Binge Eating in Overweight
Women
Martina de Zwaan, Detlev 0. Nutzinger, and Georg Schoenbeck Data on the prevalence and characteristics of binge eating in a series of 64 obese women participating in a controlled weight-reduction program are presented. Twenty-two (34.4%) reported recurrent binge eating episodes defined as overeating plus loss of control as assessed by patients’ self-report and confirmed by a clinical interview. Six of those indicated that they engaged in either self-induced vomiting or laxative use to control their weight, but only two met full criteria for current bulimia nervosa according to DSM-III-R. A detailed description of the binge eating behavior revealed similarities to the eating pattern described in patients with bulimia nervosa: obese binge eaters tended to overeat in the evening, when they were alone and at home. Compared with their non-binge
A
LTHOUGH Stunkard identified binge eating as a distinct eating disturbance in obese patients more than 30 years ago,’ only recently has increasing attention been focused on the occurrence and prevalence of binge eating in the obese population. The following observations have recently been made: (1) Binge eating represents a serious problem for 23% to 46% of obese individuals seeking weight loss treatment.2-6 In some hospital-affiliated weightreduction programs, the percentage of obese subjects who reported not having problems with binge eating is low, ranging from 17.9% to 22%.3J (2) Binge eating seems to be more common in overweight women than men.7 (3) Purging is less frequent in obese individuals than in normal-weight binge eaters or anorectics with bulimia.6,7 (4) Binge eating often complicates standard behavioral weight-reduction treatment.4,8,9 (5) Obese binge eaters are more likely to drop out of behavioral treatment than non-binge eaters.‘” (6) They are more prone to regain weight following treatment.‘O (7) They differ from obese non-binge eaters on psychological and affective variables. They seem to experience more psychological distress such as low From the Department of Psychiatry, University of Henna, Austria. Supported in part by Kali Chemie Pharma, Division Duphar, Austria. Address reprint requests to Martina de Zwaan, M.D., Depatiment of Psychiatry, University of Vienna, Waehn’nger Guertel 18-20, 1090 Vienna, Austria. Copyright 0 1992 by W.B. Saunders Company 0010-440X/92/3304-0009$03.0010 256
eating counterparts, binge eaters were significantly younger when they presented for treatment. The prevalence of childhood obesity was higher, and they were significantly younger when they first started on a diet than the non-binge eaters. Binge eaters reported more psychological problems such as body image distortion, and there was a slight tendency for binge eaters to exhibit more depressive symptomatology at baseline. No association between binge eating and weight at baseline, or weight loss during therapy or at follow-up could be found. Fluvoxamine (100 mg) did not seem to be of specific benefit in this subgroup of the obese with regard to weight loss. Copyright 0 1992 by W.B. Saunders Company
self-efficacy and self-esteem, and high levels of depressionlO-l2 and other psychiatric disorders.13 Marcus et al. found that such differences appeared to persist despite behavioral treatment.‘O Others found a personal and family history of substance abuse similar to the normalweight bulimics.12 (8) Binge eating obese individuals display more maladaptive dieting behavior and attitudes such as dietary restraint and unrealistically high dieting standards.3,5 This report concentrates on the prevalence and the description of binge eating behavior in a group of obese women, all of whom also reported that they were experiencing emotional problems, the latter being a requirement for study participation. They were evaluated for participation in a controlled treatment study for weight reduction. Patients were assigned to one of four different treatment conditions: cognitive behavioral treatment (CBT) plus fluvoxamine, CBT plus placebo, dietary management (DM) plus fluvoxamine, or DM plus placebo. Furthermore, to compare binge eaters with non-binge eaters, pooled-variance t tests and Pearson chi-square analyses were conducted on pretreatment and posttreatment variables. In addition, simple regression analyses were performed to assess the relationship between binge eating frequency and the pretreatment and posttreatment variables. METHOD
Subjects, Assessment Subjects were recruited from the Outpatient Clinic of the Psychiatry Department in Vienna, and from referrals from
Comprehensive Psychiatry, Vol. 33, No. 4 (July/August), 1992: pp 256-261
BINGE EATING IN OVERWEIGHT
257
WOMEN
rent binge eating episodes, defined as “eating a large amount of food in a short period of time.” According to the structured interview, only two patients met full criteria for a current DSMIII-R diagnosis of bulimia nervosa. The remaining 20 patients fulfilled at least criterion A (“rapid consumption of a large amount of food in a discrete period of time”) plus criterion B (“a feeling of lack of control over the eating behavior during the eating binges”), but they either did not engage in regular purging behavior, vigorous exercise, or repeated 24-hour fasting, or did not fullfill the frequency criterion of having two episodes per week for 3 months. Table 1 gives a more detailed description of the characteristics of the eating binges in our sample. Recently, it has been suggested that binge eating be defined as having two components: episodic overeating and the sense of loss of control (personal communication, DSM-IV Work Group on Eating Disorders). Our definition of binge eating is therefore in line with these newly suggested criteria. The Eating Disorders Work Group has developed prelimina~ criteria for a new eating disorder called “binge eating disorder.” Besides recurrent binge eating episodes, this diagnosis requires behavioral indicators of loss of control, marked distress regarding binge eating, and a frequency of at least two episodes per week for a h-month period. In addition, patients who meet criteria for current bulimia nervosa are to be excluded. Of the suggested six behavioral indicators of loss of control, we have information on four, since
practitioners and other health facilities who were informed about our study through letters. Only subjects who had either a history of a major affective disorder and/or reported emotional disturbances secondary to dieting were enrolled. The sample comprised 64 women. Their mean age was 39 years (range, 19 to 54). The mean pretreatment body mass index (BMI) was 36.4 kg/m” (range, 28.5 to 47.1 kg/m*). One week before beginning treatment, subjects underwent a Structured Clinical Interview (SCID) to assess DSM III-R diagnoses,‘l and were rated using the Hamilton Rating Scale for Depression (HAM-D).t5 Furthermore, subjects were asked to fill out the Diagnostic Survey of Eating Disorders (DSED)lh to gather information about their eating and weight history, the Beck Depression Inventory (BDI),” and the Body Distortion Questionnaire (BDQ).‘s
RESULTS Overall Results
Forty-eight subjects completed the study. Their mean weight loss was 5.8 ? 4.0 kg (range, 16.3 kg [35.8 lb] lost to 1.9 kg [4.2 lb] gained). There were no significant differences among the four treatment conditions with regard to the amount of weight reduction. Binge Eating and Eating-Related Variables The info~ation on binge eating and eatingrelated variables is based on responses to an eating history questionnaire (DSED)16 completed by each patient before entering the study, as well as on results of the SC1D.i” Consequently, binge eating was assessed not only by patients’ self-report, but also by clinical interview by an experienced investigator in order to more reliably distinguish between binge eating and a general tendency to overeat. Twenty-two (34.4%) patients reported recurTable 1. Characteristics
of Binge Eating Episodes (Overeatha
Plus Loss of Control1
OftWli N
AlWayS
Sometimes
Rarely
N&W?r
Consuming a large amount of 22
11
9
1
0
Eating very rapidly Feeling miserable or annoyed
22
14
6
0
2
after overeating Uncontrollable urges to eat
21
17
3
1
0
food during overeating
and then eating until physically ill Eating when alone
20
8
10
2
0
21
15
3
1
2
21
20
1
0
0
Feeling extremely or very uncomfortable with eating behavior
258
similar statements are included in the DSED: (1) eating very rapidly, (2) eating until physically ill, (3) eating when alone, and (4) feeling miserable and annoyed after an eating binge. No information is available on the two other indicators “eating large amounts of food throughout the day with no planned mealtimes,” and “eating large amounts of food when not physically hungry.” Leaving out the frequency criterion, 14 (21.9%) subjects in our sample met at least two of the four available indicators of loss of control either often or always, were very or extremely uncomfortable with their binge eating behavior, and did not meet criteria for current bulimia nervosa. In our opinion, this represents a rough but conservative estimate of what the frequency of binge eating disorder might have been in our sampIe at study entry. The mean age of the binge eaters was 33.5 years (range, 19 to 52 years), and most reported having had problems with binge eating for several years (range, 0.25 to 25 years). Patients were asked to report the frequency of binge eating and other eating-related behavior during the month preceding evaluation, Patients who reported binge eating episodes indicated a variety of frequencies: once a day (n = 3) several times a week (n = 5) once a week (n = 3), several times a month (n = 6), or once a month (n = 5). Three also reported vomiting episodes during the last month; in addition, five patients indicated they had selfinduced vomiting once in the past, but had not pursued this behavior. Three reported laxative intake for weight control purposes during the last month, whereas an additional eight indicated that they had tried using laxatives in the past, usually for a few months, but then abandoned this behavior. Three patients had used diet pills, two had used diuretics, and one had used enemas for weight control purposes during the last month. Twenty patients reported being very or extremely uncomfortable with their binge eating behavior. In summary, although almost all binge eaters were markedly distressed by their abnormal eating behavior, the overall current binge eating frequency was moderate in the majority of our patients, and only a few engaged in the characteristic compensatory behaviors associated with
de ZWAAN, NUTZINGER, AND SCHOENBECK
bulimia nervosa, such as vomiting and use of laxatives. The patients were also asked to indicate during what time of the day they were most likely to binge eat. Four indicated early morning (8 to 10 AM), late morning (10 AM to noon), or afternoon (noon to 4 PM), whereas three indicated early evening (4 to 6 PM), 10 evening (6 to 8 PM), and five late evening (8 PM to midnight). These data indicate an increasing risk for this behavior during the day, with a peak in the evening hours. This result is in line with the findings of Mitchell et al. in patients with bulimia.19 Twenty-one patients indicated that the location where binge eating episodes was most IikeIy to occur was at home, and 15 indicated that they were always or often alone when they had a binge eating episode. The most favored binge foods were sweets (n = 15), followed by bread, cereals and pasta, meat, and salty snacks. These data clearly indicate a strong similarity on eating-related variables between patients with normal-weight bulimia nervosa and overweight subjects with binge eating problems: binge eating is a secretive habit, usually carried out at home, with calorie-dense foods being the favorite binge foods. Comparison af Pretreatment Variables
Binge eaters were significantly younger than non-binge eaters (mean, 33.5 v 42.2 years; t = 3.738, P < .OOl) (Table 2). This result is consistent with other recent literature.4,s Marcus et al. suggested that women with binge eating problems might be more distressed about
Table 2. Pretreatment
Comparison of Binge
and Non-binge
Eaters
Binge Eaters (n = 22)
Age, years (mean it SD1
33.5 t 10.3
Non-binge Eaters kl = 42) 42.2 2 8.1*
76.2
47.5t
18.8 r 6.6
26.4 + 9.6*
Affective disorders (%)
54.5
57.1
Anxiety disorders (“to)
45.5
Childhood obesity (%) Age at first diet (mean & SD) Lifetime prevalence of
26.2
BMI, kg/mz; (mean f SD)
35.8 t 5.6
36.7 2 4.7
BDQ (mean t SD)
62.1 -t 38.5
42.9 2 35.2t
BDI (mean it SD)
15.9 i_ 6.9
13.0 * 9.5
9.4 * 4.7
6.7 2 5.lt
HAM-D, 17-item (mean 2 SD) *P < .Ol; tP < .05.
BINGE EATING IN OVERWEIGHT
WOMEN
their weight and seek treatment sooner than those without significant problems in this area.5 Onset of obesity in childhood (< 12 years) was more common in binge eaters than nonbinge eaters (x2 = 4.635, df= 1, P < .05), and binge eaters were significantly younger when they first started dieting (mean, 18.8 v 26.4 years; t = 3.13, P < .Ol) (Table 2). In line with these findings, Loro and Orleans found that subjects with early onset of obesity reported more serious problems with binge eating than subjects with adult onset of obesity.2 Restriction of calorie intake associated with dieting has consistently been cited as a precipitating factor in the development of binge eating in patients with bulimia nervosa. Mitchell et al. in a series of 275 females with bulimia demonstrated that 85% started binge eating during a period of voluntary dieting.?O Although our data do not allow us to confirm this, it is tempting to speculate that these patients may have dieted more frequently in the past, and were therefore at greater risk of developing binge eating. Binge eaters tended to have higher BDQ total scores than non-binge eaters (t = -2.004, P < .05) (Table 2). The BDQ is largely concerned with unpleasant bodily sensations. The 82-item questionnaire comprises seven subscales, including “smaller,” “larger,” “blocked openings, ” “boundary loss,” “skin,” “dirt,” and “depersonalization.” The significant difference in BDQ total scores in our sample was primarily due to highly significant differences (P < .Ol) in the subscales boundary loss (e.g., “I feel like my body is unprotected”), blocked openings (e.g., “My body feels like it is stuffed or too full”) and dirt (e.g., “My skin feels unclean”). Other investigators have found significantly more cognitive distortion and maladaptive dieting behavior in binge eating than non-binge eating obese subjects,3*i0 suggesting a similarity between overweight, normal-weight, and underweight binge eaters. Body image disturbances are a main feature in patients with normalweight bulimia nervosa and anorexia nervosa, and-according to our data-may also be more prevalent in binge eating obese when compared with their non-binge eating counterparts. Thirty-six (56%) patients in our sample displayed a lifetime history of a major affective disorder, including bipolar disorder, single or
259
recurrent major depressive disorder, and dysthymia. In addition, 21 (32.8%) patients met criteria for an anxiety disorder, including panic disorder and/or agoraphobia, generalized anxiety disorder, social phobia, simple phobia, and obsessive-compulsive disorder. The relative distribution was not significantly different between binge eating and non-binge eating subjects. However, among the binge eaters, there was a clear trend for patients with a lifetime history of depression to have a higher binge eating frequency during the last month (mean, 9.75 v 2.8 binge eating episodes; t = 2.042, P = .055). The binge eaters tended to have higher HAM-D scores at baseline (t = -2.064, P < .05) than the non-binge eaters. The BDI scores did not differ between binge and non-binge eating patients (Table 2); however, within the binge eating group, there was a significant relationship between the binge eating frequency and the BDI scores at baseline (simple regression, t = 3.063, P < .Ol) (Table 2). Most studies have found significantly more depressive symptomatology and overall emotional distress in binge eating than in non-binge eating obese.‘O Loro and Orleans found a positive relationship between severity of binge eating and past history of psychotherapeutic contact.’ Other@ found that obese bulimics, like normal-weight bulimic subjects, displayed a significantly higher lifetime prevalence of major affective disorder (ranging from 32% to 91%) than did obese non-binge eaters. The lack of a significant difference in the prevalence of depressive and anxiety disorders between binge eating and non-binge eating obese in our sample is most likely due to our selection criteria, since the prevalence of psychiatric disorders in our sample in general was quite high, with 72% meeting criteria for one or more psychiatric disorders according to DSMIII-R. No relationship was found between the presence of binge eating and weight (BMI) at baseline. Also, binge eating frequency was not related to weight. Data on this association are conflicting in the available literature. Some studies have found a significant association between binge severity and pretreatment weight,4JJ whereas others have not.3lirJ’
260
de ZWAAN, NUTZINGER, AND SCHOENBECK
Comparison of Treatment Outcome
Table 4. Weight Change as a Function of Binge Eating
The scores of the depression ratings (HAM-D, BDI) and the body image rating (BDQ) decreased significantly in both binge and nonbinge eaters; at the end of the treatment phase, there were no statistically significant differences between the two groups in the HAM-D or BDI scores. However, there was a slight tendency (P = .08) for the differences in the BDQ total score to persist despite treatment (Table 3). Changes in depressive symptoms assessed with the BDI and the HAM-D, as well as changes in body image scores, did not differ as a function of treatment condition or binge status with one exception: among the binge eaters, reduction of HAM-D scores was significantly greater when they were treated with fluvoxamine as compared with placebo (-8.6 and -2.1, respectively, t = 2.463, P < *OS). Fluvoxamine- and placebo-treated binge eaters did not differ significantly in their HAM-D scores at pretreatment (Table 2). Binge eaters and non-binge eaters completing the program did not differ in amount of weight lost at the end of the active treatment and at the l-year follow-up, although binge eaters regained three times more weight than non-binge eaters (P = .l) during the l-year follow-up period (Table 4). Research has indicated that this subgroup of the obese may have an earlier relapse following weight 10~s.‘~Binge eaters showed a slightly higher attrition rate (31.8% v 21.4%), but, again, this difference was not statistically significant. Binge frequency at baseline did not affect posttreatment weight change. There was no evidence whatsoever that the patients responded more favorably to one of the four treatment conditions with regard to the amount of weight loss. This is true for both groups-binge eaters and non-binge eaters, This finding is consistent with Marcus et al’s results with fluoxetine, which indicated that
Table 3. Posttreatment
Comparison of Binge and Non-binge
Eaters Who Completed Treatment
BDQ (mean -+ SD)
Binge Eaters (n = 15)
Non-binge Eaters (n = 29)
35.0 i 35.6
19.6 A 22.7x
BDI [mean f SD)
9.5 k 10.2
6.7 t- 9.1
HAM-D, 17-item (mean i: SD)
5.1 -t 4.7
3.8 + 3.6
“P = .08.
Weight Change, kg (mean i SD)
Drop Out N (%)
22
7 (31.8)
-6.12
t 4.7
+4.63 2 9.9
Non-binge
42
9 (21.4)
-5.61
i: 3.7
+1.55 + 5.1
eaters
TrEXXmE#It
Follow-Up
N Binge eaters
ffuoxetine 60 mg/d did not show a differential benefit for binge eaters= with regard to weight loss. However, it must be stressed that our sample size was small, and the dosage used was only 100 mgld, which may not be optimal in this sample. DISCUSSION
In our sample, 34.4% of subjects reported having problems with binge eating. This is in line with the results of other studies on the prevalence of binge eating in obese subjects. Binge eating was assessed not only by patients’ self-report (DSED), but was also confirmed by a clinical interview (SCID). Furthermore, the definition of binge eating included both episodic overeating and the sense of loss of control. Applying the recently proposed criteria for binge eating disorder, omitting the frequency criterion of two episodes a week for 6 months, an estimated 21.9% (n = 14) might have met the criteria at study entry. Nevertheless, our definition of a binge eater was still rather broad, since it also included patients with only moderate problems with regard to the binge eating frequency. Despite this probably overin~lusive definition, the consistency of our results with the findings of other studies comparing binge eating and non-binge eating obese subjects is striking and supports the concept of this subgroup as a distinct entity, which has behavioral and emotional similarities to normal-weight subjects with bulimia nervosa. The occurrence of binge eating was negatively correlated with age, and age at first dieting. A positive relationship was found with onset of obesity in childhood, distorted body experiences as measured by the BDQ, and depressive symptomatology as assessed by the HAM-D. Furthermore, a lifetime history of major affective illness and the BDI total score at baseline were positively related to binge eating frequency during the month preceding study entry.
BINGE EATING IN OVERWEIGHT
261
WOMEN
No significant association was found between the presence and the frequency of binge eating and pretreatment weight and the weight changes during treatment and follow-up. The amount of weight lost was not influenced by treatment condition or binge status. The addition of 100 mg fluvoxamine did not appear to have a particular benefit for the binge eating obese subjects in most of the outcome variables examined, except for a greater improvement of HAM-D scores in fluvoxaminetreated binge eaters when compared with placebo-treated subjects. However, there are several important limitations in the current study, which make interpretations of the results difficult: (1) The extent and severity of binge eating problems were not properly assessed. As suggested by others, binge eating is probably best considered a continuous rather than dichotomous variable.” Many signif-
icant correlations described in the literature included binge eating severity-as assessed, e.g., with the Binge Eating Scale (BES), which includes feelings and cognitions besides the behavioral manifestations of an eating binge.j Such other variables are important to examine rather than to only focus on the presence or absence of binge eating. (2) We did not monitor this eating pattern throughout treatment. Despite these limitations, our results support the need to investigate variations among the obese, rather than assuming homogeneity in this population. It is important that significant subgroups of obese persons be identified and described in order to be able to individualize and optimize weight-reduction treatments. ACKNOWLEDGMENT The authors gratefully acknowledge Mitchell’s helpful comments regarding
Professor James this report.
E.
REFERENCES 1. Stunkard AJ. Eating 1059:33:284-292.
patterns
and obesity.
Psychiatr
Q
2. Loro AD, Orleans CS. Binge eating in obesity: preliminary findings and guidelines for behavioral analysis and treatment. Addict Behav 1981:6:155-166. 3. Gormally J, Black S, Daston S, Rardin D. The assessment of binge eating severity among obese persons. Addict Behav 1982;7:47-55. 4. Keefe PH, Wyshogrood Binge eating and outcome obesity: a preliminary report. 321.
D, Weinberger E, Agras WS. of behavioral treatment of Behav Res Ther 1984;22:319-
5. Marcus MD, Wing RR, Lamparski DM. Binge eating and dietary restraint in obese patients. Addict Behav 1985:10:163-168. 6. Hudson JI, Pope HG, Wurtman J, Yurgelen-Todd D. Mark S. Rosenthal NE. Bulimia in obese individuals. J Nerv Ment Dis 1988;176:144-152. 7. Wardle J. Beinart H. Binge eating: review. Br J Clin Psycho1 1981;20:97-109.
a theoretical
8. Wilson GT. Obesity, binge-eating and behavior therapy: some clinical observations. Behav Ther 1976;7:700-701. 9. Gormally J, Rardin D, Black S. Correlates of successful response to a behavioral weight control clinic. J Couns Psycho1 1980;27:179-191. IO. Marcus MD, Wing RR, Hopkins J. Obese binge eaters: Affect, cognitions, and response to behavioral weight control. J Consult Clin Psycho1 1988;56:433-439. Il. Kolotkin RL, Revis ES. Kirkley BG, Janick eating in obesity: associated MMPI characteristics. sult Clin Psycho1 1987;55:872-876.
L. Binge J Con-
12. Alger SA, Schwalberg MD, Bigaouette JM, Michalek AV, Howard LJ. Effect of a tricyclic antidepressant and opiate antagonist on binge-eating behavior in normoweight
bulimic and obese, binge-eating subjects. Am J Clin Nutr 1991;53:865-871. 13. Marcus MD, Wing RR, Ewing L, Kern E. Gooding W. McDermott M. Psychiatric disorders among obese binge eaters. Int J Eating Disord 1990;9:69-77. 14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. ed. 3 rev. Washington, DC: American Psychiatric Association Press, 1980. 15. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 3960;23:56-62. 16. Johnson C. Initial consultation for patients with bulimia and anorexia nervosa. In: Garner DM, Garfinkel PE (eds): Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York, NY: Guilford. 1985:19-51. 17. Beck AT, Ward CH, Mendelson M, Mock J. Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:53-63. 18. Fisher S. Body Experience in Fantasy and Behavior. New York, NY: Appleton-Century-Crofts, 1970. 19. Mitchell JE, Hatsukami D. Eckert ED. Pyle RL. Characteristics of 275 patients with bulimia. Am J Psychiatry 1985;142:482-485. 20. Mitchell JE, Hatsukami D, Pyle RL, et al. The bulimia syndrome: course of the illness and associated problems. Compr Psychiatry 1986;27:165-170. 21. Telch CF. Agras WS. Rossiter EM. Binge eating increases with increasing adiposity. Int J Eating Disord 1988;7:115-119. 22. Lowe MR, Caputo GC. Binge eating in obesity: Toward the specification of predictors. Int J Eating Disord 1991;10:49-55. 23. Marcus MD, Wing RR, Ewing L, Kern E. McDermott M, Gooding W. A double-blind, placebo-controlled trial of fluoxetine plus behavior modification in the treatment of obese binge-eaters and non-binge-eaters. Am J Psychiatry 1990;147:876-881.
Women
Martina de Zwaan, Detlev 0. Nutzinger, and Georg Schoenbeck Data on the prevalence and characteristics of binge eating in a series of 64 obese women participating in a controlled weight-reduction program are presented. Twenty-two (34.4%) reported recurrent binge eating episodes defined as overeating plus loss of control as assessed by patients’ self-report and confirmed by a clinical interview. Six of those indicated that they engaged in either self-induced vomiting or laxative use to control their weight, but only two met full criteria for current bulimia nervosa according to DSM-III-R. A detailed description of the binge eating behavior revealed similarities to the eating pattern described in patients with bulimia nervosa: obese binge eaters tended to overeat in the evening, when they were alone and at home. Compared with their non-binge
A
LTHOUGH Stunkard identified binge eating as a distinct eating disturbance in obese patients more than 30 years ago,’ only recently has increasing attention been focused on the occurrence and prevalence of binge eating in the obese population. The following observations have recently been made: (1) Binge eating represents a serious problem for 23% to 46% of obese individuals seeking weight loss treatment.2-6 In some hospital-affiliated weightreduction programs, the percentage of obese subjects who reported not having problems with binge eating is low, ranging from 17.9% to 22%.3J (2) Binge eating seems to be more common in overweight women than men.7 (3) Purging is less frequent in obese individuals than in normal-weight binge eaters or anorectics with bulimia.6,7 (4) Binge eating often complicates standard behavioral weight-reduction treatment.4,8,9 (5) Obese binge eaters are more likely to drop out of behavioral treatment than non-binge eaters.‘” (6) They are more prone to regain weight following treatment.‘O (7) They differ from obese non-binge eaters on psychological and affective variables. They seem to experience more psychological distress such as low From the Department of Psychiatry, University of Henna, Austria. Supported in part by Kali Chemie Pharma, Division Duphar, Austria. Address reprint requests to Martina de Zwaan, M.D., Depatiment of Psychiatry, University of Vienna, Waehn’nger Guertel 18-20, 1090 Vienna, Austria. Copyright 0 1992 by W.B. Saunders Company 0010-440X/92/3304-0009$03.0010 256
eating counterparts, binge eaters were significantly younger when they presented for treatment. The prevalence of childhood obesity was higher, and they were significantly younger when they first started on a diet than the non-binge eaters. Binge eaters reported more psychological problems such as body image distortion, and there was a slight tendency for binge eaters to exhibit more depressive symptomatology at baseline. No association between binge eating and weight at baseline, or weight loss during therapy or at follow-up could be found. Fluvoxamine (100 mg) did not seem to be of specific benefit in this subgroup of the obese with regard to weight loss. Copyright 0 1992 by W.B. Saunders Company
self-efficacy and self-esteem, and high levels of depressionlO-l2 and other psychiatric disorders.13 Marcus et al. found that such differences appeared to persist despite behavioral treatment.‘O Others found a personal and family history of substance abuse similar to the normalweight bulimics.12 (8) Binge eating obese individuals display more maladaptive dieting behavior and attitudes such as dietary restraint and unrealistically high dieting standards.3,5 This report concentrates on the prevalence and the description of binge eating behavior in a group of obese women, all of whom also reported that they were experiencing emotional problems, the latter being a requirement for study participation. They were evaluated for participation in a controlled treatment study for weight reduction. Patients were assigned to one of four different treatment conditions: cognitive behavioral treatment (CBT) plus fluvoxamine, CBT plus placebo, dietary management (DM) plus fluvoxamine, or DM plus placebo. Furthermore, to compare binge eaters with non-binge eaters, pooled-variance t tests and Pearson chi-square analyses were conducted on pretreatment and posttreatment variables. In addition, simple regression analyses were performed to assess the relationship between binge eating frequency and the pretreatment and posttreatment variables. METHOD
Subjects, Assessment Subjects were recruited from the Outpatient Clinic of the Psychiatry Department in Vienna, and from referrals from
Comprehensive Psychiatry, Vol. 33, No. 4 (July/August), 1992: pp 256-261
BINGE EATING IN OVERWEIGHT
257
WOMEN
rent binge eating episodes, defined as “eating a large amount of food in a short period of time.” According to the structured interview, only two patients met full criteria for a current DSMIII-R diagnosis of bulimia nervosa. The remaining 20 patients fulfilled at least criterion A (“rapid consumption of a large amount of food in a discrete period of time”) plus criterion B (“a feeling of lack of control over the eating behavior during the eating binges”), but they either did not engage in regular purging behavior, vigorous exercise, or repeated 24-hour fasting, or did not fullfill the frequency criterion of having two episodes per week for 3 months. Table 1 gives a more detailed description of the characteristics of the eating binges in our sample. Recently, it has been suggested that binge eating be defined as having two components: episodic overeating and the sense of loss of control (personal communication, DSM-IV Work Group on Eating Disorders). Our definition of binge eating is therefore in line with these newly suggested criteria. The Eating Disorders Work Group has developed prelimina~ criteria for a new eating disorder called “binge eating disorder.” Besides recurrent binge eating episodes, this diagnosis requires behavioral indicators of loss of control, marked distress regarding binge eating, and a frequency of at least two episodes per week for a h-month period. In addition, patients who meet criteria for current bulimia nervosa are to be excluded. Of the suggested six behavioral indicators of loss of control, we have information on four, since
practitioners and other health facilities who were informed about our study through letters. Only subjects who had either a history of a major affective disorder and/or reported emotional disturbances secondary to dieting were enrolled. The sample comprised 64 women. Their mean age was 39 years (range, 19 to 54). The mean pretreatment body mass index (BMI) was 36.4 kg/m” (range, 28.5 to 47.1 kg/m*). One week before beginning treatment, subjects underwent a Structured Clinical Interview (SCID) to assess DSM III-R diagnoses,‘l and were rated using the Hamilton Rating Scale for Depression (HAM-D).t5 Furthermore, subjects were asked to fill out the Diagnostic Survey of Eating Disorders (DSED)lh to gather information about their eating and weight history, the Beck Depression Inventory (BDI),” and the Body Distortion Questionnaire (BDQ).‘s
RESULTS Overall Results
Forty-eight subjects completed the study. Their mean weight loss was 5.8 ? 4.0 kg (range, 16.3 kg [35.8 lb] lost to 1.9 kg [4.2 lb] gained). There were no significant differences among the four treatment conditions with regard to the amount of weight reduction. Binge Eating and Eating-Related Variables The info~ation on binge eating and eatingrelated variables is based on responses to an eating history questionnaire (DSED)16 completed by each patient before entering the study, as well as on results of the SC1D.i” Consequently, binge eating was assessed not only by patients’ self-report, but also by clinical interview by an experienced investigator in order to more reliably distinguish between binge eating and a general tendency to overeat. Twenty-two (34.4%) patients reported recurTable 1. Characteristics
of Binge Eating Episodes (Overeatha
Plus Loss of Control1
OftWli N
AlWayS
Sometimes
Rarely
N&W?r
Consuming a large amount of 22
11
9
1
0
Eating very rapidly Feeling miserable or annoyed
22
14
6
0
2
after overeating Uncontrollable urges to eat
21
17
3
1
0
food during overeating
and then eating until physically ill Eating when alone
20
8
10
2
0
21
15
3
1
2
21
20
1
0
0
Feeling extremely or very uncomfortable with eating behavior
258
similar statements are included in the DSED: (1) eating very rapidly, (2) eating until physically ill, (3) eating when alone, and (4) feeling miserable and annoyed after an eating binge. No information is available on the two other indicators “eating large amounts of food throughout the day with no planned mealtimes,” and “eating large amounts of food when not physically hungry.” Leaving out the frequency criterion, 14 (21.9%) subjects in our sample met at least two of the four available indicators of loss of control either often or always, were very or extremely uncomfortable with their binge eating behavior, and did not meet criteria for current bulimia nervosa. In our opinion, this represents a rough but conservative estimate of what the frequency of binge eating disorder might have been in our sampIe at study entry. The mean age of the binge eaters was 33.5 years (range, 19 to 52 years), and most reported having had problems with binge eating for several years (range, 0.25 to 25 years). Patients were asked to report the frequency of binge eating and other eating-related behavior during the month preceding evaluation, Patients who reported binge eating episodes indicated a variety of frequencies: once a day (n = 3) several times a week (n = 5) once a week (n = 3), several times a month (n = 6), or once a month (n = 5). Three also reported vomiting episodes during the last month; in addition, five patients indicated they had selfinduced vomiting once in the past, but had not pursued this behavior. Three reported laxative intake for weight control purposes during the last month, whereas an additional eight indicated that they had tried using laxatives in the past, usually for a few months, but then abandoned this behavior. Three patients had used diet pills, two had used diuretics, and one had used enemas for weight control purposes during the last month. Twenty patients reported being very or extremely uncomfortable with their binge eating behavior. In summary, although almost all binge eaters were markedly distressed by their abnormal eating behavior, the overall current binge eating frequency was moderate in the majority of our patients, and only a few engaged in the characteristic compensatory behaviors associated with
de ZWAAN, NUTZINGER, AND SCHOENBECK
bulimia nervosa, such as vomiting and use of laxatives. The patients were also asked to indicate during what time of the day they were most likely to binge eat. Four indicated early morning (8 to 10 AM), late morning (10 AM to noon), or afternoon (noon to 4 PM), whereas three indicated early evening (4 to 6 PM), 10 evening (6 to 8 PM), and five late evening (8 PM to midnight). These data indicate an increasing risk for this behavior during the day, with a peak in the evening hours. This result is in line with the findings of Mitchell et al. in patients with bulimia.19 Twenty-one patients indicated that the location where binge eating episodes was most IikeIy to occur was at home, and 15 indicated that they were always or often alone when they had a binge eating episode. The most favored binge foods were sweets (n = 15), followed by bread, cereals and pasta, meat, and salty snacks. These data clearly indicate a strong similarity on eating-related variables between patients with normal-weight bulimia nervosa and overweight subjects with binge eating problems: binge eating is a secretive habit, usually carried out at home, with calorie-dense foods being the favorite binge foods. Comparison af Pretreatment Variables
Binge eaters were significantly younger than non-binge eaters (mean, 33.5 v 42.2 years; t = 3.738, P < .OOl) (Table 2). This result is consistent with other recent literature.4,s Marcus et al. suggested that women with binge eating problems might be more distressed about
Table 2. Pretreatment
Comparison of Binge
and Non-binge
Eaters
Binge Eaters (n = 22)
Age, years (mean it SD1
33.5 t 10.3
Non-binge Eaters kl = 42) 42.2 2 8.1*
76.2
47.5t
18.8 r 6.6
26.4 + 9.6*
Affective disorders (%)
54.5
57.1
Anxiety disorders (“to)
45.5
Childhood obesity (%) Age at first diet (mean & SD) Lifetime prevalence of
26.2
BMI, kg/mz; (mean f SD)
35.8 t 5.6
36.7 2 4.7
BDQ (mean t SD)
62.1 -t 38.5
42.9 2 35.2t
BDI (mean it SD)
15.9 i_ 6.9
13.0 * 9.5
9.4 * 4.7
6.7 2 5.lt
HAM-D, 17-item (mean 2 SD) *P < .Ol; tP < .05.
BINGE EATING IN OVERWEIGHT
WOMEN
their weight and seek treatment sooner than those without significant problems in this area.5 Onset of obesity in childhood (< 12 years) was more common in binge eaters than nonbinge eaters (x2 = 4.635, df= 1, P < .05), and binge eaters were significantly younger when they first started dieting (mean, 18.8 v 26.4 years; t = 3.13, P < .Ol) (Table 2). In line with these findings, Loro and Orleans found that subjects with early onset of obesity reported more serious problems with binge eating than subjects with adult onset of obesity.2 Restriction of calorie intake associated with dieting has consistently been cited as a precipitating factor in the development of binge eating in patients with bulimia nervosa. Mitchell et al. in a series of 275 females with bulimia demonstrated that 85% started binge eating during a period of voluntary dieting.?O Although our data do not allow us to confirm this, it is tempting to speculate that these patients may have dieted more frequently in the past, and were therefore at greater risk of developing binge eating. Binge eaters tended to have higher BDQ total scores than non-binge eaters (t = -2.004, P < .05) (Table 2). The BDQ is largely concerned with unpleasant bodily sensations. The 82-item questionnaire comprises seven subscales, including “smaller,” “larger,” “blocked openings, ” “boundary loss,” “skin,” “dirt,” and “depersonalization.” The significant difference in BDQ total scores in our sample was primarily due to highly significant differences (P < .Ol) in the subscales boundary loss (e.g., “I feel like my body is unprotected”), blocked openings (e.g., “My body feels like it is stuffed or too full”) and dirt (e.g., “My skin feels unclean”). Other investigators have found significantly more cognitive distortion and maladaptive dieting behavior in binge eating than non-binge eating obese subjects,3*i0 suggesting a similarity between overweight, normal-weight, and underweight binge eaters. Body image disturbances are a main feature in patients with normalweight bulimia nervosa and anorexia nervosa, and-according to our data-may also be more prevalent in binge eating obese when compared with their non-binge eating counterparts. Thirty-six (56%) patients in our sample displayed a lifetime history of a major affective disorder, including bipolar disorder, single or
259
recurrent major depressive disorder, and dysthymia. In addition, 21 (32.8%) patients met criteria for an anxiety disorder, including panic disorder and/or agoraphobia, generalized anxiety disorder, social phobia, simple phobia, and obsessive-compulsive disorder. The relative distribution was not significantly different between binge eating and non-binge eating subjects. However, among the binge eaters, there was a clear trend for patients with a lifetime history of depression to have a higher binge eating frequency during the last month (mean, 9.75 v 2.8 binge eating episodes; t = 2.042, P = .055). The binge eaters tended to have higher HAM-D scores at baseline (t = -2.064, P < .05) than the non-binge eaters. The BDI scores did not differ between binge and non-binge eating patients (Table 2); however, within the binge eating group, there was a significant relationship between the binge eating frequency and the BDI scores at baseline (simple regression, t = 3.063, P < .Ol) (Table 2). Most studies have found significantly more depressive symptomatology and overall emotional distress in binge eating than in non-binge eating obese.‘O Loro and Orleans found a positive relationship between severity of binge eating and past history of psychotherapeutic contact.’ Other@ found that obese bulimics, like normal-weight bulimic subjects, displayed a significantly higher lifetime prevalence of major affective disorder (ranging from 32% to 91%) than did obese non-binge eaters. The lack of a significant difference in the prevalence of depressive and anxiety disorders between binge eating and non-binge eating obese in our sample is most likely due to our selection criteria, since the prevalence of psychiatric disorders in our sample in general was quite high, with 72% meeting criteria for one or more psychiatric disorders according to DSMIII-R. No relationship was found between the presence of binge eating and weight (BMI) at baseline. Also, binge eating frequency was not related to weight. Data on this association are conflicting in the available literature. Some studies have found a significant association between binge severity and pretreatment weight,4JJ whereas others have not.3lirJ’
260
de ZWAAN, NUTZINGER, AND SCHOENBECK
Comparison of Treatment Outcome
Table 4. Weight Change as a Function of Binge Eating
The scores of the depression ratings (HAM-D, BDI) and the body image rating (BDQ) decreased significantly in both binge and nonbinge eaters; at the end of the treatment phase, there were no statistically significant differences between the two groups in the HAM-D or BDI scores. However, there was a slight tendency (P = .08) for the differences in the BDQ total score to persist despite treatment (Table 3). Changes in depressive symptoms assessed with the BDI and the HAM-D, as well as changes in body image scores, did not differ as a function of treatment condition or binge status with one exception: among the binge eaters, reduction of HAM-D scores was significantly greater when they were treated with fluvoxamine as compared with placebo (-8.6 and -2.1, respectively, t = 2.463, P < *OS). Fluvoxamine- and placebo-treated binge eaters did not differ significantly in their HAM-D scores at pretreatment (Table 2). Binge eaters and non-binge eaters completing the program did not differ in amount of weight lost at the end of the active treatment and at the l-year follow-up, although binge eaters regained three times more weight than non-binge eaters (P = .l) during the l-year follow-up period (Table 4). Research has indicated that this subgroup of the obese may have an earlier relapse following weight 10~s.‘~Binge eaters showed a slightly higher attrition rate (31.8% v 21.4%), but, again, this difference was not statistically significant. Binge frequency at baseline did not affect posttreatment weight change. There was no evidence whatsoever that the patients responded more favorably to one of the four treatment conditions with regard to the amount of weight loss. This is true for both groups-binge eaters and non-binge eaters, This finding is consistent with Marcus et al’s results with fluoxetine, which indicated that
Table 3. Posttreatment
Comparison of Binge and Non-binge
Eaters Who Completed Treatment
BDQ (mean -+ SD)
Binge Eaters (n = 15)
Non-binge Eaters (n = 29)
35.0 i 35.6
19.6 A 22.7x
BDI [mean f SD)
9.5 k 10.2
6.7 t- 9.1
HAM-D, 17-item (mean i: SD)
5.1 -t 4.7
3.8 + 3.6
“P = .08.
Weight Change, kg (mean i SD)
Drop Out N (%)
22
7 (31.8)
-6.12
t 4.7
+4.63 2 9.9
Non-binge
42
9 (21.4)
-5.61
i: 3.7
+1.55 + 5.1
eaters
TrEXXmE#It
Follow-Up
N Binge eaters
ffuoxetine 60 mg/d did not show a differential benefit for binge eaters= with regard to weight loss. However, it must be stressed that our sample size was small, and the dosage used was only 100 mgld, which may not be optimal in this sample. DISCUSSION
In our sample, 34.4% of subjects reported having problems with binge eating. This is in line with the results of other studies on the prevalence of binge eating in obese subjects. Binge eating was assessed not only by patients’ self-report (DSED), but was also confirmed by a clinical interview (SCID). Furthermore, the definition of binge eating included both episodic overeating and the sense of loss of control. Applying the recently proposed criteria for binge eating disorder, omitting the frequency criterion of two episodes a week for 6 months, an estimated 21.9% (n = 14) might have met the criteria at study entry. Nevertheless, our definition of a binge eater was still rather broad, since it also included patients with only moderate problems with regard to the binge eating frequency. Despite this probably overin~lusive definition, the consistency of our results with the findings of other studies comparing binge eating and non-binge eating obese subjects is striking and supports the concept of this subgroup as a distinct entity, which has behavioral and emotional similarities to normal-weight subjects with bulimia nervosa. The occurrence of binge eating was negatively correlated with age, and age at first dieting. A positive relationship was found with onset of obesity in childhood, distorted body experiences as measured by the BDQ, and depressive symptomatology as assessed by the HAM-D. Furthermore, a lifetime history of major affective illness and the BDI total score at baseline were positively related to binge eating frequency during the month preceding study entry.
BINGE EATING IN OVERWEIGHT
261
WOMEN
No significant association was found between the presence and the frequency of binge eating and pretreatment weight and the weight changes during treatment and follow-up. The amount of weight lost was not influenced by treatment condition or binge status. The addition of 100 mg fluvoxamine did not appear to have a particular benefit for the binge eating obese subjects in most of the outcome variables examined, except for a greater improvement of HAM-D scores in fluvoxaminetreated binge eaters when compared with placebo-treated subjects. However, there are several important limitations in the current study, which make interpretations of the results difficult: (1) The extent and severity of binge eating problems were not properly assessed. As suggested by others, binge eating is probably best considered a continuous rather than dichotomous variable.” Many signif-
icant correlations described in the literature included binge eating severity-as assessed, e.g., with the Binge Eating Scale (BES), which includes feelings and cognitions besides the behavioral manifestations of an eating binge.j Such other variables are important to examine rather than to only focus on the presence or absence of binge eating. (2) We did not monitor this eating pattern throughout treatment. Despite these limitations, our results support the need to investigate variations among the obese, rather than assuming homogeneity in this population. It is important that significant subgroups of obese persons be identified and described in order to be able to individualize and optimize weight-reduction treatments. ACKNOWLEDGMENT The authors gratefully acknowledge Mitchell’s helpful comments regarding
Professor James this report.
E.
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