Redefining diagnostic parameters: the role of overvaluation of shape and weight in binge-eating disorder: a systematic review

Abstract

Introduction

Overvaluation of shape and weight is a critical component in understanding and diagnosing eating disorders. While the transdiagnostic model states that overvaluation of shape and weight is the core pathology of all eating disorders, this concept is not a criterion for binge-eating disorder. The lack of recognition of overvaluation of shape and weight may lead to overlooking, and consequently failure to address this construct during treatment. The aim of the present review is to examine whether overvaluation is a critical component in understanding and diagnosing binge-eating disorder and whether it should be addressed during treatment, and therefore be added as a criterion of binge-eating disorder.

Methods

The present review was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42024541433). PsycINFO, Web of Science, PubMed (Medline), and Google Scholar were used in order to systematically search and review literature by using a list of keywords related to overvaluation of shape and weight and binge-eating disorder. All N = 93 peer-reviewed studies were published in English from 1993 onwards.

Results

Overvaluation of shape and weight was more severe among individuals with binge-eating disorder compared to individuals with solely a similar high BMI. In addition, levels of overvaluation in binge-eating disorder were comparable in severity with that of individuals of the other named eating disorder subtypes. Overvaluation was positively associated with other psychiatric symptoms, a risk factor for the onset of binge eating in adolescents and predicted poorer treatment outcomes. It was not clear whether overvaluation predicted dropout from Cognitive Behavior Therapy interventions.

Discussion

It is suggested to consider including overvaluation of shape and weight as a criterion for the diagnosis of binge-eating disorder. Including overvaluation in the DSM and ICD may prevent overlooking this construct, and potentially enhance treatment outcomes.

Plain English summary

It is suggested that overvaluation of shape and weight is the core pathology of all eating disorders. However, this concept is not a criterion for a binge-eating disorder diagnosis. The lack of recognition of overvaluation of shape and weight may lead to overlooking, and consequently failure to address this construct during treatment. The aim of the present review is to examine whether overvaluation is a critical component in understanding and diagnosing binge-eating disorder and whether it should be addressed during treatment, and therefore be added as a criterion of binge-eating disorder. Consequently, a total of N = 93 peer-reviewed studies were examined. It was found that overvaluation of shape and weight was associated with the severity of eating disorder psychopathology, and was comparable in severity with that of individuals diagnosed with anorexia nervosa and bulimia nervosa. There is enough evidence to include overvaluation in the DSM and ICD as a criterion for binge-eating disorder. Consequently, this may prevent overlooking this construct, and potentially enhance treatment outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40337-025-01187-0.

Introduction

Binge-eating disorder (BED) is recognized as an eating disorder by the diagnostic and statistical manual of mental disorders (DSM) in 2013 [1] and the international classification of diseases (ICD) in 2019 [2]. BED is characterized by recurrent episodes of binge eating, wherein individuals consume large amounts of food within a discrete period, experiencing a sense of loss of control over their eating behavior [1]. According to the criteria in both diagnostic manuals, these episodes must occur at least once a week for a minimum of three months and be accompanied by distress regarding the binge eating. Additionally, DSM-5-TR and ICD-11 specify that binge-eating episodes must manifest at least three of the following characteristics: eating rapidly, eating until uncomfortably full, eating despite not feeling physically hungry, eating alone due to embarrassment, and experiencing negative emotions after overeating [3]. With an estimated life-time prevalence of 0.2 to 4.6%, BED is the most common of the named eating disorders [4]. Furthermore, the actual prevalence of BED might even be higher since a large proportion of individuals with a high body mass index (BMI > 30), as well as individuals from socioeconomically disadvantaged backgrounds, ethnic minorities, and males who meet the diagnostic criteria for BED never receive a formal diagnosis [5, 6].

The transdiagnostic model, as utilized in cognitive behavioral therapy-enhanced (CBT-E) [7], posits that all formally recognized eating disorders share common core psychopathological mechanisms, namely overvaluation of shape and weight, and control over eating. According to this model, these shared mechanisms, underlie the manifestation of all the eating disorder phenotypes. The transdiagnostic framework suggests that these disorders exist along a continuum, rather than as discrete entities, with overlapping features that may shift over time [8]. While BED and bulimia nervosa (BN) share similarities in terms of regular binge- eating episodes, BN is distinguished by the recurrent use of inappropriate compensatory behaviors, such as self-induced vomiting, misuse of laxatives or fasting, to prevent weight gain which is not present in BED [3]. Therefore, although being overweight or obese is not an criterion, BED is commonly associated with a high body mass index (BMI) [9, 10]. Furthermore, diagnostic criteria for anorexia nervosa (AN) and BN encompass disturbances related to body image, such as an overemphasis on weight and shape. The overvaluation of shape and weight is a critical component in understanding and diagnosing these eating disorders. This concept refers to the excessive significance individuals place on their body shape and weight, often to the point where these factors significantly influence their self-esteem, identity, and behaviors [8]. In other words, self-worth is predominantly characterized by the individuals body shape and weight [11, 12]. Though not being the same construct, overvaluation of shape and weight appears to be at least associated with constructs like shape and weight concern, preoccupation with shape and weight, as well as fear of weight gain, body-shape dissatisfaction, body uneasiness and body image concerns [8, 13]. One may report body dissatisfaction, but not mainly determine self-worth in terms of shape and weight [14]. Furthermore, overvaluation of shape and weight is present in 50 to 99% of the individuals with BED seeking treatment [12, 15–19]. However, overvaluation is yet not a criterion for a BED diagnosis [3].

Several studies argued that overvaluation of shape and weight should not be a criterion of BED, since a significant proportion of individuals with concerning binge-eating behaviors would be excluded [20–22]. In addition, at present BED is perceived as a behavioral overeating construct. Conversely, the other eating disorder subtypes are characterized by both disturbed eating and overvaluation of shape and weight [23]. Confirmation of both constructs across individuals with BED would advocate to include overvaluation as a criterion for BED. Furthermore, several studies even suggested that overvaluation of shape and weight is comparable across all eating disorders [24, 25]. As some studies already suggested [23, 24, 26], there may be enough evidence to include overvaluation of shape and weight as a criterion for BED in future revisions of the DSM and ICD. Including overvaluation of shape and weight as a criterion for BED in both diagnostic manuals could even potentially enhance treatment outcomes [27]. Furthermore, some treatments mainly address managing binge-eating behavior, with less emphasis on cognitive factors like the overvaluation of shape and weight [28, 29]. This is partly because the diagnostic criteria of BED do not highlight this construct as prominently as the other subtypes of eating disorders [30–34]. Consequently, overvaluation of shape and weight is less addressed in BED treatments and potentially leading to less effective treatment outcomes with an increased risk of relapse as a result [30–33]. The aim of the present review is to examine whether overvaluation of shape and weight is a critical component in understanding and diagnosing BED and whether it should be addressed during treatment, and therefore be added as a criterion of BED.

Method

Search strategy and study selection

This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42024541433). In order to cover sufficient relevant available data to date, peer-reviewed studies published in English were included, regardless their study design. PsycINFO, Web of Science, PubMed (Medline), were used to systematically search and review literature. In addition, a similar search was performed across Google Scholar, leading to a broad number of identified records. To facilitate the identification of studies, a list of keywords and phrases was used. All combinations of (“Binge-Eating Disorder” OR “Binge eating” OR “Binges” OR “Loss of control over eating”) AND (“Over evaluation of Shape and Weight” OR “Over evaluation of Shape “ OR “Over evaluation of Weight” OR “Overvaluation of Shape and Weight” OR “Overvaluation of Shape “ OR “Overvaluation of Weight” OR “Body Image” OR “Negative Body Image” OR " Body Satisfaction” OR “Body dissatisfaction” OR Body- Shape Satisfaction” OR “Body Shape dissatisfaction” OR “Body uneasiness” OR “Body attitude” OR “Body Evaluation” AND (“Prevalence” OR “Severity “ OR “Validation” OR “Psychometric Properties” OR “Efficacy” OR " Effectiveness” OR “treatment” OR “treatment outcomes” OR “treatment course” OR “course” OR “predictor” OR “moderator”) were searched. Figure 1 shows that the search led to N = 3590 hits. After deduplication, a content assessment based on study titles was performed by the first author, resulting in a remaining n = 3279 studies. Consequently, the abstracts and key words of the identified studies were screened for eligibility. Eligible studies reported about the prevalence and severity of overvaluation of shape and weight among individuals with binge-eating disorder, as well as treatment outcomes, and treatment predictors and moderators. This resulted in remaining n = 93 studies. Studies have been published since the first inclusion in the DSM, starting from 1993 onwards. Doubts/ irregularities were resolved by group discussion based on title, abstract, and keywords between both authors.

Fig. 1.

Flow chart of study selection process based on PRISMA

Inclusion and exclusion criteria

Studies were included in the present systematic review when they reported about BED, or binge eating among clinical and community samples. Furthermore, they also had to report about overvaluation of shape and weight. Studies could be cross-sectional, longitudinal, or evaluating treatment outcomes. Studies only reporting about AN, BN or a high BMI were excluded.

Outcome measures

Outcome measures were overvaluation of shape and weight, binge-eating frequency, overall eating disorder psychopathology, checking behaviors and comorbid psychopathology. These outcome measures were examined in samples of BED who were compared to both samples with a high BMI without an eating disorder and samples with other eating disorder subtypes (AN or BN).

Quality assessment, publication bias and data abstraction

A modified version of the Newcastle–Ottawa scale [35, 36], a seven item scale that investigates power, research design, sample, recruitment, and statistical analysis was used in order to evaluate the quality of the included studies. Studies could obtain a maximum score of 10 stars (Appendix A), which was based on [1] selection (a maximum five stars), [2] comparability (a maximum two stars), and [3] outcome (a maximum three stars). Studies with at least four stars were included in the present review, indicating a moderate risk for bias [35]. Finally, study selection was in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [37] as shown in Appendix B.

Results

How to measure overvaluation of shape and weight?

Overvaluation of shape and weight can be measured by investigator-based interviews, as well as by self-report measures. The shape and weight concern subscales of the Eating Disorder Examination [38] are the most extensively used interview subscales to measure overvaluation of shape and weight. However, alternatives are items of the Structured Clinical Interview for DSM-5 disorders (SCID-5) [39]. In addition, Tables 1, 2, 3, 4, and 5 show that various self-report questionnaires were used to measure overvaluation of shape and weight. Subsequently, overvaluation of shape and weight among patients with BED was measured in validation studies, cross-sectional studies, as well as in studies examining treatment outcome predictors and moderators.

Table 1.

Case–control studies investigating overvaluation of shape and weight in Binge-Eating Disorder with/without high body mass index

Authors	Population, diagnosis, number	Measure eating disorder	Conclusions
[83]	N = 221, Individuals with a high BMI, with (n = 168) and without BED (n = 53)	EDE	Individuals diagnosed with BED and a high BMI had greater levels of shape and weight concern compared to individuals with a high BMI
[84]	N = 70, Individuals diagnosed with BED (n = 35), individuals without BED (n = 35) enrolled in a program for weight loss	BSQ, CIMEC,QEWP, TFEQ, IDED-IV	Individuals diagnosed with BED and a high BMI had greater levels of overvaluation of shape compared to individuals with a high BMI
[85]	N = 108, Individuals with a high BMI seeking weight loss treatment, with (n = 54) and without BED (n = 54)	EDE	Individuals diagnosed with BED and a high BMI had greater levels of shape and weight concern compared to individuals with a high BMI
[30]	N = 207, Individuals diagnosed with BED (n = 163), with a high BMI (n = 44)	Clinical interview	Functional impairment was more severe among individuals with BED with overvaluation of shape and weight compared to individuals with BED without overvaluation of shape and weight
[86]	N = 300, Individuals with a high BMI, with (n = 150) and without BED (n = 150)	BES, BUT	Body uneasiness was more severe among individuals with a high BMI and BED compared to individuals with a high BMI
[87]	N = 318, Individuals with a high BMI, with(n = 159) and without BED (n = 159)	BUT	Body uneasiness was more severe among individuals with a high BMI and BED compared to individuals with a high BMI. Body uneasiness was more severe among females compared to males
[9]	N = 174, Individuals with BED, with a high (n = 123) and a normal BMI (n = 51)	EDE	Overvaluation of weight was more severe, and the frequency of binge eating was higher among individuals with BED with a high BMI compared to patients without a high BMI
[88]	N = 100, Individuals with a high BMI, with BED	WBIS, FPS, EDE	Internalized weight bias was associated with eating disorder pathology and overvaluation of shape and weight
[41]	N = 281, Individuals diagnosed with BED with a high BMI (n = 195), and a normal weight (n = 86)	EDE-Q, clinical interview	Overvaluation of shape and weight was similar across individuals diagnosed with BED with a healthy and a high BMI
[89]	N = 30, Individuals diagnosed with BED and a high BMI (n = 15) and individuals with a high BMI (n = 15)	EDI	Overvaluation of shape was more severe among individuals diagnosed with BED compared to individuals with a high BMI
[90]	N = 59, Individuals diagnosed with BED (n = 31) and a healthy control group (n = 28)	EDI, EDE-Q, BIAQ, BCQ	Overvaluation of shape was more severe among individuals diagnosed with BED compared to individuals with a high BMI
[91]	N = 278, Individuals applying for bariatric surgery, with (n = 95) and without BED (n = 183)	EDE-Q	Overvaluation of shape and weight among individuals applying for bariatric surgery was more severe among individuals with BED compared to individuals without BED
[92]	N = 54, Individuals with a high BMI and BED	BED clinical interview, EDI	Overvaluation of shape and weight was more severe among individuals with a high BMI and BED compared to individuals with a high BMI
[93]	N = 82, Individuals diagnosed with BED and a high BMI (n = unknown) and individuals with a high BMI (n = unknown)	EDI	Overvaluation of shape was more severe among individuals diagnosed with BED compared to individuals with a high BMI

NB: BMI = body mass index; BED = binge eating disorder; EDE = eating disorder examination; BSQ = body shape questionnaire; CIMEC = questionnaire of influences on the aesthetic body shape model; QEWP = questionnaire on eating and weight patterns; TFEQ = three factor eating questionnaire; IDED = interview for the diagnosis of eating disorders-IV; BES = binge eating scale; BUT = body uneasiness test; EDE = eating disorder examination; WBIS = weight bias internalization scale; FPS = fat phobia scale; EDE-Q = eating disorder examination-questionnaire; EDI = eating disorder inventory; BIAQ = body image avoidance questionnaire; BCQ = body checking questionnaire; ATOP = attitudes toward obese people scale

Table 2.

Case–control studies investigating overvaluation of shape and weight in binge eating disorder, anorexia nervosa and bulimia nervosa

Authors	Population, diagnosis, number	Eating disorder measure	Conclusions
[33]	N = 519, individuals diagnosed with BED (n = 324), individuals diagnosed with BN (n = 112)	EDE	Overvaluation of shape and weight was comparable across BN and BED
[43]	N = 119, Individuals diagnosed with AN (n = 34, BN (n = 34), and BED (n = 51)	EDE	Overvaluation of shape and weight was similar across AN, BN and BED
[94]	N = 48, Individuals diagnosed with BED (n = 22), BN (n = 22) or a high BMI (n = 16)	SCID, EDI	Overvaluation of shape was more severe among individuals with BED compared to BN, also when controlled for BMI
[42]	N = 90, Individuals diagnosed with BED (n = 30), with BN (n = 30), healthy controls (n = 30)	EDE	Overvaluation of shape and weight was similar across BED and BN
[45]	N = 422, Individuals diagnosed with an eating disorder (n = 310) and healthy controls (n = 112)	EDE, EDI, BIAQ, BCQ	Body avoidance behavior was most frequent among individuals with BED compared to AN and BN
[46]	N = 1760, Individuals diagnosed with an eating disorder	EDE-Q, PHQ-9, CIA	Feeling fat was more severe among individuals with binge eating compared to a restrictive eating pattern
[44]	N = 70, Individuals diagnosed with BED (n = 35), and BN (n = 35)	EDI	Overvaluation of shape was more severe among individuals diagnosed with BED compared to individuals diagnosed with BN

NB: EDE = eating disorder examination; SCID = structured clinical interview DSM; BIAQ = body image avoidance questionnaire; BCQ = body checking questionnaire; EDE-Q = eating disorder examination-questionnaire; PHQ 9 = patient health questionnaire; CIA = clinical impairment assessment; EDI = eating disorder inventory

Table 3.

Association of overvaluation of shape and weight in Binge- Eating Disorder with other psychopathology

Authors	Sample	Study type	Eating disorder measure	Conclusions
[95]	N = 347, Individuals diagnosed with BED	Cross-sectional	EDE	Overvaluation of weight and shape was positively associated with comorbid psychopathology
[96]	N = 87, Individuals diagnosed with BED, with a high BMI seeking weight loss treatment	Cross-sectional	BES	Binge eating mediates the relationship between body- shape dissatisfaction and psychological distress
[97]	N = 1134, Individuals with a high BMI, with (n = 227) and without overvaluation of shape and weight (n = 907)	Cross-sectional	EDE	Overvaluation of shape and weight was positively associated with overall eating disorder pathology
[98]	N = 196, Individuals with a high BMI seeking weight loss treatment, n = 2 met the criteria of BED, n = 18 of Other Specified Feeding or Eating Disorder BED	Cross-sectional	EDE	Overvaluation of shape and weight is positively associated with the frequency of binge eating
[99]	N = 170, Individuals diagnosed with BED with high (n = 135) or low levels of overvaluation (n = 137)	Cross-sectional	EDE-Q	The association of overvaluation of shape and weight with self-criticism was partly mediated by low self-esteem
[100]	N = 170, Individuals diagnosed with BED	Cross-sectional	BSQ	The association of overvaluation of shape and emotional abuse was mediated by low self-criticism
[101]	N = 272, Undergraduate females diagnosed with BED	Cross-sectional	EDE-Q	Overvaluation of shape and weight a was positively associated with vulnerability for addiction, and moderated the relationship between binge eating and vulnerability for addiction
[102]	N = 409, Undergraduate students	Cross-sectional	EPSI	Body- shape dissatisfaction was positively associated with binge eating, rejection sensitivity and with weight-based rejection sensitivity
[26]	N = 788, Individuals enrolled in various BED treatment studies, diagnosed with BED with extremely high (n = 315), high (n = 245) and low (n = 228) levels of overvaluation	Studies evaluating pharmacological and psychological BED treatments	EDE	Overvaluation of shape and weight was positively associated with eating disorder pathology
[74]	N = 268, Individuals diagnosed with BED (n = 160), and individuals without BED (n = 108)	Case control	EDE	Overvaluation of shape and weight among individuals with BED was associated with poorer psychosocial functioning
[103]	N = 210, Individuals diagnosed with BED, with overvaluation (n = 92), sublicinical levels of overvaluation (n = 73), and without Bed but a high BMI (n = 45)	Case control	EDE	Overvaluation of shape and weight was positively associated with eating disorder pathology
[57]	N = 90, Individuals diagnosed with BED, with (n = 52) and without (n = 38) overvaluation	Randomzed controlled trial examining the efficacy of CBT versus behavioral weight loss treatments	SCID, EDE	Overvaluation of shape and weight was positively associated with eating disorder pathology and poorer psychological functioning
[95]	N = 347, Individuals diagnosed with BED, with co-occuring mood disorders (n = 129), substance disorder (n = 34), or both (n = 60), or without comorbidities (n = 124)	Cross-sectional	EDE, BDI	Overvaluation of shape and weight was positively associated with eating disorder pathology and depression
[20]	N = 324, Individuals diagnosed with BED and without overvaluation (n = 47), with BED and overvaluation (n = 101), with BN (n = 53), and individuals with a high BMI (n = 123)	Case control	EDE	Overvaluation of shape and weight was positively associated with eating disorder pathology and depression. Overvaluation of shape and weight differed little across BED and BN
[40]	N = 236, Individuals diagnosed with BED (n = 90) body dysmorphic disorder (n = 90) and a community sample (n = 56)	Case control	EDE	Overvaluation of shape and weight was positively associated with eating disorder pathology and psychological disturbances
[104]	N = 90, Individuals diagnosed with BED	Cross-sectional	EDE	Overvaluation of shape and weight was positively associated with eating disorder pathology and depressive symptoms
[105]	N = 254, Females diagnosed with BED, with probable BED with (n = 102) and without overvaluation (n = 72), with a high BMI (n = 40) and healthy controls (n = 40)	Cross-sectional	EDE-Q	Overvaluation of shape and weight was positively associated with eating disorder pathology and psychological disturbances
[106]	N = 563, Female adolescents, with loss of control (LOC) eating and overvaluation (n = 30), LOC without overvaluation (n = 58), high BMI (n = 36), and normal weight (n = 439)	Case control	EDE-Q	Overvaluation of shape and weight was positively associated with the loss of control over eating as well as eating disorder pathology
[107]	N = 886, Females with probable BED, with probable BED with (n = 37) and without overvaluation (n = 78), with a high BMI (n = 198) and healthy controls (n = 573)	Case control	EDE-Q	Overvaluation of shape and weight was positively associated with eating disorder pathology and psychological disturbances
[108]	N = 254, Females diagnosed with BED, with probable BED with (n = 102) and without overvaluation (n = 72), with a high BMI (n = 40) and healthy controls (n = 40)	Cross-sectional	EDE-Q	Overvaluation of shape and weight was positively associated with eating disorder pathology and impairment of quality of life. Eating disorder pathology and quality of life were similar among individuals with a high BMI and individuals with BED without overvaluation of shape and weight
[109]	N = 408, Females, aged 18–40 years old	Cross-sectional	EDE-Q, QEWP	Overvaluation of shape and weight was positively associated with eating disorder pathology
[12]	N = 399, Individuals diagnosed with BED, with clinical levels of overvaluation (n = 207), and subclinical levels of overvaluation (n = 168)	Cross-sectional	EDE	Overvaluation of shape and weight was positively associated with eating disorder pathology and poorer psychological functioning. BMI and the frequency of binge-eating episodes were not associated with overvaluation of shape and weight
[15]	N = 145, Individuals diagnosed with (OSFED)BED post-bariatric surgery	Cross-sectional	EDE	Overvaluation of shape and weight was positively associated with binge-eating episodes, eating disorder pathology, and depressive symptoms
[110]	N = 55, Individuals with probable BED	Cross-sectional	EDE, BISS	Overvaluation of shape was positively associated with depressive symptoms and a low self-esteem
[111]	N = 365, Males with disordered eating behavior, n = 53 reported binge eating in the past 28 days	Case control	EDE-Q	Body image concerns, internalization of the male body ideal and a higher BMI were positively associated with the frequency of binge eating
[112]	N = 93, Individuals with BED	Cross-sectional	EDE, EDE-Q	Overvaluation of shape and weight was positively associated with eating disorder pathology
[113]	N = 145, Individuals post-bariatric surgery	Cross-sectional	EDE	Overvaluation of weight was positively associated with eating disorder pathology and the frequency of binge-eating episodes
[114]	N = 27, Adolescents diagnosed with BED	Case control	EDE	Overvaluation of weight was positively associated with eating disorder pathology and loss of control over eating
[115]	N = 220, Individuals diagnosed with BED	Validation study	EDE-Q	Overvaluation of shape and weight was positively associated with eating disorder pathology and poorer psychological functioning
[116]	N = 682, Males (n = 182) and females (n = 500) diagnosed with BED	Cross-sectional	EDE	Overvaluation of shape and weight was more severe among females compared to males
[117]	N = 755, Individuals diagnosed with BED	Case control	EDE	Overvaluation of shape and weight was associated with a lower self-esteem
[118]	N = 748, Individuals diagnosed with an eating disorder, with (n = 411), and without (n = 337) secretive eating	Case control	EDE	Overvaluation of shape and weight was associated with more secretive eating
[119]	N = 555, Adolescents, 15–18 years old	Validation study	BES, EDI	Overvaluation of shape was positively associated with binge-eating episodes
[120]	N = 174, Females with binge-eating disorder symptoms	Cross-sectional	EDE-Q	Overvaluation of shape and weight was positively associated with distress and functional impairment
[121]	N = 585, Individuals diagnosed with BED and a high BMI (n = 128) and individuals with a high BMI (n = 457)	Case control	EDE-Q	Overvaluation of shape and weight was positively associated with eating disorder pathology as well as psychological impairment
[122]	N = 68, Individuals diagnosed with BED (n = 29) and healthy controls (n = 39)	Case control	EDE-Q	Overvaluation of shape and weight was more severe among individuals with BED compared to healthy controls
[123]	N = 26, Individuals diagnosed with BED (n = 13), and healthy controls (n = 13)	Case control	EDE-Q, BSQ	Overvaluation of shape was more severe after negative self-esteem manipulation compared to positive manipulation. Stress was associated with greater levels of overvaluation of shape among individuals with BED compared to individuals without BED
[124]	N = 87, Individuals diagnosed with BED and a high BMI (n = 43), individuals with a high BMI (n = 44)	Case control	EDE-Q	Overvaluation of shape and weight was positively associated with the desire to binge after mirror exposure
[58]	N = 116, Individuals diagnosed with BED	Longitudinal	EDE-Q	Overvaluation of shape and weight was positively associated with eating disorder pathology
[47]	N = 330, Individuals with binge eating	Longitudinal	EDE-Q	Overvaluation of shape and weight was positively associated with distress due to binge eating, but not with frequency of binge eating, depressive symptoms or a lower self-esteem
[55]	N = 151, Female Latin Americans with BED	Case control	EDE	Overvaluation of shape and weight was positively associated with frequency of binge eating but this association dissipated after 5 years
[125]	N = 245, Individuals diagnosed with BED	Case control	EDE, WBIS	Overvaluation of shape and weight was positively associated with a low self-esteem and weight internalized bias. Overvaluation mediated the relation between self-esteem and weight internalized bias. Overvaluation was not associated with binge-eating frequency or BMI
[126]	N = 73, Individuals with a high BMI	Validation study	EDE, BSQ, BCQ	Overvaluation of shape and weight as well as overvaluation of shape were positively associated with checking behaviors
[127]	N = 377, Individuals diagnosed with BED	Cross-sectional	EDE-Q, BSQ, TFEQ	Overvaluation of shape and weight was positively associated with checking and avoidance behaviors, even when controlling for the effect of overvaluation
[128]	N = 113, Individuals diagnosed with BED and a high BMI	Cross-sectional	EDE	Shape and weight concern was positively associated with social anxiety
[129]	N = 1785, Individuals enrolled in weight loss programs of which n = 218 diagnosed with BED	Cross-sectional	QEW	Overvaluation of shape and weight was positively associated with eating disorder pathology
[130]	N = 52, Individuals diagnosed with BED and a high BMI (n = 27) and individuals with a high BMI (n = 25)	Case control	EDE-Q, BSQ	A body related film clip triggered the desire to binge and was associated with increased levels of depression and anxiety
[131]	N = 46, Individuals diagnosed with BED and a high BMI (n = 23) and individuals with a high BMI (n = 23)	Case control	EDE	Individuals with BED had more attentional bias towards their self -body picture than towards a control picture compared to individuals without BED
[132]	N = 4030, Individuals diagnosed with body image concerns	Longitudinal	EDE-Q	Overvaluation of shape and weight among all eating disorders, including BED, was associated with fear of negative evaluation
[133]	N = 709, Individuals diagnosed with an eating disorder	Cross-sectional	EDE-Q	Overvaluation of shape and weight was positively associated with the frequency of binge-eating episodes
[134]	N = 237, Individuals diagnosed with BED	Cross-sectional	EDE, WBIS	Rumination was associated with more severe eating disorder pathology and weight bias internalization beyond overvaluation of shape and weight
[135]	N = 56, Individuals diagnosed with BED	Cross-sectional	EDE	Overvaluation of shape and weight was positively associated with body-shape and weight dissatisfaction

NB: EDE = eating disorder examination; BMI = body mass index; BES = binge eating scale; EDE-Q = eating disorder examination-questionnaire; BSQ = body shape questionnaire; EPSI = eating pathology symptoms inventory; SCID = structured clinical interview DSM; CBT = cognitive behavioral therapy; BDI = beck depression inventory; QEWP = questionnaire on eating and weight patterns; BISS = body image states scale; BCQ = body checking questionnaire; QEW = questionnaire on eating and weight patterns; WBIS = weight bias internalization scale; FPS = fat phobia scale

Table 4.

Is overvaluation of shape and weight a risk factor for the development of binge-eating disorder?

Authors	Sample	Type of study	Eating disorder measure	Conclusions
[49]	N = 259, Pre-adolescent boys and girls	Longitudinal	ChEDE, CBIS	Shape and weight concern predicted binge- episodes one year later
[50]	N = 158, Adolescent girls with a high BMI, assessed at the age of 7 and 15 years old	Longitudinal	BES	Overvaluation of shape at 10 years old predicted binge eating at the age of 15 years old
[54]	N = 145, Individuals post-bariatric surgery	Longitudinal	EDE-Q	Overvaluation of shape and weight was associated with binge eating post-bariatric surgery at 1.5–3 years follow-up
[55]	N = 151, Female Latin Americans with BED	Longitudinal	EDE	Overvaluation of shape and weight was associated with a greater frequency of binge eating but this association dissipated after 5 years
[52]	N = 1327, Adolescents aged 11–19 years old	Longitudinal	EDE-Q	Overvaluation of shape and weight predicted the onset of an eating disorder, including BED one year later
[48]	N = 767, Adolescent girls with a high BMI	Longitudinal	MRFS	Overvaluation of weight at 10 years old predicted binge eating at the age of 15 years old
[53]	N = 1952, High risk adolescents with overvaluation of shape and weight enrolled in four trials examining the efficacy preventative programs	Four randomized controlled trials examining the efficacy preventative programs	EDI, IBSS, BDS,	Overvaluation of shape and weight predicted the onset of BED. Feeling fat and fear of weight gain emerged simultaneously with binge eating in BED while they preceded AN and BN

NB: EDE = eating disorder examination; CBIS = children's body image scale; BES = binge eating scale; EDE-Q = eating disorder examination-questionnaire; BED = binge eating disorder; BMI = body mass index; MRFS = mcknight risk factor survey; EDI = eating disorder inventory; IBSS = ideal-body stereotype scale-revised; BDS = body dissatisfaction scale

Table 5.

Predictive value of overvaluation of shape and weight on treatment outcome in BED: Evidence from Randomized Controlled Trails and effectiveness studies

Authors	Sample	Eating disorder measure	Conclusions
[64]	N = 52, Individuals diagnosed with BED enrolled in a randomized controlled trial examining CBT versus a waiting list	EDE	Abstinence from binge eating was marginally mediated by reduction in shape and weight concern
[61]	N = 41, Individuals diagnosed with BED enrolled in a Randomized Controlled Trial examining shortened CBT versus a waiting list	EDE-Q	Greater levels of overvaluation of shape and weight concern when treatment commenced predicted poorer treatment outcomes at 4-years follow-up
[26]	N = 788, Individuals diagnosed with BED, mean age around 45 (SD = 10) years old enrolled in BED treatment studies	EDE	Greater levels of overvaluation of shape and weight when treatment commenced predicted poorer treatment outcome at 12-months follow-up
[57]	N = 90, Individuals diagnosed with BED enrolled in a Randomized Controlled Trial examining CBT versus a behavioral weight loss intervention	EDE	Greater levels of overvaluation of shape and weight when treatment commenced predicted non-remission and greater frequency of binge-eating episodes at 12-months follow-up
[56]	N = 129, Individuals diagnosed with BED who attained abstinence from binge eating after a behavioral weight loss intervention	EDE	Greater levels of overvaluation of shape and weight when treatment commenced predicted and moderated poorer treatment outcomes
[59]	N = 304, Individuals diagnosed with BED enrolled in a group therapy effectiveness study	EDE	Greater levels of overvaluation of shape when treatment commenced predicted poorer treatment outcome
[65]	N = 398, Individuals diagnosed with BED enrolled in two Randomized Controlled Trial examining digitalized self-help interventions versus a waiting list	EDE	Overvaluation of shape and weight was not a predictor for treatment outcome
[136]	N = 75, Individuals diagnosed with BED enrolled in a Randomized Controlled Trial examining guided self-help CBT versus a behavioral weight loss intervention	EDE	Overvaluation of shape and weight predicted poorer treatment outcome
[68]	N = 113, Individuals diagnosed with BED enrolled in a CBT-E effectiveness study	EDE-Q	Overvaluation of shape and weight was not a predictor for treatment outcome at post-treatment and at a 12-week follow-up
[67]	N = 206, Individuals diagnosed with BED enrolled in a Randomized Controlled Trial examining guided self-help CBT-E versus a waiting list	EDE	Overvaluation of shape and weight wase not a predictor for treatment outcome at post-treatment and at a 12-week follow-up
[66]	N = 80, Individuals diagnosed with BED enrolled in a Randomized Controlled Trial examining CBT versus a behavioral weight loss intervention	EDE-Q	Overvaluation of shape and weight was not a predictor for treatment outcome at post-treatment and at a 6-year follow-up
[58]	N = 116, Individuals diagnosed with BED enrolled in a Randomized Controlled Trial examining group therapy and individual CBT versus group therapy and fluoxetine	EDE, EDE-Q	Greater levels of overvaluation of shape and weight when treatment commenced predicted greater frequency of binge-eating episodes when treatment concluded
[60]	N = 259, Individuals diagnosed with BED enrolled in a Randomized Controlled Trial examining group CBT versus a waiting list	EDE	Dietary restraint only, compared to dietary restraint combined with overvaluation of shape and weight, predicted better treatment outcomes
[63]	N = 73, Individuals diagnosed with BED enrolled in a CBT effectiveness study	EDE	Individuals with greater overvaluation of shape and weight when treatment commenced had greater reduction in overall eating disorder pathology post-treatment, however, their recovery rates were lower compared to patients with lower levels of overvaluation of shape and weight

NB: BED = binge eating disorder; EDE = eating disorder examination; EDE-Q = eating disorder examination-questionnaire, CBT = cognitive behavioral therapy; CBT-E = cognitive behavioral therapy- enhanced

Characteristics of studies

The present review included peer-reviewed studies published in English between 1993 and 2024. Figure 1 shows that the search strategy led to n = 93 relevant studies, of which most studies were case control studies of cross-sectional nature (n = 39), followed by cross-sectional studies (n = 30) (see Table 1, 2, 3, 4, and 5).

Overvaluation of shape and weight in BED versus healthy controls

One study [40] (N = 579 participants) compared overvaluation of shape and weight among patients with BED and body-dysmorphic disorder (BDD) to healthy controls. The severity of overvaluation of shape and weight was comparable among individuals with BED and BDD. In addition, both groups had higher levels of overvaluation compared to healthy controls.

Overvaluation of shape and weight in high body mass index with or without BED

Table 1 shows a total of n = 15 studies, with sample sizes between N = 54–300 participants, that examined whether overvaluation of shape and weight among individuals with BED is associated with BMI. Most studies compared individuals with BED and a high BMI with those with a matched high BMI without BED. All studies found that overvaluation of shape and weight was more severe in the first group compared to latter. Two studies [9, 41] compared individuals with BED with and without a high BMI. Goldsmith et al., (2011) found that overvaluation of shape and weight was similar among individuals with BED with a high BMI whereas Dingemans et al., (2012) found similar results with the exception that those with a high BMI had more concerns about weight and were older compared to those without a high BMI.

Overvaluation of shape and weight in BED versus bulimia nervosa/ anorexia nervosa

Overvaluation of shape and weight was compared among individuals with BED, BN and AN in n = 7 studies including N = 48–1760 individuals. A total of n = 3 studies found that overvaluation of shape and weight among individuals diagnosed with BED was comparable to that of BN [33, 42, 43] and AN [43]. Moreover, in one study overvaluation of shape appeared to be even more severe among individuals with BED compared to BN [44]. Finally, one study found body avoidance and feeling fat to be more frequent in individuals with BED compared to AN and BN [45, 46]. In conclusion, it can be said that the severity of overvaluation of shape and weight is not less severe in individuals with BED compared to those with AN and BN, moreover, in some cases, it is even more severe in BED (see Table 2).

Other psychiatric psychopathology among individuals with BED with and without overvaluation of shape and weight

Table 3 shows that n = 56 studies, including N = 26–4030 participants, examined if overvaluation of shape and weight was positively associated with other psychiatric psychopathology. It was reported among n = 27 studies that overvaluation of shape and weight was associated with more severe eating disorder pathology, as well as with more frequent binge-eating episodes (n = 16 studies). Those with higher levels of overvaluation also reported more psychological impairment (n = 11 studies), more comorbid psychopathology (n = 8 studies), greater distress (n = 4 studies), a lower self-esteem (n = 4 studies), more functional impairment (one study), and lower levels of quality of life (one study). As far as known, only one study found overvaluation of shape and weight among individuals with BED not to be associated with greater frequency of binge-eating episodes, depressive symptoms or a lower self-esteem [47]. In other words, the severity of overvaluation of shape and weight appears to be positively associated with other psychopathology.

Is overvaluation of shape and weight a risk factor for the development of BED?

Several studies (n = 8 studies, including N = 145–1952 participants) investigated whether overvaluation of shape and weight is a risk factor for the development of BED later in life. Table 4 shows that a total of n = 6 studies, conducted among (pre-)adolescents, confirmed that overvaluation predicted binge-eating episodes one to five years later [48–53]. In addition, overvaluation of shape and weight predicted binge-eating episodes post bariatric surgery at 1.5–3 years follow-up [54]. Conversely, among Female Latinas overvaluation of shape and weight was associated with the frequency of binge eating, while it did not predict the frequency of binge eating after five years [55]. In conclusion, overvaluation among adolescents predicted binge eating within five years.

Predictive value of overvaluation of shape and weight on treatment outcome

Table 5 shows that n = 16 studies, including N = 41–788 participants, examined if overvaluation of shape and weight was a predictor, moderator, or mediator of treatment outcome. All studies examined treatments based on the principles of CBT, except for one study, which examined the outcomes of a behavioral weight loss intervention [56]. A total of n = 8 studies found that more severe overvaluation of shape and weight at the start of treatment, predicted poorer treatment outcome at the end-of-treatment with regards to the frequency of binge eating [57, 58] or overall eating disorder pathology [56, 59, 60]. Of these studies, n = 3 studies found that more severe overvaluation of shape and weight when treatment commenced, predicted poorer treatment outcome at 12 months follow-up with regards the frequency of binge-eating episodes [57], overall eating disorder pathology [61], and overvaluation of shape [26]. In addition, one study [62] found that higher pretreatment overvaluation of shape and weight predicted more severe overall eating disorder psychopathology at 4 years follow-up. Furthermore, one study found that higher pretreatment overvaluation of shape/ weight significantly predicted greater decreases in eating disorder psychopathology over time in adults as well as in adolescents [60]. However, the recovery rates were lower compared to individuals with lower levels of pretreatment overvaluation of shape and weight [63]. It was also found that abstinence from binge eating was marginally mediated by the reduction in overvaluation of shape and weight [64]. Finally, a total of four studies found that overvaluation of shape and weight at treatment baseline, did not predict treatment outcome with regards to reduction in binge eating [65, 66], and overall eating disorder pathology [66–68]. In conclusion, most studies found that severe overvaluation of shape and weight at the start of treatment predicted poorer treatment outcomes at the end-of-treatment and at follow-up.

Predictive value of overvaluation of shape and weight on treatment dropout

Only two studies including N = 74–521 participants were identified that examined the predictive value of overvaluation on dropout from treatment. Greater levels of overvaluation of shape and weight when treatment commenced predicted dropout from treatment in one study [69], but this was not confirmed in another study [70]. Since both interventions were based on CBT principles it is not clear if overvaluation of shape and weight predicts dropout from treatment.

Discussion

The aim of the present review was to examine whether overvaluation of shape and weight is a critical component in understanding and diagnosing BED, and whether it should be added as a diagnostic criterion for BED. Levels of overvaluation of shape and weight for individuals with a similar high BMI, were higher for those with BED than for those without BED. In other words, this assumes that the psychological distress experienced by individuals with binge- eating disorder is associated with the eating disorder itself and not with their weight (i.e., BMI). In addition to that, overvaluation was comparable in severity among individuals with BED, AN and BN. Although BED, AN, and BN have different manifestations, they do appear to share a common core of intense concerns about shape and weight and other related constructs [8]. These results highlight that all individuals with an eating disorder can be treated with a similar treatment, which supports the transdiagnostic model as employed in Cognitive Behavioral Therapy- Enhanced [7]. Consequently, overvaluation of shape and weight should therefore considered to be addressed as a criterion for BED in the DSM and ICD [27]. Recognizing the similarities in overvaluation of shape and weight across the three types of the named of eating disorders is essential for the accurate diagnosis and treatment of BED. By acknowledging and taking seriously the psychological distress that individuals with BED experience regarding their weight and shape, they can be better supported. Additionally, it was found that the intensity of overvaluation of shape and weight among individuals with BED was associated with comorbid psychopathology and poorer psychosocial functioning. For instance, individuals with greater levels of overvaluation of shape and weight reported more depressive and anxiety symptoms. In other words, overvaluation of shape and weight in BED was positively associated with other (general) psychopathology. Finally, the presence of overvaluation of weight and shape predicted the onset of binge eating within 1 to 5 years among adolescents and generally led to poorer treatment outcomes. However, it was not clear whether overvaluation predicted dropout from treatments.

Overvaluation of shape and weight is not yet a diagnostic criterion of BED, but its relationship to the severity of BED psychopathology appears to be evident as the present review showed. The specified subtypes diagnoses, rather than the Other Specified Feeding or Eating Disorder (OSFED) diagnosis, resulted in more targeted treatment plans, better structured interventions, improved access to (specialized) care, and greater recognition of the eating disorder [71, 72]. Notably, studies concluded that overvaluation of shape and weight predicted the severity of BED [26, 73], and that overvaluation predicted the onset of BED [74]. Finally, individuals with BED who report overvaluation frequently exhibit increased overall eating disorder pathology and comorbid psychopathology. It is suggested to consider including overvaluation of shape and weight as a criterion for the diagnosis of BED. In the future, overvaluation of shape and weight could be considered as a dimensional severity rating.

Another argument to include overvaluation of shape and weight in future revisions of the DSM [3] and ICD [2] is that it could even potentially enhance treatment outcomes [27]. The lack of recognition of overvaluation of shape and weight can lead to overlooking, and consequently failure to address this construct in BED treatments. Individuals with severe overvaluation of shape and weight appear to benefit less from treatment compared to individuals with lower levels of overvaluation [16, 57, 63, 64, 75]. This suggests that specific attention to those with severe levels of overvaluation at the beginning of treatment is warranted since they do otherwise have a worse outcome with the standard BED treatment.

The present review is subject to several limitations. The decision to conduct a systematic review instead of a meta-analysis constitutes a limitation. Due to the variability across the included studies on different subtopics, a systematic review was deemed more appropriate as it allowed for a more comprehensive exploration of nuances within the literature. Conversely, a meta-analysis would have been restricted to the quantification of specific effect sizes [76]. In addition, although most studies suggested that severe pre-treatment levels of overvaluation of shape and weight were predictive of poorer treatment outcomes, results across studies have been inconsistent. Moreover, the present review predominantly included cross-sectional studies, which limited the ability to infer causality or determine the directionality of associations. Longitudinal data remain scarce, which constrains the understanding of the temporal relationships between overvaluation of shape and weight and binge-eating behaviors. However, a strength of the present review is that it could serve as a guidance for future longitudinal research aimed at testing whether overevaluation serves as a predictor of the persistence of eating disorder psychopathology and its correlates over time. Additionally, the potential for sampling bias should be considered, as many of the included studies may have disproportionately represented individuals from certain social, economic, and educational backgrounds [34, 35], and most of the included studies involved Western samples. Another limitation was that only studies in English were included.

To address these limitations, future research should prioritize the use of meta-analytic techniques to quantify the effect of overvaluation of shape and weight on treatment outcomes [76], and resolve the inconsistencies identified in the current literature. Furthermore, the application of machine learning methods, as opposed to traditional regression analyses, is recommended to enhance the detection of complex, non-linear interactions between predictive variables, particularly regarding pre-treatment severity of overvaluation [77, 78]. Additionally, it is recommended to employ longitudinal designs in future studies, beginning prior to pubertal onset, to clarify the role of overvaluation of shape and weight during puberty and its influence on binge- eating behaviors during adolescence and emerging adulthood [55, 79, 80]. A broader demographic representation should be pursued in future studies, incorporating diverse cultural, social, and economic backgrounds, including non-Western populations, to improve the generalizability of findings [5, 81]. Examining the presence of overvaluation of shape and weight among non-Western samples is recommended [82]. Finally, future research should aim to elucidate the mechanisms through which overvaluation of shape and weight is modified throughout treatment. A clearer understanding of these mechanisms is essential for optimizing treatment interventions for binge eating disorder (BED) [5, 81].

Conclusions

Overvaluation of shape and weight in individuals with BED is associated with more severe overall eating disorder pathology, more severe comorbid psychopathology and poorer treatment outcomes. There is enough evidence to consider inclusion of overvaluation of shape and weight as a criterion for BED in the DSM and ICD. This may prevent overlooking overvaluation in BED, and potentially enhance treatment outcomes.

Abbreviations

AN

Anorexia nervosa

BED

Binge-eating disorder

BN

Bulimia nervosa

BMI

Body mass index

DSM

Statistical manual of mental disorders

ICD

International classification of diseases

Author contributions

The manuscript has been written by BM in collaboration with AD.

Availability of data and materials

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.