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. Author manuscript; available in PMC: 2025 May 1.
Published in final edited form as: Int J Eat Disord. 2024 Feb 6;57(5):1268–1273. doi: 10.1002/eat.24141

Overvaluation of Shape/Weight at Posttreatment Predicts Relapse at 12-Month Follow-up After Successful Behaviorally-Based Treatment of Binge-Eating Disorder

Carlos M Grilo 1, Valentina Ivezaj 2, Ralitza Gueorguieva 3
PMCID: PMC11093697  NIHMSID: NIHMS1958026  PMID: 38321617

Abstract

Objective:

To test whether overvaluation of shape/weight at the end of treatment prospectively predicts relapse at 12-month follow-up in patients with binge-eating disorder (BED).

Method:

Participants were 129 patients with BED who achieved abstinence from binge eating after six months of behaviorally-based weight-loss treatments (BBWLT) in a clinical trial. Independent assessments conducted at posttreatment and at 12-month follow-up included the Eating Disorder Examination (EDE) interview, the Beck Depression Inventory (BDI), and weight measurements.

Results:

Of the 129 participants who attained abstinence from binge-eating at posttreatment, 46 (36%) were categorized with clinical overvaluation and 83 (64%) with subclinical overvaluation; 115 (89%) were re-assessed at 12-month follow-up. Participants with overvaluation at posttreatment were significantly more likely than those without to relapse at 12-months to non-abstinence from binge eating (54% vs 28%) and to diagnosis-level binge-eating frequency of once weekly or greater (31% vs 13%). Overvaluation at posttreatment predicted significantly higher eating-disorder psychopathology and depression scores at 12-month follow-up but were unrelated to weight and weight changes. Treatment groups did not have main or interaction effects; posttreatment overvaluation effects were observed regardless of treatment and of covarying for posttreatment value of dependent variables.

Conclusions:

Our findings suggest that overvaluation of shape/weight at the end of treatment predicts relapse and heightened eating-disorder psychopathology and depression scores one year later in patients who achieved abstinence from binge eating with behaviorally-based treatments. Overvaluation of shape/weight has significant clinical implications and warrants consideration as a diagnostic specifier for BED as it provides important prospective prognostic information.

Keywords: eating disorders, binge eating, relapse, body image, obesity, behavior therapy

The 12-month persistence of binge-eating disorder (BED) amongst those with lifetime diagnosis in a national sample of US adults was estimated at 63.5% (Udo & Grilo, 2018); this figure, elevated compared to other eating disorders, indicates chronicity. Although research has identified specific treatments with efficacy for BED (Hilbert et al., 2019), a substantial proportion of patients do not attain abstinence from binge eating (Linardon et al., 2018) and relapse following some treatments is not uncommon (Grilo, Crosby, Wilson, & Masheb, 2012). Finding reliable predictors of outcomes has been difficult (Vall & Wade, 2015) and remarkably little research has examined predictors of relapse following treatment for eating disorders (Sala et al., 2023). Reviews of predictors of relapse have emphasized methodological limitations, notably the small and underpowered literature, alongside absence of reliable or robust findings, and emphasized the need for research to identify those at risk to relapse (de Rijk et al., 2023).

While trials have documented different treatments for BED vary in maintenance of outcomes (Grilo, Crosby et al., 2012; Wilson et al., 2010), the dearth of research predicting relapse is striking. A systematic review (Sala et al., 2023) identified only two studies that investigated predictors of relapse following BED treatment. In the first study, Safer et al (2002) examined relapse in 32 patients with BED (pooled from two studies) who achieved abstinence following dialectical behavior therapy. Safer et al (2002) reported that 28% of patients relapsed (to non-abstinence) by 6-month follow-ups and higher restraint at posttreatment was associated with relapse. In the second study, Ricca and colleagues (2010) – in an exploratory study of a large number of baseline variables predicting several outcomes – reported that 15 of 36 patients who achieved abstinence at posttreatment relapsed (to diagnostic threshold) at follow-up and higher baseline depression was associated with relapse.

This study’s aim was to assess overvaluation of shape/weight as a predictor of subsequent relapse at 12-month follow-up in patients with BED who attained abstinence from binge-eating by posttreatment. Overvaluation is central to understanding maintenance of eating-disorder psychopathology (Fairburn et al., 2003) and has been found to prospectively predict persistence of bulimia nervosa (Fairburn et al., 2003). In contrast to bulimia nervosa, the BED diagnosis does not include overvaluation (either as a criterion or severity specifier) (Grilo, 2013) despite research supporting its psychopathological (Wang et al. 2019) and diagnostic (Forrest et al., 2022) significance. Overvaluation has been found to significantly predict psychological treatment outcomes (Grilo et al. 2013) and to moderate outcomes for CBT versus pharmacotherapy (Grilo et al. 2012). Thus, for this conceptually and empirically-driven investigation, we hypothesized overvaluation at posttreatment would predict relapse and poorer outcomes 12-months later.

As background context for this secondary analysis, we summarize trial outcomes published previously (Grilo et al. 2020a, 2020b). The trial compared two 6-month behaviorally-based treatments: behavioral weight-loss versus Stepped-Care. Stepped-Care started with the same behavioral treatment and either continued (if responder) or switched (if non-responder) to CBT-guided-self-help in addition to weight-loss medication or placebo. The treatments did not differ significantly on any primary/secondary outcomes, including binge-eating abstinence rates at posttreatment (74.4% and 66.5%; Grilo et al. 2020a) and 12-month follow-up (44.7% and 41.0%; Grilo et al., 2020b).

Methods

Participants

Participants were 129 adults with BED who achieved binge-eating abstinence at posttreatment in a treatment trial (Grilo et al. 2020a). Of 191 enrolled patients, 130 (68%) attained abstinence; one patient was excluded because of incomplete overvaluation data, resulting in N=129. Study received Yale IRB approval and participants provided written informed consent.

Eligibility criteria required age 18-65 years, body mass index (BMI) 30-50 kg/m2, and DSM-IV-defined BED. Exclusion criteria included: clinical issues requiring different treatments, contraindications to study medications (e.g., cardiovascular disease, blood pressure>160/95mmHg, resting heart rate>100 beats/minute), concurrent eating/weight treatments, uncontrolled medical conditions, and pregnancy or unreliable birth- control.

The 129 participants had mean age of 49.0 (SD=9.1) years, mean BMI 39.7 (SD=5.5) kg/m2; 69.8% (N=90) were female, 51.2% (N=66) graduated college, and 76.7% (N=99) were White, 15.5% (N=20) were African-American, 4.7% (N=6) Hispanic, and 3.1% (N=4) “other” ethnicity/race.

Diagnostic Assessments and Repeated Outcome Measures

Trained/monitored research-clinicians, blinded to treatments, performed assessments at baseline, posttreatment, and 12-month follow-up. Eating Disorder Examination Interview (EDE-16th edition; Fairburn et al., 2008) was used for diagnosis and to characterize eating-disorder psychopathology. EDE focuses on past 28 days (except diagnostic items determined for duration stipulations) assesses frequency of objective binge-eating episodes and eating-disorder psychology, reflected in the global score. In this trial, inter-rater (N=37) intra-class correlation coefficients were 0.86 for binge-eating frequency and 0.94 for EDE global score. Beck Depression Inventory (BDI; Beck & Steer, 1987), a psychometrically-sound self-report measure of depression symptoms/levels was completed by participants. In this trial, coefficient alpha for BDI was 0.90. Weight and height were measured at baseline and weight was measured at post-treatment and follow-ups using large-capacity digital scale.

Overvaluation of shape/weight

Overvaluation was assessed using two EDE interview items (question and probes asked separately for shape and weight): “Over the past four weeks, has your shape/weight influenced how you feel about (judge, think, evaluate) yourself as a person?” Overvaluation items, like other EDE scale-items, are rated on 7-point forced-choice scales (anchored 0 (No importance) to 6 (Supreme importance)). Following prior studies (Grilo et al. 2012), overvaluation was tested categorically and dimensionally. Dimensional overvaluation was based on the higher score of the two overvaluation items. Per Fairburn et al (2008) suggested clinical cut-off score of 4 (indicating “moderate importance”), participants were categorized with clinical (score≥4 on either item) or subclinical (score<4 on both items) overvaluation.

Treatments

Treatments were delivered by research-clinicians monitored throughout study to maintain adherence to manualized protocols (see Grilo et al. (2020a) for detailed information regarding the treatment protocols). Masters-level clinicians delivered behavioral-weight-loss (BWL) treatment and doctoral-level clinicians delivered CBT-guided-self-help. Treatments were matched in total sessions/time to minimize potential confounds. BWL comprised 16 sessions and Stepped-care comprised 15 sessions (of BWL or 4 BWL sessions followed by 11 CBT-guided-self-help) plus additional pharmacotherapy sessions to result in same overall total time as BWL. BWL and CBT-guided-self-help, described in detail in Grilo et al (2020a), followed manualized protocols supported in previous trials (Grilo et al. 2011; Grilo & Masheb, 2005).

Pharmacotherapy (double-blind) was delivered by a psychiatrist with minimal clinical management. There were no FDA-approved medications for BED when the trial was performed; two FDA-approved weight-loss medications (sibutramine [delivered to first half of participants] or orlistat [delivered to second half], respectively) were selected based on some empirical support (Wilfley et al. 2008; Grilo et al., 2005).

Statistical Analyses

Change in overvaluation over time was assessed using mixed models for continuous overvaluation and Generalized Estimating Equations for categorical overvaluation with group, time and group by time interaction fixed effects.

Analyses compared participants categorized at posttreatment with overvaluation to participants without (“subclinical”) overvaluation on relapse rates at 12-month follow-ups, defined in two ways: from abstinence to (1) non-abstinence from binge eating, and to (2) diagnosis-level binge-eating frequency of ≥once weekly. “Abstinence” (zero binge-eating episodes/past 28 days) and “relapse” (two definitions based on frequency of binge-eating past 28 days) were determined using EDE at posttreatment and 12-month follow-up. Relapse rates between participants with versus without overvaluation were compared using chi-square analyses and logistic regression tested overvaluation along with treatment group.

Participants with versus without overvaluation were compared on continuous outcomes (binge-eating frequency, EDE global score (calculated with/without overvaluation items), BDI score, and percent weight-loss) with general linear models using all available data without imputation. Models were fitted with overvaluation status (yes/no), treatment condition (BWL/Stepped-Care), and their interaction, and with and without the posttreatment value of the dependent variable as a covariate. Interactions were dropped when non-significant. Models were run using overvaluation score continuously in addition to categorically. Distributions of data were examined, and transformations were applied as needed to satisfy model assumptions.

Results

Overvaluation at baseline did not significantly predict binge-eating abstinence at posttreatment (chi-square(1)=0.77, p=0.38). Overvaluation, considered both categorically and dimensionally, changed significantly over time. Categorically, the proportion of participants categorized with clinical overvaluation decreased significantly from baseline (Chi-square (3)=25.29, p<0.0001) and did not differ by treatment group (Chi-square(1)=2.18, p=0.54 for group-by-time interaction and chi-square(1)=0.22, p=0.64 for group main-effect). At baseline, 70.7% had clinical overvaluation, and this decreased significantly to 35.7% at posttreatment, and 32.7% at 12-month follow-up. Similarly, dimensional overvaluation scores decreased significantly from baseline over time (F(3,358)=28.96, p<0.0001), did not differ by treatment group (F(3,358)=0.11, p=0.95 for group-by-time interaction and F(1,130)=0.51, p=0.48 for group main-effect), and were significantly lower at posttreatment and 12-month follow-up).

Posttreatment Overvaluation and Relapse at 12-Month Follow-up

Of 129 participants who achieved binge-eating abstinence at posttreatment, 46 (35.7%) were categorized at posttreatment with overvaluation and 83 (64.3%) without. Of 129 participants, 115 (89.1%) were re-assessed at 12-month follow-up. Overvaluation groups did not differ significantly in demographic features, including age, sex, or race (all ps>0.66). BMI did not differ significantly between overvaluation groups at baseline (F(1,191)=2.82, p=0.10, effect-size η2=.015) or at posttreatment (F(1,127)=2.19, p=0.14, effect-size η2=.017).

Participants with overvaluation at posttreatment were significantly more likely than those without to relapse at 12-months to non-abstinence from binge eating (53.9% vs 27.68%; chi-square(1)=7.64, p=0.006, effect size phi=0.26; Figure 1) and to diagnosis-level (≥once weekly) binge-eating frequency (30.8% vs 13.2%; chi-square(1)=5.17, p=0.02, phi=0.21). Logistic regressions revealed treatment was not significant predictor of either relapse outcome (ps>0.31) and significant effects of overvaluation (categorical and dimensional) remained essentially unchanged.

Figure 1.

Figure 1.

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Binge-Eating Relapse at 12-month Follow-Up Based on Overvaluation at Posttreatment

Posttreatment Overvaluation and Clinical Outcomes at 12-Month Follow-up

Table 1 summarizes outcomes at posttreatment and 12-month follow-up for participants with and without posttreatment overvaluation. In all models, treatment-group showed non-significant effects, overvaluation tested categorically and dimensionally resulted in generally consistent findings and therefore (unless otherwise noted) we report models for categorical overvaluation. For EDE Global score at 12-months, even when controlling for EDE Global score at posttreatment, categorical posttreatment overvaluation was significant predictor (F(1,109)=12.78, p=0.0005) including when Global Score was calculated without the overvaluation items (F(1,109)=17.17, p<0.0001). For BDI depression score, categorical overvaluation was significant predictor (F(1,111)=5.67, p=0.02) but the effect became non-significant when controlling for BDI score at posttreatment (F(1,110)=0.02, p=0.89). Overvaluation was not a significant predictor of percent weight-loss, regardless of whether tested categorically (p=0.43) or dimensionally (p=0.06) and regardless of whether BMI baseline was a covariate in the model.

Table 1.

Clinical Measures at Posttreatment and 12-Month Follow-up for Groups Categorized at Posttreatment with Clinical Overvaluation (N = 46) and Subclinical Overvaluation (N = 83)

Measure Posttreatment Clinical Overvaluation Posttreatment Subclinical Overvaluation
M SD M SD
Eating Disorder Examination Global † a
 Posttreatment 2.16 0.87 1.36 0.65
 12-month follow-up 2.28 0.95 1.26 0.63
Eating Disorder Examination Global † b
 Posttreatment 2.03 0.92 1.43 0.69
 12-month follow-up 2.19 0.94 1.28 0.63
Beck Depression Inventory
 Posttreatment 10.86 9.17 6.31 5.35
 12-month follow-up 9.85 8.63 6.37 6.33
Percent Total Weight Loss c
 Posttreatment 7.54 8.29 5.86 5.15
 12-month follow-up 0.88 6.76 2.17 8.56
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Note.

†

The Eating Disorder Examination Global scores were calculated witha and withoutb the overvaluation items included in the interview’s standard scoring methods.

c

Percent total weight loss at posttreatment represents percent weight loss from study baseline to the end of study treatment (six months); percent total weight loss at 12-month follow-up represents subsequent percent weight loss from posttreatment to the 12-month follow-up.

Discussion

Our findings suggest overvaluation of shape/weight at posttreatment is a significant predictor of relapse and higher eating-disorder psychopathology and depression one year later in patients who achieved binge-eating abstinence with behaviorally-based treatments. Relapse to non-abstinence occurred in 54% and to diagnosis-level in 31% of patients with posttreatment overvaluation (versus 28% and 13%, respectively, in those without clinical overvaluation). Overvaluation, considered both categorically and dimensionally, had significant negative prognostic significance for the eating-disorder and depression psychopathology outcomes and treatment conditions did not show main or interactive effects. Overvaluation was unrelated to BMI and weight changes.

Our findings indicate that overvaluation of shape/weight has significant clinical relevance and warrants consideration as a diagnostic specifier for BED. Presence of this cognitive feature following treatment signals that patients are at heightened risk for relapse over time (approximating medium effect-size) and warrants consideration of monitoring and specific interventions to target body-image (perhaps CBT-enhanced methods; Fairburn et al. (2009)). Diagnostically, adding overvaluation as a specifier for BED would parallel, to some degree, the nosological structure of other eating-disorder diagnoses, and would convey important information about individual differences for treatment planning.

We note methodological strengths/limitations for context. Strengths include prospective design, rigorous trial testing effective manualized treatments, large sample who achieved binge-eating abstinence allowing meaningful analysis of relapse, and multi-method assessments reliably administered. Findings pertain to patients with BED enrolled in a treatment study and may not generalize to people not willing to participate in research, different clinical settings/treatments. We previously reported overvaluation significantly predicted outcomes in different trial with traditional CBT (Grilo et al. 2013). Our sample had good diversity, but findings might not generalize to those with different sociodemographic characteristics. However, overvaluation did not differ by demography, much like previous studies with national samples (Coffino et al. 2019) and did not vary by BMI nor predict weight changes replicating previous clinical studies (Grilo et al., 2013).

Public Significance Statement.

Although effective treatments are available for binge-eating disorder, relapse following successful treatments is not uncommon. Almost nothing is known about what predicts relapse following treatments for binge-eating disorder. Our study found that overvaluation of shape/weight (i.e., body image concerns that overly impact self-worth) at posttreatment prospectively predicted relapse and higher eating-disorder psychopathology and depression one year later in patients who achieved binge-eating abstinence with behaviorally based treatments.

Funding:

This study was funded by the National Institutes of Health grant R01 DK49587 (Grilo). Dr. Grilo was also supported, in part, by grants R01 DK114075 and R01 DK121551. The funding agency (National Institutes of Health) played no role in the content of this paper.

Footnotes

Potential Conflicts of interest: The authors declare no conflicts of interest. Dr. Grilo reports broader interests, which did not influence this research, including Royalties from Guilford Press and Taylor & Francis Publishers for academic books. Dr. Ivezaj reports former consultation for Optum. Dr. Gueorguieva reports royalties from Taylor & Francis Publishers for academic book.

Authorship CRediT: Carlos M. Grilo: Conceptualization, methodology, investigation, supervision, analysis, writing - original draft, writing – review and editing, funding acquisition. Valentina Ivezaj: investigation, data curation, analysis, visualization, supervision, project administration, writing – review; Ralitza Gueorguieva: formal analysis, writing – review.

(Treatment of Obesity and Binge Eating: Behavioral Weight Loss Versus Stepped Care)

Contributor Information

Carlos M. Grilo, Department of Psychiatry, Yale University School of Medicine, New Haven

Valentina Ivezaj, Department of Psychiatry, Yale University School of Medicine, New Haven

Ralitza Gueorguieva, Department of Biostatistics, Yale School of Public Health, New Haven

Data Sharing:

De-identified data will be provided in response to reasonable written request to achieve goals in an approved written proposal (from non-commercial academic researchers).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

De-identified data will be provided in response to reasonable written request to achieve goals in an approved written proposal (from non-commercial academic researchers).

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