Marney A. White

Cognitive-Behavioral Theories of Eating Disorders:

This article presents an integrated cognitive-behavioral theory of eating disorders that is based on hypotheses developed over the past 30 years. The theory is evaluated using a selected review of the eating disorder literature pertaining to cognitive biases, negative emotional reactions, binge eating, compensatory behaviors, and risk factors for eating disorders. In general, hypotheses derived from cognitive-behavioral theories have been supported by a variety of research studies. The implications of these findings for treatment and prevention of eating disorders are discussed. This review of the literature serves as a conceptual base for some of the other articles that are included in this special issue of Behavior Modification. The article concludes with an introduction to six articles that discuss issues related to psychiatric classification, assessment, treatment, and prevention of eating disorders.

Loss of control over eating predicts outcomes in bariatric surgery patients: a prospective, 24-month follow-up study.

OBJECTIVE This study examined the clinical significance of loss of control (LOC) over eating in bariatric surgery patients over 24 months of prospective, multiwave follow-ups. METHOD Three hundred sixty-one gastric bypass surgery patients completed a battery of assessments before surgery and at 6, 12, and 24 months following surgery. In addition to weight loss and LOC over eating, the assessments targeted eating disorder psychopathology, depression levels, and quality of life. The study was conducted between January 2002 and February 2008. RESULTS Prior to surgery, 61% of patients reported general LOC; postsurgery, 31% reported LOC at 6-month follow-up, 36% reported LOC at 12-month follow-up, and 39% reported LOC at 24-month follow-up. Preoperative LOC did not predict postoperative outcomes. In contrast, mixed models analyses revealed that postsurgery LOC was predictive of weight loss outcomes: patients with LOC postsurgery lost significantly less weight at 12-month (34.6% vs 37.2% BMI loss) and 24-month (35.8% vs 39.1% BMI loss) postsurgery follow-ups. Postsurgery LOC also significantly predicted eating disorder psychopathology, depression, and quality of life at 12- and 24-month postsurgery follow-ups. CONCLUSIONS Preoperative LOC does not appear to be a negative prognostic indicator for postsurgical outcomes. Postoperative LOC, however, significantly predicts poorer postsurgical weight loss and psychosocial outcomes at 12 and 24 months following surgery. Since LOC following bariatric surgery significantly predicts attenuated postsurgical improvements, it may signal a need for clinical attention.

Two-year internet-based randomized controlled trial for weight loss in African-American girls

Objective: A randomized controlled trial tested the efficacy of an internet‐based lifestyle behavior modification program for African‐American girls over a 2‐year period of intervention.

Cognitive-behavioral therapy, behavioral weight loss, and sequential treatment for obese patients with binge-eating disorder: a randomized controlled trial.

OBJECTIVE Cognitive-behavioral therapy (CBT) is the best established treatment for binge-eating disorder (BED) but does not produce weight loss. The efficacy of behavioral weight loss (BWL) in obese patients with BED is uncertain. This study compared CBT, BWL, and a sequential approach in which CBT is delivered first, followed by BWL (CBT + BWL). METHOD 125 obese patients with BED were randomly assigned to 1 of the 3 manualized treatments delivered in groups. Independent assessments were performed posttreatment and at 6- and 12-month follow-ups. RESULTS At 12-month follow-up, intent-to-treat binge-eating remission rates were 51% (CBT), 36% (BWL), and 40% (CBT + BWL), and mean percent BMI losses were -0.9, -2.1, and 1.5, respectively. Mixed-models analyses revealed that CBT produced significantly greater reductions in binge eating than BWL through 12-month follow-up and that BWL produced significantly greater percent BMI loss during treatment. The overall significant percent BMI loss in CBT + BWL was attributable to the significant effects during the BWL component. Binge-eating remission at major assessment points was associated significantly with greater percent BMI loss cross-sectionally and prospectively (i.e., at subsequent follow-ups). CONCLUSIONS CBT was superior to BWL for producing reductions in binge eating through 12-month follow-up, while BWL produced statistically greater, albeit modest, weight losses during treatment. Results do not support the utility of the sequential approach of providing BWL following CBT. Remission from binge eating was associated with significantly greater percent BMI loss. Findings support BWL as an alternative treatment option to CBT for BED.

Overvaluation of shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic construct.

Debate continues regarding the nosological status of binge eating disorder (BED) as a diagnosis as opposed to simply reflecting a useful marker for psychopathology. Contention also exists regarding the specific criteria for the BED diagnosis, including whether, like anorexia nervosa and bulimia nervosa, it should be characterized by overvaluation of shape/weight. The authors compared features of eating disorders, psychological distress, and weight among overweight BED participants who overvalue their shape/weight (n=92), BED participants with subclinical levels of overvaluation (n=73), and participants in an overweight comparison group without BED (n=45). BED participants categorized with clinical overvaluation reported greater eating-related psychopathology and depression levels than those with subclinical overvaluation. Both BED groups reported greater overall eating pathology and depression levels than the overweight comparison group. Group differences existed despite similar levels of overweight across the 3 groups, as well as when controlling for group differences in depression levels. These findings provide further support for the research diagnostic construct and make a case for the importance of shape/weight overvaluation as a diagnostic specifier.

Efficacy of an internet-based behavioral weight loss program for overweight adolescent African-American girls

Objective: This randomized controlled trial tested the efficacy of an internetbased lifestyle behavior modification program for weight management in African-American girls. Design: African-American girls were randomly assigned to an interactive behavioral internet program or an internet health education program, the control condition. The behavioral intervention included internet counseling and was highly interactive. The control intervention was a passive (non-interactive) educational program. Parents were also participants in the study. Participants in both treatment groups met in face-to-face sessions on four occasions over the first 12 weeks of a 6-month intervention. Subjects: The study enrolled 57 African-American adolescent girls (ages 11 to 15 years) who were overweight or obese and had at least one biological parent who was obese [body mass index (BMI) >30 kg/m2]. Of the 57 participants, 50 (88%) completed the 6-month trial. Measurements: Outcome data, including BMI, body weight, body composition, dietary intake, and weight loss behaviors were collected at baseline and 6-months later. A computer server tracked utilization of the websites. Participation in the program was measured by number of “hits” on the website. Results: Compared to the control condition, adolescents in the behavioral treatment lost more body fat (group difference =1.6% body fat) and parents lost significantly more body weight (group difference =2.1 kg). Utilization of the behavioral website by adolescents and parents was associated with positive outcome. Dietary fat intake was lowered for adolescents and parents in the behavioral treatment group. Conclusion: An internet-based behavioral intervention was superior to internet-based health education and yielded decreased body fat for adolescent girls and decreased body weight for parents.

An examination of food addiction in a racially diverse sample of obese patients with binge eating disorder in primary care settings

OBJECTIVE The concept of food addiction in obesity and binge eating disorder (BED) continues to be a hotly debated topic yet the empirical evidence on the relationship between addictive-like eating and clinically relevant eating disorders is limited. The current study examined the association of food addiction as assessed by the Yale Food Addiction Scale (YFAS) with measures of disordered eating, dieting/weight history, and related psychopathology in a racially diverse sample of obese patients with binge eating disorder (BED). METHOD A consecutive series of 96 obese patients with BED who were seeking treatment for obesity and binge eating in primary care were given structured interviews to assess psychiatric disorders and eating disorder psychopathology and a battery of self-report measures including the YFAS to assess food addiction. RESULTS Classification of food addiction was met by 41.5% (n=39) of BED patients. Patients classified as meeting YFAS food addiction criteria had significantly higher levels of negative affect, emotion dysregulation, and eating disorder psychopathology, and lower self-esteem. Higher scores on the YFAS were related to an earlier age of first being overweight and dieting onset. YFAS scores were also significant predictors of binge eating frequency above and beyond other measures. DISCUSSION Compared to patients not classified as having food addiction, the subset of 41.5% of BED patients who met the YFAS food addiction cut-off appears to have a more severe presentation of BED and more associated pathology.

Overvaluation of Shape and Weight in Binge Eating Disorder.

The excessive influence of shape or weight on self-evaluation--referred to as overvaluation--is considered by some a central feature across eating disorders but is not a diagnostic requirement for binge eating disorder (BED). This study examined shape/weight overvaluation in 399 consecutive patients with BED. Participants completed semistructured interviews, including the Eating Disorder Examination (EDE; C. G. Fairburn & Z. Cooper, 1993) and several self-report measures. Shape/weight overvaluation was unrelated to body mass index (BMI) but was strongly associated with measures of eating-related psychopathology and psychological status (i.e., higher depression and lower self-esteem). Participants were categorized via EDE guidelines into 1 of 2 groups: clinical overvaluation (58%) or subclinical overvaluation (42%). The 2 groups did not differ significantly in BMI or binge eating frequency, but the clinical overvaluation group had significantly greater eating-related psychopathology and poorer psychological status than the subclinical overvaluation group. Findings suggest that overvaluation does not simply reflect concern commensurate with being overweight but is strongly associated with eating-related psychopathology and psychological functioning and warrants consideration as a diagnostic feature for BED.

Development of the Muscle Appearance Satisfaction Scale A Self-Report Measure for the Assessment of Muscle Dysmorphia Symptoms

Muscle dysmorphia has recently been described as a variant of body dysmorphic disorder that involves an intense preoccupation with one’s perceived lack of muscle size. Currently, no assessment measures specific to the cognitive, affective, and behavioral dimensions of the construct of muscle dysmorphia have been published. To address this need, the authors developed the Muscle Appearance Satisfaction Scale (MASS), a brief, 19-item self-report measure for the assessment of muscle dysmorphia symptoms. Psychometric evaluation of the MASS across two samples of male weight lifting participants (total N = 372) revealed a stable five-factor structure. An evaluation of factor content resulted in the following factor labels: Bodybuilding Dependence, Muscle Checking, Substance Use, Injury, and Muscle Satisfaction. Internal consistency, test-retest reliability, and construct validity were established with the MASS total score and its subscales. The authors believe the MASS will be a useful measure for research and applied work relating to muscle dysmorphia.

Eating Pathology, Emotion Regulation, and Emotional Overeating in Obese Adults with Binge Eating Disorder

OBJECTIVE The purpose of the current study was to examine the relationship among emotional regulation, emotional overeating, and general eating pathology in a treatment seeking sample of adults with Binge Eating Disorder (BED). METHOD The sample was composed of 326 adults (248 women, 78 men) who were obese and met DSM-IV-TR criteria for BED. Prior to treatment, participants completed the Difficulties in Emotion Regulation Scale (DERS), Emotional Overeating Questionnaire (EOQ), Beck Depression Inventory (BDI), and Eating Disorder Examination-Questionnaire (EDE-Q) as part of a larger assessment battery. RESULTS A series of hierarchical regression analyses indicated that difficulties with emotion regulation accounted for unique variance in both emotional overeating and general eating pathology above and beyond sex and negative affect. DISCUSSION Emotion regulation may play a significant role in the maintenance of emotional overeating and eating pathology in obese adults with BED.