Overweight Binge Eaters Can Diet but Need Extra Help

Miriam E Tucker

November 07, 2017

WASHINGTON, DC — Binge eating isn't a contraindication for referral to intensive-lifestyle interventions, including weight loss diets, but patients who engage in the behavior may require additional treatment, new research suggests.

New findings from the Action for Health in Diabetes (Look AHEAD) study were presented here on October 31 at Obesity Week 2017 by Ariana M Chao, PhD, RN, a family nurse practitioner who provides medical management for participants enrolled in research studies at the Center for Weight and Eating Disorders at the University of Pennsylvania School of Medicine, Philadelphia.

The results were also simultaneously published in Obesity. 

The novel data counter the concern that imposing restrictions on eating may trigger or exacerbate binge-eating behavior, but at the same time people who self-reported binge eating tended to lose less weight.

"Individuals [who binge eat] should not be excluded from lifestyle modification programs. However, binge eating should be assessed regularly during weight loss. Patients who report continued binge eating during behavioral weight loss may need to be referred for additional treatment, such as cognitive-behavioral therapy," Dr Chao told Medscape Medical News.

Asked to comment, Eric Ravussin, PhD, Boyd Professor at Louisiana State University, Baton Rouge, and coeditor of Obesity, told Medscape Medical News, "The question is, 'Is it safe in people with symptoms of binge eating or who practice it to put them on calorie restriction?' The answer is yes."

However, he also said that given that binge eating was fairly common — about one in 10 of the overweight/obese Look AHEAD study participants with type 2 diabetes exhibited it. "Before putting people on a weight-loss diet you have to assess that."

Indeed, Dr Chao noted, "Despite how common binge eating is among patients with obesity, it is frequently overlooked. Previous studies have indicated that rates of diagnosis and referral to treatment are low."

Intensive-Lifestyle Intervention Doesn't Appear to Trigger Binge Eating

The Look AHEAD study, a randomized controlled trial that compared intensive-lifestyle intervention with diabetes support and education in people with type 2 diabetes and body mass index of 25 kg/m2 or greater (or 27 kg/m2 or greater among those receiving insulin), included 4901 participants. 

The intensive-lifestyle intervention included individual and group sessions focused on improving diet and physical activity, with the goal of a mean weight loss of at least 7% of initial body weight.

Binge eating was assessed annually with a self-report questionnaire that asked whether participants had consumed a large amount of food in a short period while feeling a loss of control over eating at least once in the past 6 months. They were also asked about the frequency of the binges. 

At baseline, 11.2% (n = 546) reported having one or more binge-eating episodes in the past 6 months, while 1.1% met diagnostic criteria for binge-eating disorder (recurrent episodes of binge eating that occur at least once per week for at least 3 months, accompanied by marked distress and not associated with compensatory behaviors, such as purging).

Weight and questionnaire data were available for 89% of the participants at 4 years.

Of those without any binge eating at baseline, 10.2% of the intensive-lifestyle intervention group and 8.3% of the diabetes support and education group had begun the behavior during the study period. The difference didn't quite achieve statistical significance, with a hazard ratio of 1.22 (= .06).

In both groups, those who began binge eating during the study had made more previous weight-loss attempts, while older age and better physical- and mental-health–related quality-of-life scores were associated with a lower likelihood of bingeing. 

For the 546 patients who reported binge eating at baseline, the average number of bingeing days declined over the 4 years (P < .001 in both groups).

By year 4, nearly half of patients in both study groups who were bingeing at baseline had completely stopped (46% of the intensive lifestyle and 47% of diabetes support and education groups). No significant factors predicting remission were identified.  

Weight Loss Greater for Those Without Binge Eating

At year 4, in the intensive-lifestyle group, those who reported no binge eating at any time lost a mean of 4.6% of initial weight, while those who had begun bingeing during the study and those who had had the behavior the entire time lost less weight (3.1% and 1.9% of initial weight; P = .02 and .01, respectively).

Weight loss for those with completely remitted binge eating was 4.7%, similar to the rate in the group that never engaged in the behavior.

Dr Ravussin noted that the self-reporting of the binge-eating behavior was a limitation of the study and that the assessment was done via a short questionnaire, "not a formal binge-eating scale." 

Indeed, although not used in the study, many tools and questionnaires have been developed to screen for binge eating and disordered eating behaviors.

Addressing Binge Eating in Clinical Practice

Such tools include the Questionnaire on Eating and Weight Patterns-5, the Eating Disorder Screen for Primary Care,  and the SCOFF questionnaire.

"These brief assessments can be administered efficiently in primary-care settings," Dr Chao said.

And for those identified with bingeing, she said, "Evidence-based treatments for binge eating include psychological treatments, such as cognitive-behavioral therapy and interpersonal therapy. Pharmacological therapies are also available for patients who meet criteria for binge-eating disorder."

This study is supported by the Department of Health and Human Services g cooperative agreements from the National Institutes of Health (NIH). The following federal agencies have contributed support: National Institute of Diabetes and Digestive and Kidney Diseases, National Heart, Lung, and Blood Institute, National Institute of Nursing Research (NINR), National Center on Minority Health and Health Disparities, Office of Research on Women's Health, Centers for Disease Control and Prevention, and Department of Veterans Affairs. This research was supported in part by the Intramural Research Program of the National Institute of Diabetes and Digestive and Kidney Diseases. The Indian Health Service provided personnel, medical oversight, and use of facilities. Additional support was received from The Johns Hopkins Medical Institutions Bayview General Clinical Research Center, the Massachusetts General Hospital Mallinckrodt General Clinical Research Center and the Massachusetts Institute of Technology General Clinical Research Center, the University of Colorado Health Sciences Center, General Clinical Research Center and Clinical Nutrition Research Unit, the University of Tennessee at Memphis General Clinical Research Center, the University of Pittsburgh General Clinical Research Center, the Clinical Translational Research Center, and the Frederic C Bartter General Clinical Research Center. The following organizations have committed to make major contributions to Look AHEAD: FedEx, Health Management Resources, LifeScan, OPTIFAST of Nestle HealthCare Nutrition, Hoffmann-La Roche, Abbott Nutrition, and Slim-Fast Brand of Unilever North America. Dr Chao reports grant support from Shire Pharmaceuticals. Disclosures for the coauthors are listed in the paper. Dr Ravussin has disclosed no relevant financial relationships. 

Obesity. Published online October 30, 2017. Full text

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