Obese binge eaters: affect, cognitions, and response to behavioural weight control

A community-based feasibility randomized controlled study to test food-specific inhibitory control training in people with disinhibited eating during COVID-19 in Italy

PURPOSE

The aim of this study was to expand the evidence on the feasibility and impact of food-specific inhibitory control training in a community sample of people with disinhibited eating.

METHODS

Recruitment and data collection were conducted during the COVID-19 outbreak, in Italy. Ninety-four adult individuals with disinhibited eating were randomised to one of two conditions: App-based food-specific inhibitory control training or waiting list. Participants were assessed at baseline, end of intervention (2 weeks following baseline) and follow-up (one week later). The assessment measures included questionnaires about eating behaviour and mood.

RESULTS

Seventy-three percent of the sample reported a diagnosis of binge eating disorder, and 20.4% a diagnosis of bulimia nervosa. Retention rates were 77% and 86% for the food-specific inhibitory control training and the waiting list conditions, respectively. Almost half of the participants allocated to the training condition completed the "recommended" dose of training (i.e., 10 or more sessions). Those in the training condition reported lower levels of wanting for high-energy dense foods (p < 0.05), a trend for lower levels of perceived hunger (p = 0.07), and lower levels of depression (p < 0.05). Binge eating symptoms, disinhibition, wanting for high-energy dense foods, stress and anxiety were significantly lower at end of intervention, compared to baseline (p < .05).

CONCLUSION

Findings corroborated the feasibility of food-specific inhibitory control training, and its impact on high-energy dense foods liking. The study expands the evidence base for food-specific inhibitory control training by highlighting its impact on perceived hunger and depression. The mechanisms underlying these effects remain to be clarified.

LEVEL OF EVIDENCE

Level I, Evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies.

Binge-eating behaviors in adolescents and young adults during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic and subsequent public health measures have resulted in a worsening of eating disorder symptoms and an increase in psychological distress. The present study examined symptoms and behaviors in adolescents and young adults with emotional eating, bingeing behaviors and binge eating disorder during the pandemic. Additionally, the study explored if individuals who experienced pandemic-related food availability and food affordability issues experienced increased binge-eating symptoms and negative feelings.

METHOD

Participants (n = 39) were a convenience sample who participated between November 2020 and January 2021 in a weight and lifestyle management program at an urban New England pediatric hospital. Participants completed online surveys that assessed (1) participant's exposure to COVID-19 related stress and binge-eating behaviors using the COVID-19 Exposure and Family Impact Survey-Adolescent and Young Adult Version (CEFIS-AYA) and the Binge Eating Scale (BES) respectively, (2) participants' and their families' ability to attain and afford food and its association with bingeing behaviors, and (3) the relationship between food availability and affordability and negative emotions.

RESULTS

Nearly half of all participants (48.7%) reported moderate to severe bingeing during the COVID-19 pandemic; those who experienced greater COVID-related stress reported more binge-eating behaviors (p = 0.03). There were no associations between indicators of food availability and affordability and binge eating or between food availability and affordability and negative feelings.

CONCLUSIONS

Higher pandemic-related stress was associated with more binge-eating behaviors among adolescents and young adults. These results underscore the need to monitor symptoms and provide treatment for these patients despite barriers to care imposed by the COVID-19 pandemic. Research and clinical care for adolescents and young adults with EDs must recognize and respond to pandemic effects across the weight and disordered eating spectrum.

Disordered eating behaviour in adolescents with type 1 diabetes on continuous subcutaneous insulin infusion; relation to body image, depression and glycemic control

BACKGROUND

Disordered eating behaviour (DEB) represents a significant morbidity among people with type-1 diabetes (T1D). Continuous-subcutaneous insulin infusion (CSII) improves glycemic control and psychological wellbeing in those with T1D. However, its relation to DEB remains obscure.

OBJECTIVES

To compare DEB among adolescents with T1D on CSII versus basal-bolus regimen and correlate it with body image, HbA1C and depression.

METHODS

Sixty adolescents with T1D (30 on CSII and 30 on basal-bolus regimen), aged 12-17 years were studied focusing on diabetes-duration, insulin therapy, exercise, socioeconomic standard, hypoglycemic attacks/week and family history of psychiatric illness. Anthropometric measures, HbA1C, binge eating scale (BES), body image tool, patient health questionnaire-9 (PHQ9) and the Mini-KID depression scale were assessed.

RESULTS

Among the studied adolescents with T1D, six had DEB (10%), 14 had poor body-image perception (23.3%), 42 had moderate body-image perception (70%) and 22 had depression (36.7%). Adolescents with T1D on CSII had significantly lower BES (p = 0.022), Mini-KID depression (p = 0.001) and PHQ9 (p = 0.02) than those on basal-bolus regimen. BES was positively correlated to depression (p < 0.001), HbA1C (p = 0.013) and diabetes-duration (p = 0.009) and negatively correlated to body-image (p = 0.003).

CONCLUSION

DEB is a prevalent comorbidity among adolescents with T1D, with higher frequency in those on basal-bolus regimen than CSII.

Psychometric properties of the Chinese version of the modified Yale Food Addiction Scale version 2.0 (C-mYFAS 2.0): Prevalence of food addiction and relationship with resilience and social support

PURPOSE

This study aimed to examine the psychometric properties of the Chinese version of the modified Yale Food Addiction Scale 2.0 (C-mYFAS 2.0) and to analyze the prevalence of food addiction among Chinese college students and its relationship with resilience and social support.

METHODS

A total of 1132 Chinese college students completed the C-mYFAS 2.0, BES, EAT-26, PHQ-9, GAD-7, TFEQ-18, CD-RISC-10, and PSSS. Confirmatory factor analysis was used to evaluate the factor structure of the C-mYFAS 2.0 and psychometric properties were assessed. Test-retest reliability was evaluated in a sub-sample (n = 62). Spearman correlation and logistic regression were used to examine the relationship between resilience, social support, and food addiction.

RESULTS

The prevalence of food addiction according to the C-mYFAS 2.0 was 6.2%. Confirmatory factor analyses suggested a single-factor structure (comparative fit index = 0.961). The C-mYFAS 2.0 had good test-retest reliability and internal consistency (Kuder-Richardson's α = 0.824). Good convergent validity was indicated by correlations with binge eating, eating disorder symptoms, depressive symptoms, generalized anxiety symptoms, uncontrolled eating, emotional eating, and BMI (ps < 0.001). Appropriate divergent validity was reflected by no association with cognitive restraint. Finally, binge eating was significantly predicted by C-mYFAS 2.0, depressive symptoms, and eating disorder symptoms (ps < 0.001), confirming incremental validity. In addition, our study found that poorer resilience and social support were related to food addiction (ps < .001).

CONCLUSIONS

The C-mYFAS 2.0 is a brief but reliable and valid screening instrument for food addiction among Chinese college students. In addition, we found that resilience and social support were negatively associated with food addiction.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Effects of night eating and binge eating disorders on general health in university students in Lebanon

BACKGROUND

Eating disorders (EDs) have an important impact on both physical and mental wellbeing, especially in a young population. There is a lack in research about EDs in the Middle East, and especially in Lebanon, where the co-occurring obesity is a widespread health problem.

AIM

Our study aims to assess the relation between night eating syndrome (NES) with binge eating disease (BED) and obesity (BMI) on one hand, and between NES and general health on the other hand, in university students.

MATERIALS AND METHODS

An observational cross-sectional study was conducted on 460 university students in Lebanon. Data collection was carried out using an online questionnaire. Socio-demographic and general health characteristics, BMI, Arabic validated General Health Questionnaire (GHQ-12), Arabic validated Binge Eating Scale (BES) and the Night Eating Diagnostic Questionnaire (NEDQ). Statistical analysis was accomplished on SPSS.

RESULTS

Participants having highest income showed highest NEDQ score. Females and participants with a history of eating disorders were more likely to have BED. A significant correlation was also found between having an ED history and negative impact on general health. BMI was correlated with both NEDQ and BES. Having NES was associated with also having BED. Furthermore, those with NES showed higher scores regarding GHQ-12.

CONCLUSION

Relatively high prevalence of NES and BED was noted in university students in Lebanon. This was correlated to a household income, general health, and BMI. The repercussion on both physical and mental morbidities highlights the importance for stepping up of the Lebanese organizational system to perform periodic screening.

Faculty Service-Learning Students as Home-Visitors: Outcomes of a Lifestyle Modification Program for Vulnerable Families With Residents in Rural Indonesian Communities

Background: Risks attributed to chronic diseases, cancer, musculoskeletal discomfort, and infectious diseases among Indonesians were found to be associated with lifestyle behaviors, particularly in rural areas. The aim of this study was to examine the outcomes of a home-visiting lifestyle modification program on improving health risk behaviors among Indonesians living in rural areas. Methods: A total of 160 Indonesians living in rural hamlets in the Yogyakarta Region of Indonesia participated in the program in the period of June 21 to July 21, 2019. In the pre-intervention home interview, learning needs of diet, exercise, hand hygiene, and substance use were identified by using structured assessment tools. In the next home visit, the visitors provided health education and facilitated lifestyle planning based on the related affective and cognitive domains of learning. Subsequent follow-up interviews were conducted 3 weeks after intervention. Results: The results showed that the self-reported intake of vegetables, fruits, meat and salt, cooking with less oil, hand hygiene before eating, number of cigarettes smoked, and symptoms of muscle stiffness significantly improved after the intervention. The lifestyle modification program consisted of the affective and cognitive domains of learning, and could lead to the target behavioral changes in self-reported and observable measures over 1 month. Conclusions: The findings contributed to the framework of community-based health education for health risk reduction and behavioral modification in developing rural communities where health care resources were limited. Further studies with control groups and vigorous objective measures were recommended to elucidate its long-term impacts. The factors leading to its sustainability concerning collaborative care partnerships between community residents and faculty resources are worthy of continued exploration.

Self-report versus clinical interview: Discordance among measures of binge eating in a weight-loss seeking sample

PURPOSE

Obese, behavioral weight-loss (BWL) seeking individuals may be prone to over-reporting binge-eating (BE). However, many studies rely on self-reported measures of BE in this population, which may be inaccurate. As such, this is the first-ever study to examine the concordance rates among one self-reported and one clinician- administered measure of BE in a BWL-seeking sample with overweight/obesity.

METHODS

At baseline of a BWL trial, participants (N = 94) completed two measures of BE: The Eating Disorders Examination Questionnaire (EDE-Q) and the interview-based Eating Disorder Examination (EDE, Overeating section).

RESULTS

Cohen's kappa detected poor agreement between measures (κ < 0). A paired samples t-test detected large, significant differences in OBE frequency across the EDE-Q and EDE, p < 0.001. The self-reported EDE-Q detected a significantly greater frequency of OBEs compared to the EDE (M_EDE-Q = 0.73, SD = 1.29 vs. M_EDE = 0.06, SD = 0.34). The EDE-Q detected that approximately 50% of participants have experienced OBEs, while the EDE detected that only 5% of participants have experienced OBEs. The frequency of OBEs detected by the EDE-Q was statistically greater than the frequency of OBEs detected by the EDE, p < 0.001.

DISCUSSION

Results suggest poor agreement between one self-reported measure and the "gold-standard," clinician-administered measure of BE in a BWL-seeking sample with overweight/obesity. The EDE-Q exhibited high sensitivity but low-to-moderate specificity of OBEs, with the number of false positives (41) outweighing that of true positives (4). Studies measuring BE in this population should consider relying solely on assessor-administered measures, as this sample may require clinical guidance or clarification on the definition and features of BE.

LEVEL OF EVIDENCE

Level V, cross-sectional, descriptive study.

Structural validity, measurement invariance, reliability and diagnostic accuracy of the Italian version of the Yale Food Addiction Scale 2.0 in patients with severe obesity and the general population

PURPOSE

To examine the structural validity, measurement invariance, reliability, and some other psychometrical properties of the Italian version of the Yale Food Addiction Scale 2 (I-YFAS 2.0) in patients with severe obesity and the general population.

METHODS

704 participants-400 inpatients with severe obesity and 304 participants enrolled from the general population-completed the I-YFAS 2.0 and questionnaires measuring eating disorder symptoms. A first confirmatory factor analysis (CFA) tested a hierarchical structure in which each item of the I-YFAS 2.0 loaded onto one of the twelve latent symptoms/criteria which loaded onto a general dimension of Food Addiction (FA). The second CFA tested a first-order structure in which symptoms/criteria of FA simply loaded onto a latent dimension. Measurement invariance (MI) between the group of inpatients with severe obesity and the sample from the general population was also tested. Finally, convergent validity, test-retest reliability, internal consistency, and prevalence analyses were performed.

RESULTS

CFAs confirmed the structure for the I-YFAS 2.0 for both the hierarchical structure and the first-order structure. Configural MI and strong MI were reached for hierarchical and the first-order structure, respectively. Internal consistencies were shown to be acceptable. Prevalence of FA was 24% in the group of inpatients with severe obesity and 3.6% in the sample from the general population.

CONCLUSIONS

The I-YFAS 2.0 represents a valid and reliable questionnaire for the assessment of FA in both Italian adult inpatients with severe obesity and the general population, and is a psychometrically sound tool for clinical as well as research purposes.

LEVEL OF EVIDENCE

Level V, descriptive study.

Psychiatric Assessment and Management of Clients Undergoing Cosmetic Surgery: Overview and Need for an Integrated Approach

Background  Psychiatric disorders are more common among people undergoing cosmetic procedures than the general population and evaluating mental health can be cumbersome for plastic surgeons. We aim to summarize the available literature in this regard and propose an integrated approach to psychiatric assessment and management of mental health issues among this group. Methods  Electronic search of MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles from inception till April 2020. Generated abstracts were screened for their eligibility. Included articles were grouped according to their thematic focus under the following headings; prevalence of psychiatric morbidity among clients posted for cosmetic surgery, assessment tools, and management of psychiatric morbidity in relation to undergoing cosmetic surgery. Results  A total of 120 articles were reviewed. The prevalence of psychiatric disorder in patients undergoing cosmetic surgery was 4 to 57% for body dysmorphic disorder (BDD); the corresponding figures for depression, anxiety, and personality disorder were 4.8 to 25.8, 10.8 to 22, and 0 to 53%, respectively. A range of tools have been used to assess these disorders and specific measures are also available to assess clinical outcomes following surgery. Screening for these disorders is essential to prevent unnecessary surgical procedures, as well as to ensure timely management of the psychiatric comorbidity. Conclusion  Psychiatric morbidity is a common concomitant in cosmetic surgery. A structured and integrated approach to evaluation and management of psychiatric morbidity will help to optimize postsurgical outcomes.

Weight Gain in a Sample of Patients Affected by Overweight/Obesity with and without a Psychiatric Diagnosis during the Covid-19 Lockdown

The present study aimed at identifying psychological and psychosocial variables that might predict weight gain during the COVID-19 lockdown in patients affected by overweight/obesity with and without a psychiatric diagnosis. An online survey was administered between 25 April and 10 May 2020, to investigate participants' changes in dietary habits during the lockdown period. 110 participants were recruited and allocated to two groups, 63 patients had no psychiatric diagnosis; there were 47 patients with psychiatric diagnosis. ANOVA analyses compared the groups with respect to psychological distress levels, risk perception, social support, emotion regulation, and eating behaviors. For each group, a binary logistic regression analysis was conducted, including the factors that were found to significantly differ between groups. Weight gain during lockdown was reported by 31 of the participants affected by overweight/obesity without a psychiatric diagnosis and by 31 patients with a psychiatric diagnosis. Weight gain predictors were stress and low depression for patients without a psychiatric diagnosis and binge eating behaviors for patients with a psychiatric diagnosis. Of patients without a psychiatric diagnosis, 60% reported much more frequent night eating episodes. The risk of night eating syndrome in persons affected by overweight/obesity with no psychiatric diagnosis should be further investigated to inform the development of tailored medical, psychological, and psychosocial interventions.

Depressive symptoms, psychological flexibility, and binge eating in individuals seeking behavioral weight loss treatment

Depressive symptoms and binge eating are both prevalent in weight management populations and may be associated with reduced benefit from behavioral weight loss, including higher attrition, more perceived barriers, lower weight loss, and increased weight regain. These two potential risk factors for poor behavioral weight loss outcomes may also be associated with each other as depressive symptoms may trigger binge eating, and binge eating-related distress could increase depressive symptoms. The depressive symptom-binge eating link has not been well studied in weight management samples, and psychological processes involved in this relationship have not yet been elucidated. Psychological flexibility, an individual's ability to be connected with and conscious of the present moment and to engage in values-consistent behavior even in the presence of difficult internal experiences, may be one psychological process that changes the depressive symptom-binge eating relationship. High psychological flexibility may be a protective factor in the association of depressive symptoms with binge eating. This study examined the relationship between depressive symptom and binge eating and a potential interactive role of psychological flexibility. Participants (N = 468, 76% female) completed self-report questionnaires of binge eating, depressive symptoms, and psychological flexibility at baseline prior to initiating behavioral weight loss. Depressive symptoms were positively associated with binge eating (B = 1.00, p < 0.001). Psychological flexibility had an interactive role (B = -0.03, p = 0.005). Among participants with minimal to mild depressive symptoms, those with higher psychological flexibility had less severe binge eating. Findings suggest that psychological flexibility may be a protective factor in the association between depressive symptoms and binge eating in the majority of individuals initiating behavioral weight loss. Psychological flexibility is a psychological process to consider targeting for enhancing efficacy of weight loss treatment, especially among individuals with minimal to mild depressive symptoms and binge eating behavior.

Developing an Acceptance-Based Behavioral Weight Loss Treatment for Individuals With Binge Eating Pathology: A Preliminary Proof of Concept Study and Clinical Case Series

Binge eating (BE; i.e., the consumption of a large amount of food in a discrete time period, accompanied by a sense of loss of control) is highly comorbid with overweight or obesity and is the primary symptom of binge eating disorder (BED). Current gold-standard treatment for BED (i.e., CBT) does not produce meaningful weight loss, thus failing to address a critical treatment target. This article describes the development of a novel acceptance-based behavioral treatment (ABBT) for individuals with clinically significant BE desiring to reduce BE symptoms and achieve concurrent weight loss. We discuss the development and structure of the novel treatment approach, and describe the test of a proof of concept version of the treatment in a clinical case series of four individuals. In the context of each clinical case description, we present initial acceptability of the treatment and challenges faced in treatment development and delivery. Finally, we discuss future research directions for the treatment, which could improve BE symptoms and weight loss outcomes for individuals with BE pathology.

Do stress eating or compulsive eating influence metabolic health in a mindfulness-based weight loss intervention?

OBJECTIVE

We aimed to understand the associations of compulsive eating (CE) and stress eating (SE) with metabolic health among adults with obesity and whether mindfulness-based weight loss training may buffer these associations.

METHOD

We used data from a trial in which we randomized 194 participants with obesity to a diet-exercise weight loss intervention with either mindful eating training plus mindfulness-based eating awareness and stress management training (n = 100) or active control components (n = 94). We measured CE, SE, weight, and fasting blood glucose (FBG) at baseline, and 6, 12 months, and 18 months. We tested CE and SE as both moderators and mediators of intervention effects on changes in metabolic health.

RESULTS

Participants higher (+ 1 SD) in CE at baseline randomized to the mindfulness (vs. control) intervention had greater improvements in FBG at 18 months (p = .05). Twelve-month reductions in CE mediated the effect of the intervention on changes in FBG and weight at 12 and 18 months postbaseline (p ≤ .05). Furthermore, those higher (+ 1 SD) in SE at baseline were nearly 2 BMI points higher than those lower (-1 SD) in SE (p < .01). Decreases in SE (B = 3.42; p < .001; 95% CI [2.55, 4.30]) and CE (B = 0.45; p < .001; 95% CI [0.36, 0.54]) in all participants at 6 months were associated with greater weight loss at 18 months.

CONCLUSIONS

Those with greater compulsive eating may reduce risk for metabolic decline by participating in a mindfulness-based weight loss program. Future obesity interventions should consider tailoring treatment toward trait-level characteristics, such as compulsive eating. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Effectiveness of lifestyle interventions to reduce binge eating symptoms in African American and Hispanic women

OBJECTIVE

Lifestyle interventions that promote physical activity and healthy dietary habits may reduce binge eating symptoms and be more feasible and sustainable among ethnic minority women, who are less likely to seek clinical treatment for eating disorders. The purpose of this study was to investigate (1) whether participating in a lifestyle intervention is a feasible way to decrease binge eating symptoms (BES) and (2) whether changes in BES differed by intervention (physical activity vs. dietary habits) and binge eating status at baseline (binger eater vs. non-binge eater) in African American and Hispanic women.

METHOD

Health Is Power (HIP) was a longitudinal randomized controlled trial to promote physical activity and improve dietary habits. Women (N = 180) who completed anthropometric measures and questionnaires assessing fruit and vegetable and dietary fat intake, BES and demographics at baseline and post-intervention six months later were included in the current study.

RESULTS

Over one-fourth (27.8%) of participants were categorized as binge-eaters. Repeated measures ANOVA demonstrated significant two- and three-way interactions. Decreases in BES over time were greater in binge eaters than in non-binge eaters (F(1,164) = 33.253, p < .001), and women classified as binge eaters who participated in the physical activity intervention reported greater decreases in BES than non-binge eaters in the dietary habits intervention (F(1,157) = 5.170, p = .024).

DISCUSSION

Findings suggest behavioral interventions to increase physical activity may lead to reductions in BES among ethnic minority women and ultimately reduce the prevalence of binge eating disorder and health disparities in this population.

Binge eating behavior and weight loss maintenance over a 2-year period

OBJECTIVE

To investigate the relationship between binge eating behavior and weight loss maintenance over a two-year period in adults.

DESIGN

Secondary data analysis using the Keep It Off study, a randomized trial evaluating an intervention to promote weight loss maintenance.

PARTICIPANTS

419 men and women (ages: 20 to 70 y; BMI: 20-44 kg/m2) who had intentionally lost ≥10% of their weight during the previous year.

MEASUREMENTS

Body weight was measured and binge eating behavior over the past 6 months was reported at baseline, 12 months and 24 months. Height was measured at baseline.

RESULTS

Prevalence of binge eating at baseline was 19.4% (n = 76). Prevalence of binge eating at any time point was 30.1% (n = 126). Although rate of weight regain did not differ significantly between those who did or did not report binge eating at baseline, binge eating behavior across the study period (additive value of presence or absence at each time point) was significantly associated with different rates of weight regain.

CONCLUSION

Tailoring weight loss maintenance interventions to address binge eating behavior is warranted given the prevalence and the different rates of weight regain experienced by those reporting this behavior.

Examination of food reward and energy intake under laboratory and free-living conditions in a trait binge eating subtype of obesity

Background/Aims: Trait binge eating has been proposed as a “hedonic subtype” of obesity characterized by enhanced food liking and wanting, and a preference for high-fat sweet foods in the laboratory. The current study examined the influence of trait binge eating in overweight or obese women on eating behavior under laboratory and free-living conditions over a 48-h period.

Methods: In a matched pairs design, 24 overweight or obese females (BMI: 30.30 ± 2.60 kg/m²; Age: 25.42 ± 3.65 years) with high or low scores on the Binge Eating Scale (BSE) were divided into one of two groups; Obese Binge (O-B) and Obese Non-binge (O-NB). Energy intake was assessed using combined laboratory energy intake measures and 24-h dietary recall procedures. Liking and wanting were assessed using the Leeds Food Preference Questionnaire (LFPQ).

Results: There was a significant association between overall energy consumed, and energy consumed from snack foods under laboratory and free-living conditions. O-B exhibited a greater preference for sweet snack foods in their laboratory and free-living eating behavior. These findings were supported by greater laboratory-based measures of wanting and craving for this food type in O-B. In addition, O-B consumed significantly more energy than their estimated daily energy requirements in the laboratory suggesting that they over-consumed compared to O-NB.

Conclusions: The measurement concordance between laboratory and free-living based energy intake supports the validity of laboratory-based test meal methodologies Variation in trait binge eating was associated with increased craving and wanting for high-fat sweet foods and overconsumption in the laboratory. These findings support the use of trait binge eating as a common hedonic subtype of obesity and extend the relevance of this subtype to habitual patterns of energy intake.

Effect of BMI and binge eating on food reward and energy intake: further evidence for a binge eating subtype of obesity

BACKGROUND

The psychological characteristics of binge eating have been proposed as a phenotype to further understanding of overconsumption and susceptibility to obesity. This study examined the influence of trait binge eating in lean and overweight or obese women on appetite, food reward and energy intake.

METHODS

25 lean and 25 overweight or obese women were categorised as either 'binge type' or 'non-binge type' based on their scores on the Binge Eating Scale. Food reward and food intake were assessed in fasted and fed conditions.

RESULTS

Overweight or obese binge types (O-B) consumed more energy than overweight or obese non-binge types (O-NB) and lean binge (L-B) and non-binge types (L-NB). Both L-B and O-B exhibited greater preference for sweet foods. In O-NB, L-B and L-NB, lower liking and wanting for sweet foods was exhibited in the fed condition compared to the fasted condition. However, in O-B wanting for sweet foods was greater when they were fed compared to when they were in a fasted state.

CONCLUSIONS

These findings provide further support for trait binge eating as a hedonic subtype of obesity. Binge types were characterised by greater intake of high-fat sweet foods and increased wanting for these foods when satiated. Additionally, these findings highlight the potential for separation in liking and wanting for food as a marker of susceptibility to overeat.

Examining the Binge Eating Scale in screening for binge eating disorder in bariatric surgery candidates

BACKGROUND

This study assessed the utility of the Binge Eating Scale (BES) as a measure of binge eating disorder (BED) in a bariatric surgery-seeking population by (a) determining the optimal BES cut score for predicting BED, (b) calculating concordance statistics, and (c) determining the predictive value of each BES item.

METHODS

Four hundred seventy-three patients presented for a psychological evaluation prior to Roux-en-Y gastric bypass surgery. The BES and the SCID semi-structured interview for BED were administered.

RESULTS

Receiver operating characteristic curve analyses identified an optimal BES cut score of 17, which correctly classified 78% of patients with BED. A cut score of 27 improved this statistic, but significantly increased the number of false negatives, which is undesirable for a screening assessment. Discriminant function analyses revealed that nearly all BES items significantly predicted BED.

CONCLUSIONS

The BES is a valid screener of BED for patients seeking bariatric surgery; however, false positives can be expected. Administering the BES as part of a comprehensive psychological evaluation can help improve the assessment and treatment of patients presenting for bariatric surgery.

Internalized weight bias: ratings of the self, normal weight, and obese individuals and psychological maladjustment

Current measures of internalized weight bias assess factors such as responsibility for weight status, mistreatment because of weight, etc. A potential complementary approach for assessing internalized weight bias is to examine the correspondence between individuals' ratings of obese people, normal weight people, and themselves on personality traits. This investigation examined the relationships among different measures of internalized weight bias, as well as the association between those measures and psychosocial maladjustment. Prior to the beginning of a weight loss intervention, 62 overweight/obese adults completed measures of explicit and internalized weight bias as well as body image, binge eating, and depression. Discrepancies between participants' ratings of obese people in general and ratings of themselves on both positive and negative traits predicted unique variance in measures of maladjustment above a traditional assessment of internalized weight bias. This novel approach to measuring internalized weight bias provides information above and beyond traditional measures of internalized weight bias and begins to provide insights into social comparison processes involved in weight bias.

The validation of the malay version of binge eating scale: a comparison with the structured clinical interview for the DSM-IV

BACKGROUND

The Binge Eating Scale (BES) questionnaire is a self-administered instrument developed to identify binge eaters. The aim of this study was to assess the validity of the Malay language version of BES as a screening instrument for binge eating. A cut-off point of 17 is taken as comparable to the Structured Clinical Interview for the DSM-IV patient version (SCID-I/P), the gold standard for the diagnosis of Binge Eating Disorder.

METHOD

The questionnaire was structured from the English version of the original scale which has 16 items. The sample was obtained from outpatients and healthy adult volunteers at a teaching hospital. After completion of BES, the participants were interviewed with the SCID-I/P. The interviewer was blinded to the BES score.

RESULTS

The Malay version of BES yielded a sensitivity of 84.6%, specificity of 94.9%, a positive predictive value of 81.8%, a negative predictive value of 95.7%. Area under the curve was 0.95 (95% confidence interval: 0.90-0.99). The results of factor analysis indicated a two factor structure of feelings/cognition and behavioural manifestation of binge eating. Internal consistency, Cronbach's alpha was 0.89.

CONCLUSION

The BES performed satisfactorily as a valid instrument for screening of binge eating among Malay-speaking population.

Factor structure and predictive utility of the Binge Eating Scale in bariatric surgery candidates

BACKGROUND

Screening for binge eating before bariatric surgery is a component of the recommended clinical practice for bariatric surgery candidates. The Binge Eating Scale (BES) is 1 of the most commonly used self-report measures of eating behaviors in preoperative evaluations; however, the factor structure of this measure has not been evaluated in the bariatric population. The aims of the present study were to report the mean, standard deviation, and reliability of the BES for patients seeking bariatric surgery; to evaluate the 2-factor structure of the BES using confirmatory factor analysis; and to investigate the association between the BES and its factors with surgical weight loss. The setting was an academic medical center.

METHODS

A total of 530 patients completed the BES as a component of their psychological evaluation before undergoing Roux-en-Y gastric bypass surgery.

RESULTS

Approximately one third of patients reported at least mild to moderate binge eating, with 9% of patients reporting severe binge eating on the BES. The BES demonstrated good internal consistency. The results of the confirmatory factor analysis indicated that a 2-factor structure, consisting of feelings/cognitions related to binge eating and behavioral manifestations of binge eating, was the best fit to the data. Nonsignificant correlations were found between the BES and its 2 factors with short-term postoperative weight loss.

CONCLUSION

The BES measures 2 aspects of binge eating in bariatric surgery candidates, feelings/cognitions and behavioral manifestations of binge eating. Consideration of these factors in patients presenting for bariatric surgery could allow for a more detailed understanding of binge eating in this population.

Weight reduction in obese adolescents with and without binge eating

Little is known about binge eating (BE) in adolescents. The primary aim of the present study was to examine the relationship between BE and weight loss in adolescents (BMI ≥95th percentile) enrolled in a randomized controlled trial of behavioral and pharmacologic treatment of obesity. Participants were 82 treatment-seeking adolescents (BMI = 37.9 ± 3.8 kg/m(2); age = 14.1 ± 1.2 years; 67% females; 42% African American, 55% white). Participants completed the Children's Depression Inventory (CDI), the Piers Harris Self-Esteem Questionnaire, and the Eating Inventory (including cognitive restraint, disinhibition, and hunger scales). BE was assessed by a questionnaire and a confirmatory interview. At baseline, 24% of participants met criteria for BE (N = 13 met full BE disorder (BED) criteria; N = 7 met subthreshold BE). There were no significant differences in percentage reduction in initial BMI between participants with or without BE at month 6 (-7.0 ± 1.6 vs. -6.9 ± 0.9%) or month 12 (-8.8 ± 2.4 vs. -8.3 ± 1.3%) (omnibus main effect BE P = 0.89, interaction BE × time P = 0.84, interaction BE × drug P = 0.61). The rate of BE declined significantly over time from 24% (n = 20) at baseline to 8% (n = 6) at month 6 and 3% (n = 2) at month 12 (P = 0.003). There were significant decreases in hunger and disinhibition as well as an increase in cognitive restraint over time (all P ≤ 0.0001). Findings suggest a combination of behavioral and pharmacologic therapy may produce both weight loss and improvement in BE.

Psychological treatments of binge eating disorder

CONTEXT

Interpersonal psychotherapy (IPT) is an effective specialty treatment for binge eating disorder (BED). Behavioral weight loss treatment (BWL) and guided self-help based on cognitive behavior therapy (CBTgsh) have both resulted in short-term reductions in binge eating in obese patients with BED.

OBJECTIVE

To test whether patients with BED require specialty therapy beyond BWL and whether IPT is more effective than either BWL or CBTgsh in patients with a high negative affect during a 2-year follow-up.

DESIGN

Randomized, active control efficacy trial.

SETTING

University outpatient clinics.

PARTICIPANTS

Two hundred five women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED. Intervention Twenty sessions of IPT or BWL or 10 sessions of CBTgsh during 6 months.

MAIN OUTCOME MEASURES

Binge eating assessed by the Eating Disorder Examination.

RESULTS

At 2-year follow-up, both IPT and CBTgsh resulted in greater remission from binge eating than BWL (P < .05; odds ratios: BWL vs CBTgsh, 2.3; BWL vs IPT, 2.6; and CBTgsh vs IPT, 1.2). Self-esteem (P < .05) and global Eating Disorder Examination (P < .05) scores were moderators of treatment outcome. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT; for self-esteem, they were 2.4 for BWL, 1.9 for CBTgsh, and 0.9 for IPT.

CONCLUSIONS

Interpersonal psychotherapy and CBTgsh are significantly more effective than BWL in eliminating binge eating after 2 years. Guided self-help based on cognitive behavior therapy is a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00060762.

Quality of life in Brazilian obese adolescents: effects of a long-term multidisciplinary lifestyle therapy

Background

Obesity has adverse physical, social, and economic consequences that can negatively affect quality of life (QOL). Thus the aim of this study was to verify the effects of a long-term multidisciplinary lifestyle intervention on QOL, body image, anxiety, depression and binge eating in obese adolescents.

Methods

Sixty-six obese adolescents (41 girls and 25 boys; BMI: 35.62 ± 4.18 kg/m²) were recruited from the Multidisciplinary Obesity Intervention Program outpatient clinic, and were submitted to a multidisciplinary lifestyle therapy (short-term = 12 weeks and long-term = 24 weeks), composed of medical, dietary, exercise and psychological programs. Validated self-report questionnaires were used to assess symptoms of anxiety Trait/State (STAI); depression (BDI); binge eating (BES), body image dissatisfaction (BSQ) and QOL (SF-36). Data were analyzed by means of scores; comparisons were made by ANOVA for repeated measures, and Tukey's test as post-hoc and Students T test.

Results

Long-term therapy decreased depression and binge eating symptoms, body image dissatisfaction, and improved QOL in girls, whereas, for boys, 24 weeks, were effective to reduce anxiety trait/state and symptoms of binge eating, and to improve means of dimensions of QOL (p < .05).

Conclusion

A long-term multidisciplinary lifestyle therapy is effective to control psychological aspects and to improve QOL in obese adolescents.

Depression and anxiety: their predictive function for weight loss in obese individuals

OBJECTIVE

To investigate the impact of current mental disorders on weight loss with special consideration of depressive and/or anxiety disorders as well as binge eating behavior in obese individuals undergoing different weight loss treatments.

METHODS

Three different samples of obese individuals were investigated in a prospective, longitudinal study: participants in a conventional weight loss treatment program (CONV TREAT; n = 250), obesity surgery patients (OBES SURG; n = 153), and obese control individuals (OC; n = 128). Current mental disorders and BMI were assessed at baseline and at 4-year follow-up.

RESULTS

OBES SURG patients with a depressive and/or anxiety disorder lost significantly less weight compared with those without a comorbid mental diagnosis. This result was not detected for CONV TREAT participants. A trend to gain weight was seen in OC participants with a depressive and/or anxiety disorder, whereas OC participants without current mental disorders at baseline lost some weight. Binge eating behavior at baseline did not predict weight loss at 4-year followup.

CONCLUSIONS

These results underline the importance of addressing current depressive and anxiety disorders in obese patients, especially when such patients are undergoing obesity surgery.

Use of an operant task to estimate food reinforcement in adult humans with and without BED

OBJECTIVE

The purpose of this study was to demonstrate the utility of food-reinforced operant task performance in modeling binge-eating disorder (BED). We hypothesized that food reinforcement after a caloric preload would be related to BED status, but not hunger.

METHODS AND PROCEDURES

We investigated the association between reports of hunger, binge tendency, and food reinforcement in a sample of 18 women (12 non-BED, 7 lean, 5 obese, and 6 obese BED). Participants completed two sessions of operant task performance after consuming 600 ml of flavored water or 600 ml of a 1 kcal/ml liquid meal.

RESULTS

Under the water condition, food reinforcement did not differ between the non-BED and BED groups, and was positively correlated with hunger ratings across all participants (r = 0.55, P = 0.023). Under the liquid meal condition, food reinforcement was significantly decreased compared with the water condition in the non-BED group (t = -2.6, P = 0.026). There was also a significant difference between the non-BED and BED groups in the fed condition (41 +/- 40, 117 +/- 60, F = 10.3, P = 0.005, non-BED vs. BED, respectively, mean +/- s.d.). The correlation between food reinforcement and hunger remained significant only in the non-BED group (r = 0.69, P = 0.011).

DISCUSSION

Our results support the hypothesis that food reinforcement measured after a caloric preload is related to BED status but not hunger in those subjects with BED. The data also suggest that operant task performance can be useful in modeling BED criteria such as "eating when not physically hungry."

A comparison of eating disorders among patients receiving surgical vs non-surgical weight-loss treatments

BACKGROUND

Little is known about differences between patients in surgical and non-surgical weight-loss treatments (WLT) regarding eating disorders, level of general psychopathology, and health-related quality of life (HRQL). Such differences could indicate different clinical needs in the management of surgical compared to non-surgical WLT patients.

METHODS

Participants were a subset of 100 patients from a Swedish study investigating the long-term effects of eating disorders in WLT. Participants filled out the Eating Disorders in Obesity Questionnaire as well as self-rating questionnaires of general psychopathology and HRQL before initiating surgical (n = 54) or non-surgical (n = 46) WLT.

RESULTS

Eating disorders were found to be more common among patients accepted for surgical treatments, whereas binge eating (as a symptom) was found to be equally common in both groups. Surgical patients also indicated higher levels of psychopathology compared to those receiving non-surgical treatment.

CONCLUSION

Patients in surgical WLT are younger, more obese, and indicate higher levels of eating disorders and psychopathology than non-surgical WLT patients. Results highlight the importance of surgical WLT units having adequate knowledge, resources, and methods for detecting and addressing issues of eating disorders and psychopathology before and during the WLT. Future longitudinal studies need to ascertain to what extent eating and general psychopathology influence the outcome of WLT in terms of lapses, complications, weight gain, quality of life, etc.

Weight gain prevention among women

OBJECTIVE

Women 25 to 45 years old are at risk for weight gain and future obesity. This trial was designed to evaluate the efficacy of two interventions relative to a control group in preventing weight gain among normal or overweight women and to identify demographic, behavioral, and psychosocial factors related to weight gain prevention.

RESEARCH METHODS AND PROCEDURES

Healthy women (N = 284), ages 25 to 44, with BMI < 30 were randomized to one of three intervention conditions: a clinic-based group, a correspondence course, or an information-only control. Intervention was provided over 2 years, with a follow-up at Year 3. BMI and factors related to eating and weight were assessed yearly.

RESULTS

Over the 3-year study period, 40% (n = 114) of the women remained at or below baseline body weight (+/-2 lbs), and 60% gained weight (>2 lbs). Intervention had no effect on weight over time. Independently of intervention, women who were older, not actively dieting to lose weight, and who reported less perceived hunger at baseline were more likely to be successful at weight maintenance. Weight maintenance also was associated with increasing dietary restraint (conscious thoughts and purposeful behaviors to control calorie intake) and decreasing dietary disinhibition (the tendency to lose control over eating) over time.

DISCUSSION

This study raises concern about the feasibility and efficacy of weight gain prevention interventions because most women were interested in weight loss, rather than weight gain prevention, and the interventions had no effect on weight stability. Novel approaches to the prevention of weight gain are needed.

Do people with diabetes who need to talk want to talk?

AIM

Our objective was to determine whether people with diabetes who ask for psychological support are those who are experiencing clinically significant levels of psychological distress.

METHOD

Three hundred people with diabetes were asked to complete psychometrically validated questionnaires that assessed subjective need and objective psychological distress.

RESULTS

High levels of psychological distress were reported: 25% reported depressive symptomatology, 41% reported clinically significant levels of anxiety and 51% reported some binge eating behaviour. Participants also indicated a desire to talk to diabetes professionals about various problem areas in diabetes. Those reporting psychological distress, especially depression, were most likely to indicate a desire to talk to someone about living with diabetes.

CONCLUSIONS

Those who want to talk are those who need to talk. Future service development issues should acknowledge the needs and expressed wishes of service users.

Changes in eating behaviour following group therapy for women who binge eat: a pilot study

Survey research is demonstrating that binge eating and compulsive eating may be a significant problem in the obese population. There is higher incidence of binge eating among women, associated with subjective distress and poor prognosis for weight control. Despite attendant health risks, researched clinical responses have not been developed. A before and after uncontrolled pilot study aimed to evaluate the effectiveness of group therapy for women who binge eat and compulsively eat. Participants attended a weekly integrative therapy group for 6 months. Measurements before and after the group intervention were taken using the Binge Eating Scale and Clinical Outcomes in Routine Evaluation inventories. Before and after interviews were thematically analysed for changes in eating behaviour. Following the group intervention, all participants demonstrated changes in eating behaviour measured by the Binge Eating Scale, the overall effect from baseline to 1 year demonstrates statistical significance. Qualitative data revealed four categories that underpinned reduction in binge eating: changes in dichotomous thinking, awareness of eating behaviour, detachment from food and dietary changes. An integrative model of group therapy warrants further research and refinement for this population, a group protocol for nurses working in the field of obesity and eating disorders could be developed.

Effect of sibutramine and of cognitive-behavioural weight loss therapy in obesity and subclinical binge eating disorder

AIM

In this randomized, double-blind, placebo-controlled study, the effect of sibutramine and cognitive-behavioural weight loss (cognitive-BWL) treatment was assessed in obese subjects with and without subclinical binge eating disorder (sBED).

METHODS

Seventy-three obese participants were recruited from the community, 29 with and 44 without sBED. Subjects were randomly assigned to a 16-week treatment with either sibutramine or placebo while simultaneously participating in a cognitive-behavioural weight loss treatment.

RESULTS

Intent-to-treat analysis showed moderate weight loss after treatment in all subject groups. Treatment with BWL programs and sibutramine leads to a higher weight loss in all subjects compared with that in patients who had undergone BWL programs alone. Subjects with sBED significantly reduced their binge episodes during treatment, but with no augmenting effect of sibutramine.

DISCUSSION

Our results yield further evidence that sBED is associated with characteristics comparable with full-syndrome BED, significantly differing from those of obesity alone. These findings call for a systematic assessment of eating behaviour before starting obesity treatment.

Assessment of binge eating disorder in morbidly obese patients evaluated for gastric bypass: SCID versus QEWP-R

OBJECTIVE

Binge eating disorder (BED) has been hypothesized to be associated with poor outcome in gastric bypass surgery (GBP). However, past studies have yielded inconsistent results regarding BED and surgical outcome, which may be due to the variety of measures used to assess BED. The present study examines the utility of two commonly used BED diagnostic tools: the Structured Clinical Interview (SCID) and the Questionnaire of Eating and Weight Patterns-Revised (QEWP-R).

METHOD

Subjects were 168 adult patients evaluated for GBP. BED was assessed using the SCID and the

RESULTS

27% of the sample received a diagnosis of BED using the QEWP-R, compared with 14% using the SCID. Agreement using Cohen's kappa was 0.37. Compared to sub-non-concordant diagnoses of BED, subjects with concordant diagnoses scored on a measure of self-esteem.

DISCUSSION

Although both diagnostic tools use the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) criteria, each yielded different results. Further studies are needed to determine the most accurate method of assessing BED in this population.

Predictive factors of binge eating disorder in women searching to lose weight

METHODS

The aim of this study was to detect predictive factors of binge eating disorder (BED) in an out-patient obesity clinic. Eating behaviour, weight history and body composition were assessed in 138 consecutive patients. BED was diagnosed according to the criteria of appendix B of the Diagnostic and Statistical Manual of Mental Disorders.

RESULTS

The body mass index (BMI; p < 0.005) and the waist circumference (p < 0.05) were significantly higher in binge patients than in patients without eating disorders. Similar differences were observed between patients who regularly went through weight loss programmes and patients who consulted for the first time. The prevalence of BED increases with the degree of obesity and especially with the number of previous intentional weight loss programmes. A positive and significant correlation was found between the weight cycling syndrome and BMI (p < 0.0001), waist circumference (p < 0.0001) and body fat (p < 0.001).

DISCUSSION

The patients with BED present a specific anthropometric profile and a typical behavioural pattern characterized by a higher degree of central obesity and a weight history with a higher number of attempts of weight loss.

Psychopathological differences between morbidly obese binge eaters and non-binge eaters after bariatric surgery

AIMS

To determine the psychological characteristics of a group of morbidly obese patients with binge eating disorders and to investigate whether the psychopathological status of binge eaters is different from that of other morbidly obese patients.

METHODS

We used the Binge Eating Scale, the Three-Factor Eating Questionnaire and the Millon Clinical Multiaxial Inventory-II (MCMI-II) to interview 140 morbidly obese patients 18 months after bariatric surgery (vertical banded gastroplasty), and compared the results obtained in binge eaters (n = 25) and non-binge eaters (n = 115).

RESULTS

The binge eaters had more eating disturbances (more binge eating, less restriction, more disinhibition, more hunger) and psychopathological characteristics (passive-aggressive traits, aggressive-sadistic traits, manic disorders, alcohol dependence and major depression) than the non-binge eaters. They were also younger and achieved a lower percentage of weight loss.

CONCLUSIONS

After bariatric surgery, our obese binge eaters reported significantly more psychiatric symptoms, especially those relating to eating disorders, depression, alcohol dependence and personality disturbances. Their weight loss was less satisfactory, and they sought bariatric surgery at a younger age.

Eating patterns, weight status and egogram characteristics among Japanese pupils

The purpose of this study was to investigate the actual conditions of eating patterns and the relationships among eating patterns, degree of overweightness and egogram characteristics among pupils. The subjects were 871 boys and girls whose grades ranged from 4th to 6th. They were selected from five elementary schools in Hirosaki and its suburbs, Japan. They were classified into the following 5 groups by the degree of overweightness: lean group, standard group, slightly obese group, moderately obese group, and extremely obese group. Eating patterns were measured by questionnaries, and AN-egogram was used for the measurement of egogram characteristics.The results were as follows: 1. The ego state of pupils who eat their favorite dish even with a full stomach showed significantly lower A (adult) qualities and higher FC (free child) qualities than those who would not eat in this situation. The egogram pattern of the former pupils exhibited the NP (nurturing parent)-low type. 2. The egogram pattern of pupils who engage in substitutive food intake exhibited the NP-low type. 3. Significant differences existed among the ego states CP (critical parent), NP, A, and FC as to reasons given for eating between meals. 4. The egogram pattern of the person who eats between meals at the time of "an empty stomach" showed a flat type of ego state with relatively low NP. The person who eats "just at meal time" showed an A-dominant type. The person who eats "when food is present" showed an NP - low type with relatively low CP. 5. The ego state A was significandy less common in the extremely obese group than in the lean group. 6. The egogram pattern of the lean, standard, and slightly obese groups showed an A - dominant type of ego state, and that of moderately and extremely obese groups showed an AC-dominant type with CP slightly high.

Sertraline enhances the effects of cognitive-behavioral treatment on weight reduction of obese patients

Serotonin reuptake inhibitors, such as dexfenfluramine, fluoxetine and fluvoxamine, have been proposed as therapeutical tools for the treatment of eating disorders and obesity. Sertraline, a SSRI used in the treatment of depression, interferes with eating behavior in animal models, but it has not been tested in obese humans. Aim of this study is the assessment of the effects of sertraline on eating attitudes and body weight in obese patients with and without mood disorders. A consecutive series of 65 obese out-patients aged 18-65 years, with a body mass index (BMI) > 30 kg/m2, was treated for 6 months with sertraline 150 mg/day per os, in addition to a cognitive-behavioral treatment (CBT). A consecutive series of 60 obese patients with similar characteristics, who were treated with CBT only, were used as control group. A greater reduction of BMI (mean +/- SD) was observed in sertraline-treated patients when compared to controls (from 35.3 +/- 5.7 to 32.0 +/- 5.4 kg/m2 in sertraline-treated patients, from 37.1 +/- 7.0 to 36.0 +/- 7.1 kg/m2 in controls; 6.5 +/- 5.4% vs. 3.0 +/- 6.3%; p < 0.01), while a similar change in eating attitudes (evaluated through the BITE questionnaire) was observed in both groups. Effects of sertraline on eating attitude and body weight were similar in patients with and without mood disorders. In conclusion, sertraline, administered together with CBT, seems to be more effective in inducing weight loss in obese patients when compared with CBT alone, and therefore it could be a useful tool in the first months of CBT for severe obesity.