Nutrient intake of obese female binge eaters.

OBJECTIVE: To compare the 6-month change in selected nutrients and number of binge days (from 7-day food records) between obese binge eaters randomly assigned to either a behavioral self-management (BSM) or waiting list control (WLC) group. Within each of the 2 groups, the average intake of selected nutrients on binge and nonbinge days at baseline and at 6 months were compared. DESIGN: A randomized, controlled, intervention study with assessments at entry and 6 months later. SUBJECTS: Forty-six women in the BSM group and 36 in the WLC group completed the 6-month measurement. Participants were 25 to 50 years of age, 30 to 90 pounds overweight, did not have a history of physical or psychological illnesses, and scored 20 or greater on the binge eating scale. INTERVENTION: Participants in the BSM intervention received 6 months of weekly, 1-hour classes taught by registered dietitians. Participants in the WLC group were not contacted during the 6 months. OUTCOME MEASURES: The main outcome measures were change in energy consumed (kilocalories); percentage of energy from fat, protein, and carbohydrate; grams of fiber/1,000 kcal; and change in the number of self-reported binge days. STATISTICAL ANALYSES: Weight at 6 months was compared using a 2-sample t test. The change in the number of binge days at 6 months and the amount of change in selected nutrients by group was compared using the 2-sample t test. The paired t test was used to compare the average nutrient intakes on binge and nonbinge days within groups. RESULTS: No significant difference was found in the 6-month change between groups in any of the selected nutrients. The BSM group reported a greater reduction in binge days between baseline and 6 months compared with the WLC group (mean 1.0 vs 1.7, P < 0.03). Within the BSM group at 6 months, energy intake and percentage of energy from fat on nonbinge days were significantly reduced compared with binge days. At baseline within the WLC group, energy intake increased and percentage of energy from protein decreased significantly on nonbinge days compared with binge days. Within the WLC group at 6 months, energy intake and percentage of energy from fat significantly decreased and percentage of energy from protein significantly increased on nonbinge days. CONCLUSIONS: Our results suggest that collecting dietary information from participants identified with binge eating disorder is challenging. Dietitians who conduct behavioral weight management programs may require additional training in identifying and understanding the psychological characteristics of participants with binge-eating disorder.

Negative stress and the outcome of treatment for binge eating.

This study investigated the ability of negatively versus positively perceived stress to predict outcome of treatment for binge eating disorder (BED). Participants were 62 obese women satisfying the DSMIV research criteria for BED. Stress was measured using an instrument based on the Recent Life Change Questionnaire (RLCQ). Participants experiencing high negative stress during the study period reported a binge eating frequency three times greater than that reported by subjects experiencing low negative stress (2.14 vs. 0.65 binge-days/week). Negative stress predicted how fast an individual would reduce binge eating and demonstrated more predictive power than positive stress.

Reliability and validity of the dieter's inventory of eating temptations (DIET) in overweight binge eating women.

The aim of this study was to evaluate the validity of the Dieter's Inventory of Eating Temptations (DIET). TJye DIET, Tennessee Self-Concept Scale (TSCS), and Binge Eating Scale (BES) were completed by 219 obese, binge-eating women. A 5-factor solution was generated that accounted for 46.9% and 95.0% of the total and common variance, respectively. The DIET demonstrated high internal consistency (alpha=0.93), as did the 5 factors (alphas ranging from 0.71-0.89). The DIET was correlated positively with the TSCS (r=0.212; p=0.002) and negatively with the BES (r=-0.199: p=0.003) suggesting that women who report higher ability to manage problematic diet situations have higher self-esteem and lower binge-related emotional distress. The results of this study suggest that the DIET is a reliable and valid instrument, but the six subscales could probably be reduced to five distinct domains.

Binge eating severity, self-concept, dieting self-efficacy and social support during treatment of binge eating disorder.

OBJECTIVE: In treatment of binge eating, measures of self-concept, eating self-efficacy, and social support were examined at 0, 6, and 18 months to determine if improvements in these variables were associated with reductions in binge eating severity. METHOD: Obese adult females (N = 125) were treated for 6 months, with 12 months of maintenance meetings. The Binge Eating Scale (BES), Tennessee Self-Concept Scale (TSC), Dieter's Inventory of Eating Temptations (DIET), and a social support measure (SocSup) were used. RESULTS: Over the first 6 months, improvements in BES were associated with improvements in the TSC and DIET. Over 18 months, improvements in BES were associated with improvements in the TSC, DIET, and SocSup. DISCUSSION: Therapy for binge eating should result in improvement in self-concept and eating self-efficacy, as well as reductions in binge eating. This study showed that self-concept and eating self-efficacy were associated with improvement in binge eating severity. The association with social support did not appear until long-term follow-up. Improvement in self-concept and eating self-efficacy may be processes leading to clinical improvement in this eating disorder, or they may result from changes in binge eating.

Personality and the prediction of weight loss and relapse in the treatment of obesity.

OBJECTIVE: This prospective study examined whether stable personality traits, as measured by the Karolinska Scales of Personality (KSP), predicted initial weight loss or long-term maintenance in obesity patients. METHOD: The KSP was administered to 102 obese patients prior to entering an 8-week weight loss program. Patients were weighed again at the end of treatment and at 3- and 12-month follow-up. RESULTS: The KSP did not predict initial weight loss after the 8-week program. Several of the KSP scales (Muscle Tension, Monotony Avoidance, Suspicion, and Guilt) had weak associations with 12-month relapse status. Weight gain at the 3-month follow-up was the strongest predictor of 12-month relapse status (O.R. = 0.46; 95% C.I. = 0.32, 0.66). DISCUSSION: Personality traits, as measured by the KSP, do not appear to be important predictors of initial weight loss or 12-month relapse status. Personality assessment may not substantially contribute to predicting treatment outcome in obesity research.

Echocardiographic assessment of patients receiving long-term treatment with anorexiant medications.

OBJECTIVE: To describe the prevalence and evaluate the risk of echocardiogram-determined valvulopathy in patients who received fenfluramine and phentermine in an effort to lose weight, in comparison with normal control subjects. METHODS: A historical cohort study was conducted in a clinical obesity-management practice. A total of 164 patients (88% women) who were treated with fenfluramine-phentermine for weight loss had echocardiographic evaluations. A subsample was cross-validated. RESULTS: The prevalence of mild or greater aortic regurgitation was 18.3%, and the prevalence of moderate or greater mitral regurgitation was 3.7%. The prevalences of mild or greater tricuspid and pulmonary valve regurgitation, valve thickening, and pulmonary hypertension were 23.2%, 5.5%, 10.4%, and 6.7%, respectively. No significant increases in risk were found for moderate or greater regurgitation of any valve. Patients had at least a 3-fold risk for mild or greater aortic regurgitation (standardized morbidity ratio [SMR] = 3.03; 95% confidence interval [CI] = 2.05 to 4.33) and a 2-fold risk for tricuspid regurgitation (SMR = 2.24; 95% CI = 1.58 to 3.06) in comparison with normal healthy adults. Age and duration of drug therapy predicted increased risk for aortic regurgitation. Four patients who had moderate or greater aortic regurgitation had taken the fenfluramine-phentermine combination continuously for 454, 615, 645, and 984 days. CONCLUSION: Use of serotonergic anorexiant medications may increase risk for mild or greater aortic and tricuspid regurgitation, although selection bias and obesity as causes of the association cannot be ruled out. Age and duration of drug therapy were predictors of aortic valvulopathy. Population-based studies are needed to confirm these preliminary findings.

The predictive validity of the Diet Readiness Test in a clinical population.

OBJECTIVE: To evaluate the psychometric properties, including the factorial and predictive validity, of the Diet Readiness Test (DRT) in a clinical population. METHOD: The DRT was administered to 132 women who participated in an obesity and binge eating treatment study. RESULTS: The DRT demonstrated adequate internal consistency. The DRT's proposed factor structure was not supported. Neither the DRT subscales nor the derived factors predicted changes in weight, binge eating, or exercise. DISCUSSION: The DRT did not demonstrate factorial or predictive validity in this study. Based on the DRT's cutoff criteria, 100% of the sample was considered not ready to begin a weight loss program, suggesting that the DRT may have limited utility with clinical populations.

Nondieting versus dieting treatment for overweight binge-eating women.

This study evaluated the effectiveness of nondieting versus dieting treatments for overweight, binge-eating women. Participants (N = 219) were randomly assigned to 1 of 3 groups: diet treatment (DT), nondiet treatment (NDT), or wait-list control (WLC). DT received a balanced-deficit diet reinforced with behavioral strategies. NDT received therapy designed to help participants break out of their dieting cycles. Treatment in both conditions was administered in weekly groups for 6 months, followed by 26 biweekly maintenance meetings, for a total of 18 months of contact. At 6 months posttreatment, DT lost 0.6 kg while NDT gained 1.3 kg. Both treatment groups reduced their Binge Eating Scale scores significantly more than WLC. At 18-month follow-up, both treatment groups experienced weight gain but maintained similar reductions in binge eating. Results indicate that neither intervention was successful in producing short- or long-term weight loss. Therapist biases, which may have affected treatment integrity, and other methodological issues are discussed in relation to the small weight losses achieved.

Perceived coping capacity: a comparison between obese patients and patients on long-term sick leave.

Overweight is a significant health problem and perceived by many as a disability. While obese persons in the general population are no more likely to suffer from mental disorders, many obese individuals experience significant difficulties coping with their weight and weight-loss failures. The purpose of this study was to investigate the similarities and differences in coping capacity among obese and disabled individuals. We compared a group of obese adults (76 consecutive obese patients, 82% female) with unemployed long-term sick leave disability patients (59 consecutive patients, 46% female) who had an average of 13 +/- 9 months on disability. We used the Perception of Cognitive Structure, Emotion and Control questionnaire (PASEC), which assesses an individual's coping capacity for general problems in life and to specific health problems. Both groups significantly differed from PASEC normative data, suggesting that they had more negative and harmful emotional perceptions of their lives than individuals in the normative sample. Compared to long-term sick leave patients' perceptions of disabilities, obese patients perceived their weight problems with more negative and harmful emotional investment, even after adjustment for gender differences in the groups. This suggests that obese patients may experience substantial difficulties in coping with their weight problems.

Future directions in obesity and eating disorders.

The purpose of this article is to explore future directions in the treatment of obesity and eating disorders. After briefly reviewing the costs of eating disorders, in terms of morbidity, mortality, and economics, we provide suggestions for future research and treatment. We first focus on changes that should be considered to improve etiological and outcome research, with the idea that a better understanding of etiological factors will lead to better interventions. We then examine promising treatment approaches, public health initiatives, and the importance of focusing on health and self-acceptance as valid treatment outcomes.

Methods for voluntary weight loss and control: update 1996.

The prevalence of obesity increased nearly eight percent over the last decade. In response to the obesity epidemic in the United States. The National Institutes of Health Technology Assessment Conference Panel published "Methods for voluntary weight loss and control" in 1993. Unfortunately, in 1996, the evidence suggests that the prevalence of obesity is still steadily increasing. Current trends predict that most Americans will struggle with weight problems and obesity in the future. There have been no major advances in the treatment of obesity. Interventions produce short-term losses followed by weight regain, and no current treatments appear capable of producing permanent weight loss. Newer treatment approaches assume that obesity is a chronic disorder that requires a continuous care model of treatment. Social and environmental influences on eating and physical activity, along with perceptions of inability to self-control, continually mitigate against maintenance of prudent weight management behaviors. Since the etiology of obesity is multifactorial and can be viewed as an interaction between biology and environmental factors, environmental changes and biological interventions aimed at correcting genetic and metabolic irregularities will be central to any efforts to stem the tide of obesity.

Comparison of 2-year weight loss trends in behavioral treatments of obesity: diet, exercise, and combination interventions.

OBJECTIVE: The effects of three cognitive-behavioral weight control interventions for adults were compared: diet only, exercise only, and a combination of diet and exercise. This article reports 2-year follow-up data. DESIGN: The three interventions were compared in a randomized, experimental design. SUBJECTS: A total of 127 men and women who were at least 14 kg overweight (according to height-weight tables) were recruited from an urban community and assigned randomly to the experimental conditions. INTERVENTION: The dietary intervention was a low-energy eating plan adjusted to produce a 1 kg/week loss of weight. The exercise component involved training in walking and a home-based program of up to five exercise periods per week. There were 12 weekly instructional sessions, followed by 3 biweekly and 8 monthly meetings. All sessions were led by registered dietitians. OUTCOME MEASURES: Changes in body weight. STATISTICAL ANALYSES: Analysis of variance for weight changes and repeated measures analysis of variance for weight change trends. RESULTS: At 1 year, no significant differences were noted among the three groups. The diet-only group lost 6.8 kg, the exercise-only group lost 2.9 kg, and the combination group lost 8.9 kg (P=.09). During the second year, the diet-only group regained weight--reaching 0.9 kg above baseline; the combination group regained to 2.2 kg below baseline; and the exercise-only group regained slightly to 2.7 kg below baseline (P=.36). Repeated measures analysis of variance showed a group-by-time interaction (P=.001); data for the dieting groups best fit a U-shaped regain curve (P=.001). APPLICATIONS: The results suggest that dieting is associated with weight loss followed by regain after treatment ends, whereas exercise alone produced smaller weight losses but better maintenance. The large outcome variability and unequal difficulty of the regimens across groups limit the generalizability of the findings.

Psychological correlates of reported physical activity in normal-weight and obese adults: the Reno diet-heart study.

This investigation assessed psychological correlates of reported physical activity in a sample of 381 normal-weight and obese adults who were enrolled in a 4-year, prospective, natural history study. The psychological measures included the Eating Self-Efficacy Scale, the General Well-Being Schedule, and the Center for Epidemiological Studies Depression Scale. Reported Physical Activity was defined as a composite measure of reported recreational physical activity and perceived importance of activity in health and recreation. Physical activity was correlated with a more positive psychological profile in obese subjects at both year 1 and year 5. Increases in reported physical activity over the four years were associated with improvements in depression and well-being in normal-weight subjects, and with improvements in eating self-efficacy and well-being in obese subjects.

Psychological correlates of weight fluctuation.

This investigation attempted to determine psychological correlates of weight fluctuation in a sample of 497 normal weight and obese adults who were enrolled in a prospective, natural history study. Subjects were stratified by gender, obesity, and age and classified as weight maintainers, gainers, or losers based on their changes in weight over a 1-year period. Subjects were further classified as either weight fluctuators or nonfluctuators based on historical self-report. Nonfluctuators reported significantly higher general well-being, greater eating self-efficacy, and lower stress than weight fluctuators, regardless of body weight. Weight maintainers had more favorable eating self-efficacy related to negative affect than weight gainers. Results suggest that weight fluctuation is strongly associated with negative psychological attributes in both normal weight and obese individuals. Future research should focus on the assessment and treatment of weight fluctuation and on weight maintenance, irrespective of weight status.

Evidence for success of behavior modification in weight loss and control.

Behavior modification applied to the treatment of obesity has evolved from the environmental control of eating behavior to a broader approach characterized by systematic manipulation of all factors associated with eating and exercise patterns. This approach has shown success in helping obese persons lose modest amounts of weight. The average length of treatment is 18 weeks, and the average weight loss is 9.9 kg. About 66% of these weight losses are maintained at 52 weeks of follow-up. Because obesity is a chronic condition with a substantial potential for relapse, longer-term treatments are needed. In the future, behavioral modification is likely to be further combined with other treatment methods.

Potential impact of sugar and fat substitutes in American diet.

Nonnutritive sweeteners and fat substitutes have achieved rapid consumer acceptance. This is largely due to the perception held by the public that these products are helpful in weight control and diet improvement. The cognitive component in human eating behavior makes it difficult to generalize from animal research. The effectiveness of these products in weight control has yet to be demonstrated conclusively in human research. Currently these products appear to add palatibility to reduced-calorie diets and may be helpful to weight-loss efforts as part of an overall balanced, nutritious diet and healthy life-style that includes exercise.

Why treatments for obesity don't last.

Behavioral self-management training is the state of the art in the treatment of obesity. However, most of those treated experience only temporary success in keeping weight off. In some individuals, relapse appears to be related to the development of binge eating, which is characterized by perceived lack of eating control and symptoms of food dependence. Treatment for such patients should be based on the assumptions that self-management is very difficult and that emphasis should be on cognitive-behavioral methods with a reliance on social support for control of behavior. For some patients, continued use of the self-management model may result in harmful weight cycling.

Factors common to successful therapy for the obese patient.

The majority of patients treated for obesity regain lost weight after treatment. We speculate on what might be done to improve long-term success rates by examining the factors associated with success or relapse. An emphasis on exercise and prescribing more gradual changes in diet and exercise appears to be associated with better outcomes. There may be a need to conceptualize obesity as a food dependency disorder not amenable to self-control strategies. External social control through peer support groups may be indicated to help patients through temptations.