Binge-eating disorder (BED) is associated strongly with obesity and chronic medical conditions (1). Behavioral lifestyle weight management (BLWM) has been found to be effective for BED in patients with co-existing obesity, with trials reporting significant reductions in binge-eating and associated eating-disorder psychopathology (2-4). Further, BWLM produces weight loss, which is not observed with cognitive-behavioral therapy (CBT) (2-4). Heated debate has emerged concerning whether BLWM triggers or exacerbates eating-disorder psychopathology (5,6). Systematic reviews of BLWM for obesity (i.e., distinct from self-directed “dieting”) have noted low frequencies (ranging 0-6.5%) of new onsets of eating-disorder symptoms (7).
While the low frequency of cases experiencing worsening eating-disorder symptoms during obesity treatments (7) is somewhat reassuring, further research is needed with rigorous assessments to establish whether eating-disorder psychopathology worsens with BLWM in individuals with eating disorders who might be at higher risk (8). A recent study assessed the frequency of increased eating-disorder psychopathology at the specific participant level in a BLWM trial for BED (9). The frequency of cases with increased symptoms of binge-eating (2.1%) and eating-disorder psychopathology (13.7%) at 12-month follow-up after 6-month treatments was low and the magnitudes of the increases were generally quite small. This study, however, did not have a comparator, and an extension/replication in a controlled trial is warranted.
The present analysis utilized data from a RCT testing BLWM and CBT for BED (2) to examine heterogeneity of outcomes in order to identify/compare the frequency of increased binge-eating and eating-disorder psychopathology across treatments and to explore predictors of increased symptoms. Supplemental Text summarizes the methods (treatments and assessments), participant characteristics (Supplemental Table 1), and clinical outcomes through 12-month follow-ups (Supplemental Table 2). For additional context, binge-eating remission rates (zero episodes/past 28 days) were 33.3% (for BLWM) and 51.1% (for CBT) at 12-month follow-up.
Figure 1-A depicts specific participants’ changes in binge-eating frequency from baseline to 12-month follow-up. In BLWM, 5 participants (13.9% of 36) had increased binge-eating frequency (range 4-10 episodes/past 28 days) whereas in CBT there were none (0.0% of 35) (Fisher’s Exact Test p=0.054). Figure 1-B depicts specific participants’ changes in eating-disorder psychopathology scores from baseline to 12-month follow-up. In BLWM, 8 (22.2% of 36) participants had increased scores (range 0.09 to 0.84) whereas in CBT, 2 (5.7% of 35) participants had increased scores (0.24 and 0.74) (Fisher’s Exact Test p=0.085).
Figure 1-A.
Individual changes in binge-eating frequency for cognitive-behavioral therapy and behavioral lifestyle weight management from baseline to 12-month follow-ups after treatments (18 months after baseline).
Note. CBT = Cognitive Behavioral Therapy; BLWM = Behavioral Lifestyle Weight Management; Binge-eating frequency determined with Eating Disorder Examination interview and denoted number of episodes/past 28 days. Change value = (baseline frequency – follow-up frequency)
Figure 1-B.
Individual changes in global eating-disorder psychopathology from baseline to 12-month follow-up after 6-month cognitive-behavioral therapy and behavioral lifestyle weight management.
Note. CBT = Cognitive Behavioral Therapy; BWLM = Behavioral Lifestyle Weight Management; Eating-disorder psychopathology is the Global Score on the Eating Disorder Examination (past 28 days). Change score = (Baseline EDEglobal – Followup EDEglobal); range of possible scores 0-6; range of possible change scores = −6 to +6.
Inspection of the increases revealed most were small in magnitude and potentially clinically meaningful increases were rare. As Figure 1 shows, there were 2 cases of increased binge-eating of 9 and 10 episodes/month in BLWM and 3 cases with increased eating-disorder psychopathology scores by 0.50 units, 2 of which were in BLWM and 1 in CBT. Of cases with potentially clinically meaningful increases, 1 had increases in both binge-eating and eating-disorder psychopathology, for a 4 total cases (3 received BLWM and 1 received CBT).
Analyses explored whether participants’ sociodemographic and baseline clinical variables predicted increased versus improved eating-disorder symptoms at 12-month follow-up. No sociodemographic variables (gender [Fisher’s Exact Test p=0.20], age [p=0.31], age of BED onset [p=0.53], race [Fisher’s Exact Test p=0.72], education [Fisher’s Exact Test p=0.68]) nor clinical variables (binge-eating frequency (p=0.56), EDE global score (p=.28), and BMI (p=0.32) predicted increased symptoms.
In summary, this secondary analysis of a controlled trial revealed that individual cases of increased binge-eating and/or eating-disorder psychopathology were rare, mostly small magnitudes that were more frequent in BLWM than CBT. These findings extend those reported by Yurkow et al (9) and provide further context for the potential benefits/risks of BLWM and CBT for BED in patients with co-existing obesity (2). As an important broader context, we emphasize that BED is associated with a myriad of biopsychosocial/functional impairments and high chronicity (1). These participant-level analyses add to previous findings (9) and expert (8) and patient perspectives (10), and they challenge concerns from some groups (7) that BLWM is contraindicated because it exacerbates eating-disorder psychopathology.
We note several methodological issues to consider. One limitation is missing data, with analyses limited to 79% of participants with 12-month follow-ups. While it is possible that some participants with missing data had increased symptoms, dropouts from BLWM (and CBT) often note other reasons including unrelated illnesses, pregnancy, and logistical issues (e.g., time, job, family, costs). Sample size and statistical power were limited for identifying small effects. The treatments were delivered by highly trained and carefully monitored clinicians, and the generalizability of findings to other practitioners and clinical settings is uncertain. The findings might not generalize to patients with different sociodemographic characteristics or with other eating disorders.
Supplementary Material
Funding
This research was supported by National Institutes of Health (NIH) grant R01 DK49587 (Grilo). Dr. Lydecker was supported by K23 DK112771. The authors were also supported, in part, by grants R01 DK114075 and R01 DK121551. Funding agency played no role in the content of this paper.
Footnotes
Ethical standards and informed consent
The study had Yale Institutional Review Board approval and was conducted in accordance with the Yale Human Investigation Committee and ethical standards. All participants provided written informed consent.
CRediT authorship contribution statement
Dr. Carlos Grilo conceptualized and designed the study, obtained funding, supervised data collection, conducted analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript. Dr. Sydney Yurkow contributed to the conceptualization of the study and critically reviewed and revised the manuscript. Dr. Marney White administered the study protocol, supervised data collection, and critically reviewed and revised the manuscript. Dr. Janet Lydecker contributed to the conceptualization of the study, created visuals, and critically reviewed and revised the manuscript. Dr. Valentina Ivezaj contributed to the conceptualization of the study, performed data analyses, created visuals, and critically reviewed and revised the manuscript.
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Declaration of competing interest
The authors declare no conflicts of interest. Dr. Grilo reports broader interests, which did not influence this research, including royalties from Guilford Press for an academic book.
Data availability
Data from the overall study, including the study protocol, statistical analysis plan, and informed consent form, are posted on clinicaltrials.gov. Deidentified participant data (including data dictionaries) will be made available to academic researchers who make a reasonable request and provide a methodologically sound proposal and IRB-approved protocol for use in achieving the goals of the approved proposal.
REFERENCES
- 1.Udo T, Grilo CM. Prevalence and correlates of DSM-5-defined eating disorders in a nationally representative sample of US adults. Biol Psychiatry. 2018;84:345–354. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Grilo CM, Masheb RM, Wilson GT, Gueorguieva R, White MA. Cognitive–behavioral therapy, behavioral weight loss, and sequential treatment for obese patients with binge-eating disorder: a randomized controlled trial. J Consult Clin Psychol. 2011;79:675–685. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Grilo CM, Lydecker JA, Fineberg J, Moreno VI, Gueorguieva R. Naltrexone plus bupropion combination medication and behavior therapy, alone and combined, for binge-eating disorder: randomized double-blind placebo-controlled trial. Am J Psychiatry. 2022;179:927–937. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Wilson GT, Wilfley DE, Agras WS, Bryson SW. Psychological treatments of binge eating disorder. Arch Gen Psychiatry. 2010;67:94–101. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Steinberg DM, Bohon C. To truly reduce weight stigma and eating disorder risk, we need to stop promoting weight loss. J Acad Nutr Diet. 2023;123:399–400. [DOI] [PubMed] [Google Scholar]
- 6.Cardel MI, Newsome FA, Pearl RL, et al. Patient-centered care for obesity: how health care providers can treat obesity while actively addressing weight stigma and eating disorder risk. J Acad Nutr Diet. 2022;122:1089–1098. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Jebeile H, Libesman S, Melville H, et al. Eating disorder risk during behavioral weight management in adults with overweight or obesity: a systematic review with meta-analysis. Obes Rev. 2023;24(6):e13561. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.McMaster CM, Paxton SJ, Maguire S, et al. The need for future research into the assessment and monitoring of eating disorder risk in the context of obesity treatment. Int J Eat Disord 2023;56:914–924. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Yurkow A, Ivezaj V, & Grilo CM Lifestyle behavioral weight loss treatment for binge-eating disorder in patients with obesity: where’s the harm? Obesity 2025;33:1067–1075. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Sonnenblick RM, Liu J, Riddle DR, Manasse SM, Forman EM, Juarascio AS. Behavioral weight loss treatment for adults with binge-eating disorder: A qualitative analysis of patients' perspectives and experiences. Int J Eat Disord. 2024;57:1854–1867. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data from the overall study, including the study protocol, statistical analysis plan, and informed consent form, are posted on clinicaltrials.gov. Deidentified participant data (including data dictionaries) will be made available to academic researchers who make a reasonable request and provide a methodologically sound proposal and IRB-approved protocol for use in achieving the goals of the approved proposal.