1

Developing a new treatment

approach to binge eating and weight

management

Clinical Psychology Forum, Number 244, April 2013

Dr Marie Prince

Contents• Service information• Binge Eating Disorder• Binge Eating Disorder and Weight Loss• DEG Model• DEG Outcomes• Summary

Health and Social Care Information Centre, The Times, 21st February 2013www.nhsggc.org.uk/gcwms

Glasgow Drivers

Prevalence

Healthcare costs

Surgical waiting lists

3

1 in 4 Obese 2008, Route Map

£175 mill (2%)2007/2008

£49.9 billion2050 Foresight, 2008

Clear Pathway

GCWMS Aim

To establish a weight management pathway of care, from prevention through to the management of morbid

obesity, which is evidence based and equitable across NHS GGC Board

• offer consistent treatment approaches• optimise current resources• provide a clear referral route• ensure the appropriate use of drugs and surgical

interventions

4

.

A healthier weight through lasting lifestyle changes

SIGN: 08, 1996

SIGN: 115, 2010 Management of Obesity

NICE Clinical Guideline 43, 2006

The Scottish Government

Review of Bariatric Surgical Services in Scotland 2005

The Evidence Base

GCWMS Whole System Approach

7

Psychological Service Provision

← Priority Referrals directly to this level

← Routine Referralsdirectly to this level

Aims of Integrated Psychology Service

• Improve treatment outcomes (adherence to diet & activity changes required for weight management)

• To alleviate psychological distress interfering with obesity treatment (e.g. disordered eating; low self esteem; body image distress)

• Improve delivery of healthcare (reduce inappropriate uptake of treatment e.g. re-route clients to appropriate services; consider ‘readiness to change’)

• Lead, train & support other health professionals (in the use of psychological approaches)

8Glasgow & Clyde Weight Management Service

Developing a new treatment approach to binge eating and

weight management

Binge Eating Disorder DSM-IV• Recurrent episodes of binge eating

• Binge eating episode: Eating in a discrete period of time an amount of food that is definitely larger

than most people would eat in a similar period of time in similar circumstances A sense of lack of control over eating during the episode

• The binge eating episodes are associated with at least three of the following:• Eating more rapidly than normal• Eating until feeling uncomfortably full• Eating large amounts of food when not physically hungry• Eating alone because of being embarrassed by how much one is eating• Feeling disgusted with oneself, depressed, or guilty after overeating.

• Marked distress regarding binge eating

• The binge eating occurs, on average at least 2 days a week for six months.

• The binge eating is not associated with regular use of inappropriate compensatory behaviours and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Binge Eating Disorder

• Frequent weight fluctuations

• Childhood weight gain

• Higher levels of psychological co-morbidity compared to those without BED

• Female

• BMI>40 Kg/m2 Yanovski, 1993, Friedman & Brownell, 2002

A healthier weight through lasting lifestyle changes

Prevalence of BED

• General population: 3%(Hudson et al 2007)

• Obese population: 10% • Treatment seeking obese population: 30%

(Blaine & Rodman, 2007)

• Half of outpatient diagnoses (Fairburn et al, 2009)

Clinical Experience• Other individuals present with sub-clinical

disordered eating requiring psychological intervention:

• compulsive eating• using food as an emotional coping strategy• dysfunctional eating patterns

www.nhsggc.org.uk/gcwms

Weight Loss Interventions & BED

• Matched study meta-analysis, obese patients with BED lost 2% of body weight compared with 11% in non-BED participants

(Blaine and Rodman, 2007)

• Presence of disordered eating may reduce motivation and adherence to treatment

(Hainer et al., 2005)

A healthier weight through lasting lifestyle changes

BED Interventions and Weight Loss

• Systematic review of 7 RCTs comparing individual and group interventions in patients with BED, found CBT was effective in reducing binge eating and improving abstinence, but does not lead to weight loss.

(Brownley, 2007, Wilson, 2010)

• The effectiveness of CBT in reducing binge frequency but without influencing weight loss was also confirmed in an RCT with two years follow up.

(Devlin et al., 2005)

Glasgow & Clyde Weight Management Service

BED and Mood

• Increased levels of depression are seen in adults with severe obesity (BMI>40kg/m2) and obese adults with BED.

(Onyike et al, 2003)

• Increased rates of anxiety and lower levels of self esteem are also observed in obese adults with BED compared to non bingeing obese adults.

(Jirik-Bibb and Geliebter, 2003)

• In addition to the above BED is also associated with guilt and shame.

(APA, 2000)

www.nhsggc.org.uk/gcwms

Predictors of Outcome

• Baseline high level of negative affect lead to less weight loss.

• Increased severity of disordered eating is

observed in people with higher negative affect and increased psychiatric co morbidities.

• Lifetime history of depression predicted less remission from binge eating behaviours.

(Wilson et al, 2010)

Glasgow & Clyde Weight Management Service

Psychological Treatment

• Guided Self Help

• CBT-E Fairburn, 2008, 2009

• Interpersonal Therapy Wilson et al, 2010

• Mindfulness

• Compassion Focussed Therapy

Glasgow & Clyde Weight Management Service

DEG Model

• Integrate CBT for BED within an evidence based, multi component lifestyle intervention program.

• Address disordered eating and encourage weight loss and weight maintenance.

• Beneficial & supportive for clients

• Research in this area limited

A healthier weight through lasting lifestyle changes

DEG Structure

• 11 sessions

• 2 hours per session

• Fortnightly

• Delivered by a clinical psychologist and assistant

• Successful pilot study N=10

www.nhsggc.org.uk/gcwms

DEG Overview

CBT ModelPsychoeducation re dietingTaking control of eatingSelf MonitoringMotivationGoal settingRegular eatingCravings

Changing habits

Problem Solving

Mindful Eating

Emotional Eating

Body Image

Self Esteem

Being assertive

Relapse prevention

Glasgow & Clyde Weight Management Service

Measures• Questionnaire on Eating and Weight

Patterns-Revised

• Presence & Frequency of binge eating• Control over eating• Eating related distress• Body shape and weight concerns

• Psychometrically sound• Categorical data Spitzer, Yanovski & Marcus, 1994

• Hospital Anxiety and Depression Scale

• Widely used self rating scale• Psychometrically sound Zigmond & Snaith, 1983www.nhsggc.org.uk/gcwms

Outcomes

n mean sd median range

Whole

Cohort

Age 167 43.45 10.89 43 20-71

Weight 134

120.17 22.42 119.25 79.55-208

Completers Age 101

42.78 10.33 41 20.68

Weight

101 121.68 23.19 120.80 82.40-208

Demographics

49.7 12.6

23.4114.5

Kg

Years

Years

Kg

20-88

Change in BED

0

10

20

30

40

50

60

70

80

Pre Group Post Group

YesNo

McNemar: x 2 =17.93, df=1, p<0.001, N=58

%

Change in Binge Frequency

0

10

20

30

40

50

60

Stopped Reduced Stable Increased

N = 62

Pre-Intervention Post-Intervention p value

N Mean (SD) N Mean (SD)

Distress 46 4.17 (0.82) 46 3.76 (0.95) <.008

Control 47 4.23 (0.81) 47 3.62 (1.13) <.001

Body Image 56 3.50 (0.76) 56 3.02 (0.82) <.01

Eating Related Distress

n median

pre*

median

post*

median

change

95%

CI

p

Anxiety

90 13

(3-21)

10

(2-20)

1.50 1, 2.50 <0.001

Depression

90 11

(1-19)

7

(0-18)

2.50 1.50,

3.50

<0.001

HADS Scores Pre and Post Intervention

Statistics for completers who had baseline values (per protocol analysis)* Median (Range)

Kg

N 59

Mean

Median

2.70

2.00

Std. Deviation 4.53Range 22.6Percentiles 25 .000

50 2.2075 4.30

2006/7 1 in 32012 1 in 2 vs 1 in 4

Glasgow & Clyde Weight Management Service

Summary

• Successful BED treatment

• Improvements in mood, self esteem, body image

• Successful weight loss

• Efficient

• Initial Follow Up • Retaining clients through the next step of the program • ‘Catching up’ with standard group outcomes• Indicates this group are ready to focus on weight loss

www.nhsggc.org.uk/gcwms

Glasgow & Clyde Weight Management Service

marie.prince@ggc.scot.nhs.uk

www.nhsggc.org.uk/gcwms 0141 201 6115

ReferencesBackground Information National Institute for Health and Clinical Excellence (NICE). (2006). Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. London. Retrieved 25th July 2011, from http://guidance.nice.org.uk/CG43. The Scottish Government. (2010). Preventing overweight and obesity in Scotland: a route map. Retrieved 25th July 2011 from http://www.scotland.gov.uk/Publications/2010/02/17140721/0. Foresight-Tackling Obesities: Future Choices, Project Report 2nd Edition Government Office for Science .2008

Scottish Executive, (2004), Review of bariatric surgical services in Scotland, SEHD, Edinburgh

ReferencesGlasgow & Clyde Weight Management Service

Morrison, D., Boyle, S., Morrison, C., Allerdice, G., Greenlaw, N., & Forde, L. (2011). Evaluation of the first phase of a specialist weight management programme in the UK National Health Service: prospective cohort study. Public Health Nutrition, First View. Retrieved 19th August 2011, from http://journals.cambridge.org/action/displayJournal?jid=PHN DOI: 10.1017/S1368980011001625

www.nhsggc.co.uk/gcwms

References• American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, Text Revision. Washington DC: American Psychiatric Association.

• Blaine, B., & Rodman, J. (2007). Responses to weight loss treatment among obese individuals with and without BED: A matched-study meta-analysis. Eating and Weight Disorders, 12, 54-60.

• Brownley, K., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. (2007). Binge eating disorder treatment: A systematic review of randomized controlled trials. International Journal of Eating Disorders, 40, 337-348. DOI: 10.1002/eat

• Fairburn, C. G., Cooper, Z., Doll, H., O’Connor, M., Bohn, K., Hawker, D., Wales, J., & Palmer, R. (2009). Transdiagnostic cognitive-behavioural therapy for eating disorders: A two site trail with 60 week follow up. American Journal of Psychiatry, 166, 311-319. DOI: 10.1176/appi.ajp.2008.08040608

• Hudson, J. I., Hiripi, E., Pope, H. G., Kessler, R. C.(2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61 (3), 348-358. DOI: 10.1016/j.biopsych.2006.03.040

• Jirik-Babb, P., & Geliebter, A. (2003). Comparison of psychological characteristics of binging and non-binging obese, adult, female out. Eating and Weight Disorders, 8, 173-177.

• Onyike, C. U., Crum, R. M., Lee. H. B., Lyketsos, C. G., & Eaton, W. W. (2003). Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. American Journal Epidemiology. 158 (12), 1139-1147. DOI: 10.1093/aje/kwg275

• Spitzer, R. L., Yanovski, S. Z., & Marcus, M. D. (1994). Questionnaire on Eating and Weight Patterns-Revised. Pittsburgh PA: Behavioural Measurement Database Services (Producer). McLean, VA: B.

• Wilson, T. G., Wilfley, D. E., Agras, W. S., & Bryson, S. (2010). Psychological Treatments of Binge Eating Disorder. Archives of General Psychiatry, 67 (1): 94-101.

• Zigmond, A. S., & Snaith, R. P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67 (6), 361-370. DOI: 10.1111/j.1600-0447.1983.tb09716.x

References