1999;23(5):485-93. 64 I joakim de man lapidoth Binge Eating and Obesity Treatment 112. Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lonroth H, Naslund I, Olbers T, Stenlof K, Torgerson J, Agren G, Carlsson LM. Effects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine 2007;357(8):741-52. 113. Spitzer RL, Devlin MJ, Walsh B, Hasin D, et al. Binge eating disorder: A multisite field trial of the diagnostic criteria. International Journal of Eating Disorders 1992;11(3):191-203. 114. Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard A, Devlin M, Mitchell J, Hasin D, Horne RL. Binge eating disorder: its further validation in a multisite study. International Journal of Eating Disorders 1993;13(2):137-53. 115. Striegel-Moore RH, Dohm FA, Solomon EE, Fairburn CG, Pike KM, Wilfley DE. Subthreshold binge eating disorder. International Journal of Eating Disorders 2000;27(3):270-8. 116. Striegel-Moore RH, Wilson GT, Wilfley DE, Elder KA, Brownell KD. Binge eating in an obese community sample. International Journal of Eating Disorders 1998;23(1):27-37. 117. Stunkard AJ. Eating patterns and obesity. Psychiatric Quarterly 1959;33:284-95. 118. Stunkard AJ, Messick S. The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. Journal of Psychosomatic Research 1985;29(1):71-83. 119. Sullivan M, Karlsson J. The Swedish SF-36 Health Survey III. Evaluation of criterion-based validity: results from normative population. Journal of Clinical Epidemiology 1998;51(11):1105-13. 120. Sullivan M, Karlsson J, Taft C. SF-36 Hälsoenkät: Swedish Manual and Interpretation Guide. 2nd ed. Gothenburg: Sahlgrenska University Hospital; 2002. 121. Sullivan M, Karlsson J, Ware JE, Jr. The Swedish SF-36 Health Survey–I. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden. Social Science and Medicine 1995;41(10):1349-58. Binge Eating and Obesity Treatment joakim de man lapidoth I 65 122. Svanborg P, Asberg M. A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale. Acta Psychiatrica Scandinavica 1994;89(1):21-8. 123. Teixeira PJ, Going SB, Houtkooper LB, Cussler EC, Metcalfe LL, Blew RM, Sardinha LB, Lohman TG. Pretreatment predictors of attrition and successful weight management in women. International Journal of Obesity and Related Metabolic Disorders 2004;28(9):1124-33. 124. Teixeira PJ, Going SB, Sardinha LB, Lohman TG. A review of psychosocial pre-treatment predictors of weight control. Obesity Reviews 2005;6(1):4365. 125. Telch CF, Agras WS. Obesity, binge eating and psychopathology: are they related? International Journal of Eating Disorders 1994;15(1):53-61. 126. Torgerson JS, Sjostrom L. The Swedish Obese Subjects (SOS) study– rationale and results. International Journal of Obesity and Related Metabolic Disorders 2001;25 Suppl 1:S2-4. 127. Turk MW, Yang K, Hravnak M, Sereika SM, Ewing LJ, Burke LE. Randomized clinical trials of weight loss maintenance: a review. Journal of Cardiovascular Nursing 2009;24(1):58-80. 128. Wadden TA, Berkowitz RI. Eating Disorders and Obesity. In: Fairburn CG, Brownell KD, editors. Very-Low-Calorie Diets. New York: The Guilford Press; 2002. p. 534-8. 129. Wadden TA, Foster GD, Letizia KA, Wilk JE. Metabolic, anthropometric, and psychological characteristics of obese binge eaters. International Journal of Eating Disorders 1993;14(1):17-25. 130. Wadden TA, Foster GD, Sarwer DB, Anderson DA, Gladis M, Sanderson RS, Letchak RV, Berkowitz RI, Phelan S. Dieting and the development of eating disorders in obese women: results of a randomized controlled trial. American Journal of Clinical Nutrition 2004;80(3):560-8. 131. Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Obesity (Silver Spring) 2006;14 Suppl 2:53S-62S. 132. Wadden TA, Sarwer DB, Womble LG, Foster GD, McGuckin BG, Schimmel A. Psychosocial aspects of obesity and obesity surgery. Surgical Clinics of North America 2001;81(5):1001-24. 66 I joakim de man lapidoth Binge Eating and Obesity Treatment 133. Wade TD, Bergin JL, Martin NG, Gillespie NA, Fairburn CG. A transdiagnostic approach to understanding eating disorders. Journal of Nervous and Mental Disease 2006;194(7):510-7. 134. van Hout GC, Hagendoren CA, Verschure SK, van Heck GL. Psychosocial Predictors of Success After Vertical Banded Gastroplasty. Obesity Surgery 2008. 135. Wardle J, Waller J, Rapoport L. Body dissatisfaction and binge eating in obese women: the role of restraint and depression. Obesity Research 2001;9(12):778-87. 136. Vargas A, Rojas-Ruiz MT, Roman SS, Salin-Pascual RJ. Development of bulimia nervosa after bariatric surgery in morbid obesity patients. Salud Mental 2003;26(5):28-32. 137. Wilfley DE, Bishop ME, Wilson GT, Agras WS. Classification of eating disorders: toward DSM-V. International Journal of Eating Disorders 2007;40 Suppl:S123-9. 138. Wilfley DE, Friedman MA, Dounchis JZ, Stein RI, Welch RR, Ball SA. Comorbid psychopathology in binge eating disorder: relation to eating disorder severity at baseline and following treatment. Journal of Consulting and Clinical Psychology 2000;68(4):641-9. 139. Wilfley DE, Schwartz MB, Spurrell EB, Fairburn CG. Using the eating disorder examination to identify the specific psychopathology of binge eating disorder. International Journal of Eating Disorders 2000;27(3):259-69. 140. Wilfley DE, Wilson GT, Agras WS. The clinical significance of binge eating disorder. International Journal of Eating Disorders 2003;34 Suppl:S96106. 141. Williamson DA, Martin CK. Binge eating disorder: a review of the literature after publication of DSM-IV. Eating and Weight Disorders : EWD 1999;4(3):103-14. 142. Williamson DA, Martin CK, Anton SD, York-Crowe E, Han H, Redman L, Ravussin E. Is caloric restriction associated with development of eatingdisorder symptoms? Results from the CALERIE trial. Health Psychology 2008;27(1 Suppl):S32-42. 143. Wilson GT. Assessment of binge eating. In: Fairburn CG, Wilson GT, editors. Binge eating: nature assessment and treatment. New York: Guilford Press; 1993. p. 227-49. Binge Eating and Obesity Treatment joakim de man lapidoth I 67 144. Wilson GT, Brownell KD. Eating Disorders and Obesity. In: Fairburn CG, Brownell KD, editors. Behavioral Treatment for Obesity. New York: The Guilford Press; 2002. p. 524-33. 145. Wilson GT, Nonas CA, Rosenblum GD. Assessment of binge eating in obese patients. International Journal of Eating Disorders 1993;13(1):2533. 146. Wonderlich S, Mitchell J, de Zwaan M, Steiger H. Eating Disorder Review Part 1. Oxford: Radcliffe Publishing; 2005. 147. Wonderlich SA, de Zwaan M, Mitchell JE, Peterson C, Crow S. Psychological and dietary treatments of binge eating disorder: conceptual implications. International Journal of Eating Disorders 2003;34 Suppl:S58-73. 148. Wonderlich SA, Joiner TE, Jr., Keel PK, Williamson DA, Crosby RD. Eating disorder diagnoses: empirical approaches to classification. American Psychologist 2007;62(3):167-80. 149. Yanovski SZ. Binge eating disorder: current knowledge and future directions. Obesity Research 1993;1(4):306-24. 150. Yanovski SZ. Binge eating disorder and obesity in 2003: could treating an eating disorder have a positive effect on the obesity epidemic? International Journal of Eating Disorders 2003;34 Suppl:S117-20. 151. Yanovski SZ, Gormally JF, Leser MS, Gwirtsman HE, Yanovski JA. Binge eating disorder affects outcome of comprehensive very-low-calorie diet treatment. Obesity Research 1994;2(3):205-12. 152. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric comorbidity in obese subjects. American Journal of Psychiatry 1993;150(10):1472-9. 153. Yanovski SZ, Sebring NG. Recorded food intake of obese women with binge eating disorder before and after weight loss. International Journal of Eating Disorders 1994;15(2):135-50. 154. Zimmerman M, Francione-Witt C, Chelminski I, Young D, Boerescu D, Attiullah N, Pohl D, Roye GD, Harrington DT. Presurgical psychiatric evaluations of candidates for bariatric surgery, part 1: reliability and reasons for and frequency of exclusion. Journal of Clinical Psychiatry 2007;68(10):1557-62. 68 I joakim de man lapidoth Binge Eating and Obesity Treatment Publikationer i serien Örebro Studies in Medicine 1. Bergemalm, Per-Olof (2004). Audiologic and cognitive long-term sequelae from closed head injury. 2. Jansson, Kjell (2004). Intraperitoneal Microdialysis. Technique and Results. 3. Windahl, Torgny (2004). 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