How many therapists? Practical guidance on investigating therapist effects in randomized controlled trials for eating disorders.

OBJECTIVE: An important question in implementation/dissemination research is whether the efficacy of a given treatment varies in part based on the therapist delivering the treatment. This study sought to provide practical guidance to researchers in the field of eating disorders for building measurement of therapist effects into the design of a typical, relatively small randomized controlled trial (RCT). METHOD: Using assumptions based on past trials of eating disorder treatments, Monte Carlo simulations were used to examine 12 different scenarios based on crossing the number of therapists (between two and five) and the estimated therapist effect size (small, medium, and large). Patient sample size and study design were held constant. RESULTS: There was reasonable power (≥70%) to detect the therapist effect with three or four therapists and a large effect size. DISCUSSION: Several practical implications for testing therapist effects in RCT are discussed.

Demographic and clinical characteristics of individuals utilizing an internet-based digital coaching program for recovering from binge eating.

OBJECTIVE: While digital coaching self-help interventions to facilitate behavioral change are offered increasingly on the Internet, few studies have examined who uses them. This study examined demographic and clinical characteristics of adults who accessed a self-help program for binge eaters made available to them via their employers or health plans. METHOD: Cross-sectional data from 4,051 men and women who registered for the online program during a 13-month period were used. Gender differences and differences across three diagnostic groupings based on self-reported symptoms were tested using t-tests and ANOVAs (dimensional variables) or Chi-Square analyses (categorical variables). RESULTS: More women (3,053) than men (998) accessed the program. A majority of participants reported binge eating below frequency levels required for a clinical diagnosis, yet reported high levels of motivation to overcome their eating binges. Few had received prior treatment for an eating disorder. Although women reported greater symptomatology on most variables, these differences typically reflected small effects. Comparisons of diagnostic subgroups found few differences between those with probable diagnoses of bulimia nervosa or binge eating disorder. DISCUSSION: Digital coaching programs may be a viable treatment option, particularly for individuals with infrequent binge eating who otherwise might not seek or receive treatment.

Health-service use in women with binge eating disorders.

OBJECTIVE: To compare health-care utilization between participants who met DSM-IV criteria for binge eating disorder (BED) and those engaged in recurrent binge eating (RBE) and to evaluate whether objective binge eating (OBE) days, a key measurement for diagnosing BED, predicted health-care costs. METHOD: We obtained utilization and cost data from electronic medical records to augment patient reported data for 100 adult female members of a large health maintenance organization who were enrolled in a randomized clinical trial to treat binge eating. RESULTS: Total costs did not differ between the BED and RBE groups (ß = -0.117, z = -0.48, p = .629), nor did the number of OBE days predict total costs (ß = -0.017, z = -1.01, p = .313). DISCUSSION: Findings suggest that the medical impairment, as assessed through health care costs, caused by BED may not be greater than impairment caused by RBE. The current threshold number of two OBE days/week as a criterion for BED may need to be reconsidered.

Behavioral symptoms of eating disorders in Native Americans: results from the ADD Health Survey Wave III.

OBJECTIVE: To examine prevalence and correlates (gender, Body Mass Index) of disordered eating in American Indian/Native American (AI/NA) and white young adults. METHOD: We examined data from the 10,334 participants (mean age 21.93 years, SD = 1.8) of the National Longitudinal Study of Adolescent Health (ADD Health) Wave III for gender differences among AI/NA participants (236 women, 253 men) and ethnic group differences on measures of eating pathology. RESULTS: Among AI/NA groups, women were significantly more likely than men to report loss of control and embarrassment due to overeating. In gender-stratified analyses, a significantly higher prevalence of AI/NA women reported disordered eating behaviors compared with white women; there were no between group differences in prevalence for breakfast skipping or having been diagnosed with an eating disorder. Among men, disordered eating behaviors were uncommon and no comparison was statistically significant. DISCUSSION: Our study offers a first glimpse into the problem of eating pathology among AI/NA individuals. Gender differences among AI/NA participants are similar to results reported in white samples. That AI/NA women were as likely as white women to have been diagnosed with an eating disorder is striking in light of well documented under-utilization of mental health care among AI/NA individuals.

Eating patterns in patients with spectrum binge-eating disorder.

OBJECTIVE: We sought to describe meal and snack frequencies of individuals with recurrent binge eating and examine the association between these eating patterns and clinical correlates. METHOD: Data from 106 women with a minimum diagnosis of recurrent binge eating were used. Meal and snack frequencies were correlated with measures of weight, eating disorder features, and depression. Participants who ate breakfast every day (n = 25) were compared with those who did not (n = 81) on the same measures. RESULTS: Breakfast was the least, and dinner the most, commonly consumed meal. Evening snacking was the most common snacking occasion. Meal patterns were not significantly associated with clinical correlates; however, evening snacking was associated with binge eating. DISCUSSION: Our findings largely replicated those reported in earlier research. More research is needed to determine the role of breakfast consumption in binge eating.

Guided self-help treatment for recurrent binge eating: replication and extension.

OBJECTIVE: The aim of this study was to replicate and extend results of a previous blended efficacy and effectiveness trial of a low-intensity, manual-based guided self-help form of cognitive-behavioral therapy (CBT-GSH) for the treatment of binge eating disorders in a large health maintenance organization (HMO) and to compare them with usual care. METHODS: To extend previous findings, the investigators modified earlier recruitment and assessment approaches and conducted a randomized clinical trial to better reflect procedures that may be reasonably carried out in real-world practices. The intervention was delivered by master's-level interventionists to 160 female members of a health maintenance organization who met diagnostic criteria for recurrent binge eating. Data collected at baseline, immediately posttreatment, and at six- and 12-month follow-ups were used in intent-to-treat analyses. RESULTS: At the 12-month follow-up, CBT-GSH resulted in greater remission from binge eating (35%, N=26) than usual care (14%, N=10) (number needed to treat=5). The CBT-GSH group also demonstrated greater improvements in dietary restraint (d=.71) and eating, shape, and weight concerns (d=1.10, 1.24, and .98, respectively) but not weight change. CONCLUSIONS: Replication of the pattern of previous findings suggests that CBT-GSH is a robust treatment for patients with recurrent binge eating. The magnitude of changes was significantly smaller than in the original study, however, suggesting that patients recruited and assessed with less intensive procedures may respond differently from their counterparts enrolled in trials requiring more comprehensive procedures.

Clarifying boundaries of binge eating disorder and psychiatric comorbidity: a latent structure analysis.

Binge eating disorder (BED) presents with substantial psychiatric comorbidity. This latent structure analysis sought to delineate boundaries of BED given its comorbidity with affective and anxiety disorders. A population-based sample of 151 women with BED, 102 women with affective or anxiety disorders, and 259 women without psychiatric disorders was assessed with clinical interviews and self-report-questionnaires. Taxometric analyses were conducted using DSM-IV criteria of BED and of affective and anxiety disorders. The results showed a taxonic structure of BED and of affective and anxiety disorders. Both taxa co-occurred at an above-chance level, but also presented independently with twice-as-large probabilities. Within the BED taxon, diagnostic co-occurrence indicated greater general psychopathology, lower social adaptation, and greater premorbid exposure to parental mood and substance disorder, but not greater eating disorder psychopathology. Eating disorder psychopathology discriminated individuals in the BED taxon from individuals in the affective and anxiety disorders taxon. Diagnostic criteria of BED were more indicative of the BED taxon than were criteria of affective and anxiety disorders. The results show that at the latent level, BED was co-occurring with, yet distinct from, affective and anxiety disorders and was not characterized by an underlying affective or anxiety disorder.

Social network media exposure and adolescent eating pathology in Fiji.

BACKGROUND: Mass media exposure has been associated with an increased risk of eating pathology. It is unknown whether indirect media exposure--such as the proliferation of media exposure in an individual's social network--is also associated with eating disorders. AIMS: To test hypotheses that both individual (direct) and social network (indirect) mass media exposures were associated with eating pathology in Fiji. METHOD: We assessed several kinds of mass media exposure, media influence, cultural orientation and eating pathology by self-report among adolescent female ethnic Fijians (n=523). We fitted a series of multiple regression models of eating pathology, assessed by the Eating Disorder Examination Questionnaire (EDE-Q), in which mass media exposures, sociodemographic characteristics and body mass index were entered as predictors. RESULTS: Both direct and indirect mass media exposures were associated with eating pathology in unadjusted analyses, whereas in adjusted analyses only social network media exposure was associated with eating pathology. This result was similar when eating pathology was operationalised as either a continuous or a categorical dependent variable (e.g. odds ratio OR=1.60, 95% CI 1.15-2.23 relating social network media exposure to upper-quartile EDE-Q scores). Subsequent analyses pointed to individual media influence as an important explanatory variable in this association. CONCLUSIONS: Social network media exposure was associated with eating pathology in this Fijian study sample, independent of direct media exposure and other cultural exposures. Findings warrant further investigation of its health impact in other populations.

Development of a measure of "acculturation" for ethnic Fijians: methodologic and conceptual considerations for application to eating disorders research.

Acculturation has been examined as a risk factor for eating disorders, but interpretation of findings has been limited by inconsistent operationalization of this construct across studies. The study aim was to develop and evaluate a population-specific measure of acculturation for ethnic Fijian adolescent schoolgirls, to use in future analyses related to eating disorders. Our findings suggest that acculturation is a multidimensional construct characterized by distinct, though related, dimensions of orientation to ethnic Fijian and/or western/global culture with respect to a range of behaviors and attitudes. In contrast to theoretical models positing uni-dimensional, orthogonal, or oblique relations between cultural identities in individuals undergoing acculturation, our study findings support a heterogeneous pattern among correlations of dimensions across contrasting cultural identities. We suggest multidimensional measures of acculturation are optimal--and socio-demographic proxies inadequate--for characterization of this complex process for health research.

Cognitive behavioral guided self-help for the treatment of recurrent binge eating.

OBJECTIVE: Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). METHOD: In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. RESULTS: At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. CONCLUSIONS: CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa.

Cost-effectiveness of guided self-help treatment for recurrent binge eating.

OBJECTIVE: Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive-behavioral therapy guided self-help intervention (CBT-GSH) to treat recurrent binge eating compared to treatment as usual (TAU). METHOD: Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT-GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs. RESULTS: Compared to those receiving TAU only, those who received TAU plus CBT-GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of -$20.23 per binge-free day or -$26,847 per QALY). Lower costs in the TAU plus CBT-GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT-GSH. CONCLUSIONS: Findings support CBT-GSH dissemination for recurrent binge-eating treatment.

Youth health-risk behavior assessment in Fiji: the reliability of Global School-based Student Health Survey content adapted for ethnic Fijian girls.

OBJECTIVE: The Global School-based Student Health Survey (GSHS) is an assessment for adolescent health-risk behaviors and exposures, supported by the World Health Organization. Although already widely implemented - and intended for youth assessment across diverse ethnic and national contexts - no reliability data have yet been reported for GSHS-based assessment in any ethnicity or country-specific population. This study reports test-retest reliability for GSHS content adapted for a female adolescent ethnic Fijian study sample in Fiji. DESIGN: We adapted and translated GSHS content to assess health-risk behaviors as part of a larger study investigating the impact of social transition on ethnic Fijian secondary schoolgirls in Fiji. In order to evaluate the performance of this measure for our ethnic Fijian study sample (n=523), we examined its test-retest reliability with kappa coefficients, % agreement, and prevalence estimates in a sub-sample (n=81). Reliability among strata defined by topic, age, and language was also examined. RESULTS: Average agreement between test and retest was 77%, and average Cohen's kappa was 0.47. Mean kappas for questions from core modules about alcohol use, tobacco use, and sexual behavior were substantial, and higher than those for modules relating to other risk behaviors. CONCLUSIONS: Although test-retest reliability of responses within this country-specific version of GSHS content was substantial in several topical domains for this ethnic Fijian sample, only fair reliability for the module assessing dietary behaviors and other individual items suggests that population-specific psychometric evaluation is essential to interpreting language and country-specific GSHS data.

Nocturnal eating: association with binge eating, obesity, and psychological distress.

OBJECTIVE: To examine clinical correlates of nocturnal eating, a core behavioral symptom of night eating syndrome. METHOD: Data from 285 women who had participated in a two-stage screening for binge eating were utilized. Women (n = 41) who reported one or more nocturnal eating episodes in the past 28 days on the eating disorder examination and women who did not report nocturnal eating (n = 244) were compared on eating disorder symptomatology, body mass index (BMI), and on measures of psychosocial adjustment. RESULTS: Nocturnal eaters were significantly more likely to report binge eating and differed significantly from non-nocturnal eaters (with responses indicating greater disturbance) on weight and shape concern, eating concern, self-esteem, depression, and functional impairment, but not on BMI or dietary restraint. Group differences remained significant in analyses adjusting for binge eating. DISCUSSION: This study confirms the association between nocturnal eating and binge eating previously found in treatment seeking samples yet also suggests that the elevated eating disorder symptoms and decreased psychosocial adjustment observed in nocturnal eaters is not simply a function of binge eating.

A qualitative study of perceived social barriers to care for eating disorders: perspectives from ethnically diverse health care consumers.

OBJECTIVE: The study aim was to identify and describe health consumer perspectives on social barriers to care for eating disorders in an ethnically diverse sample. METHOD: We conducted an exploratory secondary analysis of qualitative data comprising transcripts from semi-structured interviews with past and prospective consumers of eating disorder treatment (n = 32). Transcripts were inputted into NVivo 8 for coding, sorting, and quantifying thematic content of interest within strata defined by ethnic minority and non-minority participants. We then examined the influence of key social barriers-including stigma and social stereotypes-on perceived impact on care. RESULTS: The majority of respondents (78%) endorsed at least one social barrier to care for an eating or weight concern. Perceived stigma (or shame) and social stereotyping-identified both within social networks and among clinicians-had adversely impacted care for 59% and 19% of respondents, respectively. DISCUSSION: Social barriers to care for eating and weight related concerns may be prevalent in the U.S. and impact both ethnic minority and non-minority health care consumers.

The significance of overvaluation of shape and weight in binge eating disorder.

As publication of DSM-V draws near, research is needed to validate the diagnostic scheme for binge eating disorder (BED). Shape and weight overvaluation has stimulated considerable debate in this regard, given associations with psychosocial impairment and poor treatment outcome in BED. This study sought to further explore the convergent validity and diagnostic specificity of shape and weight overvaluation in BED. A total of 160 women with BED, and 108 women with non-eating disordered psychiatric disorders were recruited from the community. Women with BED were classified as more or less severe based on a global measure of eating-related psychopathology; subsequent receiver operating characteristics analysis determined that a threshold of at least "moderate" overvaluation best predicted membership into a more severe group. BED participants with threshold overvaluation exhibited poorer psychosocial functioning than those with subthreshold overvaluation, as well as participants with other psychiatric disorders. Discriminant function analysis revealed that threshold overvaluation predicted a diagnosis of BED versus other psychiatric disorder with 67.7% accuracy. Results suggest that shape and weight overvaluation is a useful diagnostic specifier in BED. Continued research is warranted to examine its predictive validity in natural course and treatment outcome studies.

Adaptation and evaluation of the Clinical Impairment Assessment to assess disordered eating related distress in an adolescent female ethnic Fijian population.

OBJECTIVE: Measurement of disease-related impairment and distress is central to diagnostic, therapeutic, and health policy considerations for eating disorders across diverse populations. This study evaluates psychometric properties of a translated and adapted version of the Clinical Impairment Assessment (CIA) in an ethnic Fijian population. METHOD: The adapted CIA was administered to ethnic Fijian adolescent schoolgirls (N = 215). We calculated Cronbach's alpha to assess the internal consistency, examined the association between indicators of eating disorder symptom severity and the CIA to assess construct and criterion validity, and compared the strength of relation between the CIA and measures of disordered eating versus with measures of generalized distress. RESULTS: The Fijian version of the CIA is feasible to administer as an investigator-based interview. It has excellent internal consistency (alpha = 0.93). Both construct and criterion validity were supported by the data, and regression models indicated that the CIA predicts eating disorder severity, even when controlling for generalized distress and psychopathology. DISCUSSION: The adapted CIA has excellent psychometric properties in this Fijian study population. Findings suggest that the CIA can be successfully adapted for use in a non-Western study population and that at least some associated distress and impairment transcends cultural differences.

Validity and reliability of a Fijian translation and adaptation of the Eating Disorder Examination Questionnaire.

OBJECTIVE: Assessment of disordered eating has uncertain validity across culturally diverse populations. This study evaluated Eating Disorder Examination Questionnaire (EDE-Q) performance in an ethnic Fijian study population. METHOD: The EDE-Q was translated, adapted, and administered to school-going Fijian adolescent females (N = 523). A subsample (n = 81) completed it again within approximately 1 week. We assessed feasibility, internal consistency, and test-retest reliability; evaluated construct validity through factor analysis and correlation with similar constructs; and examined the marginal utility of an additional question on traditional purgative use. RESULTS: Internal consistency reliability was adequate for the global scale and subscales (Cronbach's alpha = 0.66-0.91); retest reliability was adequate for both the languages (range of ICCs, 0.50-0.79, and of kappas, 0.46-0.81, excluding purging items). Construct validity was supported by significant correlations with measures of similar constructs. Factor analysis confirms multiple dimensions of eating disorder symptoms but suggests possible culture-specific variation in this population. The majority of respondents endorsing traditional purgative use (58%) did not endorse conventional EDE-Q items assessing purging. DISCUSSION: The EDE-Q is a valid measure of eating disorder pathology for ethnic Fijian adolescent females and measures a unitary underlying construct.

Screening for binge eating disorders using the Patient Health Questionnaire in a community sample.

OBJECTIVE: To examine the operating characteristics of the Patient Health Questionnaire eating disorder module (PHQ-ED) for identifying bulimia nervosa/binge eating disorder (BN/BED) or recurrent binge eating (RBE) in a community sample and to compare true positive (TP) versus false positive (FP) cases on clinical validators. METHOD: Two hundred and fifty-nine screen-positive individuals and a random sample of 89 screen negative cases completed a diagnostic interview. Sensitivity, specificity, and positive predictive value (PPV) were calculated. TP and FP cases were compared using t-tests and Chi-square tests. RESULTS: The PHQ-ED had high sensitivity (100%) and specificity (92%) for detecting BN/BED or RBE, but PPV was low (10 or 19%). TP and FP cases did not differ significantly on frequency of subjective bulimic episodes, objective overeating, restraint, on BMI, and on self-rated health. DISCUSSION: The PHQ-ED is recommended for use in large populations only in conjunction with follow-up questions to rule out cases without objective bulimic episodes.

Beliefs about eating and eating disorders.

Beliefs about foods and binge eating may influence the development and maintenance of eating disorders and the likelihood that people will seek treatment. We found that the majority of a random sample of members of a large health maintenance organization considered binge eating a problem for which there are effective treatments. Self-reported binge eaters, however, were significantly less likely to agree that there are effective treatments. Two thirds of the sample reported that certain foods are addictive and also believed that strict dieting is an effective means of reducing binge eating. Therapeutic implications of these attitudes are discussed.