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. Author manuscript; available in PMC: 2026 May 2.
Published before final editing as: Eur Eat Disord Rev. 2026 Apr 5:10.1002/erv.70112. doi: 10.1002/erv.70112

A Multi-Site Study of Brief Cognitive-Behavioral Therapy for Eating Disorders for Individuals with BMI ≥ 30

Ashley Dunford 1,2, P Evelyna Kambanis 1,2, Lilian P Palmer 1,2, Haley Graver 4, Megan E Liu 5, Jordan Hillard 5, Stefania Yee 1,2, Hannah Turner 5, Lauren Breithaupt 1,2,3, Emma Evans 6, Ellen Blythe 6, Chloe White 6, Jade Broadley 5, Glenn Waller 7, Kamryn T Eddy 1,2, Jennifer J Thomas 1,2,*, Kendra R Becker 1,2,8,*
PMCID: PMC13133702  NIHMSID: NIHMS2166669  PMID: 41937408

Abstract

Objective:

Cognitive-behavioral therapy (CBT) for eating disorders (EDs) has raised concerns of appropriateness for patients in higher-weight bodies. We evaluated acceptability (Sample 1—United States [USA]) and effectiveness (Sample 1—USA, Sample 2—United Kingdom [UK]) of CBT-T by body mass index [BMI] category. We hypothesized that individuals with BMI ≥ 30 kg/m2 would be more likely to drop out and show smaller symptom reductions compared to participants with BMI < 30 kg/m2.

Methods:

Participants with non-underweight EDs (USA: n = 63; UK: n = 58) received CBT-T and completed the ED-15 to evaluate change in behaviors (objective binge eating, purging, restriction, excessive exercise) and cognitions (Eating Concern, Weight/Shape Concern, Global Score).

Results:

Contrary to hypotheses, CBT-T completion did not differ by BMI category. Participants demonstrated large and significant reductions in binge eating, excessive exercise, and ED cognitions, with no significant differences by BMI (USA, UK). Although the BMI ≥ 30 kg/m2 group demonstrated significantly smaller reductions in restriction and purging (UK only), smaller reductions in the higher-weight group were fully explained by their significantly lower pre-treatment symptoms.

Discussion:

Results from this exploratory multisite study found no evidence that CBT-T was less acceptable or effective for participants in higher-weight bodies.

Keywords: feeding and eating disorders, higher-weight bodies, binge eating, cognitive-behavioral therapy, body mass index

Introduction

Cognitive-behavioral therapy (CBT) is a well-established treatment for individuals with non-underweight eating disorders (EDs). Between 36% (Cuijpers et al., 2024) and 65% (Keegan et al., 2022) of patients achieve a good outcome, including reductions in weight/shape and eating concerns, binge eating, vomiting, and clinical impairment (Cuijpers et al., 2024; Keegan et al., 2022). CBT is the most widely used and empirically supported psychotherapy for the treatment of binge-eating disorder (BED) and bulimia nervosa (BN; Linardon et al., 2017), which tend to present in individuals with “normal” and higher weight (Kessler et al., 2013) and is particularly effective when delivered as individual psychotherapy (Bruns et al., 2025). CBT is efficacious in reducing both cognitive and behavioral symptoms of BN and of behavioral symptoms of BED and is often offered in a briefer format compared to other treatments (Monteleone et al., 2022).

Compared to other psychotherapy modalities, CBT produces outcomes comparable to interpersonal psychotherapy (Fairburn et al., 2015), integrative cognitive-affective therapy (Wonderlich et al., 2014), and dialectical behavior therapy for BED (de Vos et al., 2020). However, CBT typically leads to faster symptom reduction than interpersonal psychotherapy, even though outcomes are comparable at treatment follow-up (Fairburn et al., 2015). When compared to dialectical behavior therapy for BED, CBT shows greater reductions in ED behaviors and psychopathology, but both treatments demonstrate clinically meaningful improvements (de Vos et al., 2020). Finally, CBT and integrative cognitive-affective therapy appear to produce comparable outcomes with no significant differences between therapies (Wonderlich et al., 2014).

Early studies of CBT focused primarily on non-underweight patients with EDs with average body mass indices (BMIs) well below 30 kg/m2. For example, the patient cohort in Fairburn and colleagues’ (2009) seminal study of enhanced cognitive-behavioral therapy for EDs had an average BMI of 22.9 kg/m2. Similarly, the patient cohort in Waller and colleagues’ (2018) case series of 10-session cognitive-behavioral therapy for non-underweight eating disorders (CBT-T, where “T” stands for “ten”) had an average BMI of 24.4 kg/m2. CBT-T for non-underweight EDs is an updated brief transdiagnostic therapy for non-underweight EDs with comparable outcomes to traditional CBT-Enhanced (Keegan et al., 2022). However, BMI is increasing across the general population (Fan et al., 2023), and it is becoming increasingly common for individuals with bulimia nervosa (BN) and other EDs to present for treatment in higher-weight bodies (Bulik, 2012). Yet, research has lagged on inclusive evaluations of treatment outcomes for those in higher-weight bodies, and questions have been raised about whether CBT (Milner & Mulheim, 2021) and other ED treatments (Harrop et al., 2025) are inappropriate—or even iatrogenic—for patients of higher weight.

Scholars have expressed reservations that CBT may (1) overlook restrictive eating behaviors among patients with higher-weight bodies (Harrop et al., 2023), (2) over-emphasize weekly weighing (which could potentially carry the risk of pathologizing weight gain during the course of interventions that institute regular eating and eliminate dietary restriction), and (3) inadvertently perpetuate weight stigma by evaluating weight gain as the feared prediction in behavioral experiments (Milner & Mulheim, 2021). Furthermore, there is criticism that body image interventions, such as exposure to wearing form-fitting clothing in public, may not be suitable for patients in higher-weight bodies, who may be unprepared for the very real weight stigma they may face in public settings (Milner & Mulheim, 2021).

Although weight stigma is widely documented among individuals with higher weight, a growing concern in the field is that standard CBT for eating disorders may be inappropriate or even harmful for patients with BMI ≥ 30. Scholars have recently suggested that weight- and shape-focused CBT techniques may inadvertently reinforce fat-phobia and undermine engagement (McEntee et al., 2023) when treatment is perceived as weight-centric rather than weight-inclusive (Tylka et al., 2014). For example, repeated exposure to stigmatizing messages about weight may reinforce negative beliefs about body size and self-worth, potentially contributing to harm and limiting CBT’s effectiveness in targeting ED psychopathology (McEntee et al., 2023), particularly among individuals with BMIs ≥ 30 who experience high levels of weight stigma (Hatzenbuehler et al., 2009).

Indeed, epidemiological research in the United States suggests that adults with BMI ≥ 30 kg/m2 are twice as likely to encounter weight stigma and discrimination across multiple settings (e.g., healthcare, the workplace, and in public) compared to those with BMI between 25 kg/m2 and 30 kg/m2 (Hatzenbuehler et al., 2009). Given these lived experiences, there is a growing need to evaluate the effectiveness of CBT for individuals whose BMI falls in the obesity range of BMI ≥ 30 kg/m2 and who may be least likely to benefit from CBT in part due to higher rates of experienced weight stigma (McEntee et al., 2023). However, current research on CBT-T outcomes has not yet evaluated outcomes specifically for those in higher-weight bodies.

Aims

Since individuals with BMIs ≥ 30 kg/m2 are more likely to experience direct stigma and discrimination (Hatzenbuehler et al., 2009) and there is a research gap in understanding how effective CBT may be for patients with higher-weight bodies, the purpose of the present study was to examine the acceptability and effectiveness of CBT-T for these patients. We evaluated treatment outcomes in two treatment samples at different sites, one from an EDs specialty clinic at an academic medical center in the United States (Sample 1—USA, Boston, Massachusetts) and the other from a community EDs service in United Kingdom (Sample 2—Hampshire, UK). These samples seemed uniquely suited to answer our research questions as the mean BMIs of 29.8 kg/m2 (USA sample) and 36.2 kg/m2 (UK sample) are both notably higher than the mean BMIs for previous studies that have evaluated the acceptability and effectiveness of CBT (e.g., 22.9 kg/m2 in Fairburn et al., 2009; 24.4 kg/m2 in Waller et al., 2018), and both mirror population trends of increasing BMI over time. Thus we divided each sample into two categories comprising individuals with BMIs ≥ 30 kg/m2 and individuals with BMIs ranging from 18.5kg/m2 – 29.9 kg/m2. We stratified analyses based on BMI group and not clinical diagnosis as available data on CBT-T suggests that it produces meaningful symptom improvement in both BN and BED (Keegan et al., 2022). Based on concerns expressed by scholars in the field, in our exploratory multisite study, we hypothesized that: (1) CBT-T would be less acceptable to individuals with BMIs ≥ 30 kg/m2, such that these participants would be significantly more likely to drop out of CBT-T than those with BMIs < 30 kg/m2 (Sample 1—USA only, as dropout data were unavailable for the UK site); and that (2) individuals with BMIs ≥ 30 kg/m2 would be less likely to benefit from CBT-T, as evidenced by significantly smaller reductions in ED behaviors and cognitions from pre- to post-CBT-T compared to those with BMIs < 30 kg/m2 in Samples 1 (USA) and 2 (UK).

Method

Participants

Sample 1—USA

Full demographics are depicted in Table 1. Data from 63 adults with non-underweight EDs (mean age 34.1 years, SD = 14.4) who presented to the Massachusetts General Hospital Eating Disorders Clinical and Research Program in Boston, MA, USA and received CBT-T between November 2019 to August 2024 comprised Sample 1. A comprehensive description of methods and treatment outcomes for the full sample are available in Kambanis et al. (2025).

Table 1.

Demographic Characteristics Across Two Treatment Samples (United States and United Kingdom) of 121 Non-underweight Adults Presenting for Cognitive Behavioral Therapy – Ten Session Version

Sample 1 (United States) Sample 2 (United Kingdom)
N = 63 N = 58
Age M = 34.1 (SD = 14.4) M = 37.8 (SD = 15.5)
Sex
 Female 55 (87%) 46 (80%)
 Male 8 (13%) 10 (17%)
Race/ethnicity
 White 57 (90%) 53 (91%)
 Black < 5% 0%
 Other < 5% < 5%
Body Mass Index (BMI)
M = 29.8 (SD = 8.9) M = 36.2 (SD = 10.5)
 BMI ≥ 30 kg/me 24 (38%) 39 (67%)
 BMI < 30 kg/me 39 (62%) 19 (33%)
Eating Disorder Diagnosis
BMI ≥ 30kg/me
 Bulimia nervosa 4 (6%) 21 (36%)
 Binge-eating disorder 14 (22%) 18 (31%)
 Other specified 6 (10%) 0%
  Atypical anorexia 1 (2%) 0%
  Low frequency BED 1 (2%) 0%
BMI < 30 kg/m e
 Bulimia nervosa 12 (19%) 17 (29%)
 Binge-eating disorder 13 (21%) 2 (3%)
 Other specified 14 (22%) 0%
  Atypical anorexia 11 (17%) 0%
  Low frequency BED 1 (2%) 0%
  Night eating syndrome 1 (2%) 0%
  Purging disorder 1 (2%) 0%
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*

Note: Mean – M, Standard Deviation – SD, Body Mass Index – BMI, Binge-eating disorder – BED, Race/ethnicity data were collected differently each sample based on population make-up. “Other” includes Asian American (US sample); and Mixed Asian, Polish, and Mixed British (UK sample).

Clinicians measured participants’ weight on the clinic scale during in-person evaluations, but after the transition to telemedicine evaluations in the wake of COVID-19, participants took their own weight in real time on their home scales during video appointments, consistent with recommended practice (Waller et al., 2020). Participants had an average pre-treatment BMI of 29.8 kg/m2, spanning a range from 19.4 kg/m2 – 71.1 kg/m2. Just under two thirds (n = 39, 62%) of participants had BMIs < 30 kg/m2 and just over one third (n = 24, 38%) had BMIs ≥ 30 kg/m2.

Participants received Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5; American Psychiatric Association[APA], 2013) ED diagnoses after a routine semi-structured clinical interview with a doctoral-level clinician (i.e., psychologist, psychiatrist) or clinical trainee (i.e., pre-doctoral clinical psychology intern, post-doctoral psychology fellow) supervised by a doctoral-level clinician (Kambanis et al., 2025). We conducted clinical interviews keyed to diagnostic criteria using a template derived from the DSM-5 (APA, 2013) as part of routine clinical practice which has been previously published as a valid method for clinical diagnostic assessment (Becker et al., 2018; Becker et al., 2019; Stern et al., 2024). Among participants with BMIs < 30 kg/m2, 12 had BN, 13 had BED, and 14 had other specified feeding or eating disorder (which included 11 with atypical anorexia nervosa (AN), one with low-frequency/limited-duration BED, one with night eating syndrome, and one with purging disorder). Among participants with BMIs ≥ 30 kg/m2, four participants had BN, 14 had BED, and six had other specified feeding or eating disorder (which included one with atypical AN and one with low-frequency/limited-duration BED).

Sample 2—UK

Full demographics are depicted in Table 1. Data from 58 adults with non-underweight EDs (mean age 37.8 years, SD = 15.5) who presented to the Community Eating Disorder Service in the UK and received CBT-T between October 2023 to November 2024 comprised Sample 2. Appointments were a mix of virtual and in person. Participants’ weight was either measured on the clinic scale during in-person sessions or self-reported during video appointments. Participants had an average BMI of 36.2 kg/m2, spanning a range from 19.2 kg/m2 to 63.7 kg/m2. One third (n = 19, 33%) of participants had BMIs < 30 kg/m2 and two thirds (n = 39, 67%) had BMIs ≥ 30 kg/m2.

Participants received DSM-5 (APA, 2013) ED diagnoses after a routine semi-structured clinical interview with either a qualified therapist or assistant psychologists supervised by a qualified psychologist. Among participants with BMIs < 30 kg/m2, 17 had BN and 2 had BED. Among participants with BMIs ≥ 30 kg/m2, 21 participants had BN and 18 had BED.

Measures

Eating Disorder-15 (ED-15)

The ED-15 (Tatham et al., 2015) is a brief weekly self-report measure of eating attitudes/behaviors. The ED-15 comprises five behavioral items assessing objective binge eating, self-induced vomiting, laxative use, restriction, and excessive exercise and 10 cognitive items (0–6 scale) comprising Weight/Shape Concern and Eating Concern, with an overall Global Score calculated as the mean of all 10 items (range = 0–6).

Procedure

CBT-T is a brief, manualized, evidence-based treatment for non-underweight EDs, typically limited to 10 weekly sessions, but can be varying lengths (Kambanis et al., 2025) and include two follow-up sessions at one and three months after ending therapy (Waller et al., 2019). CBT-T consists of five treatment phases incorporating primary CBT interventions focusing on early dietary change and exposure, conducting behavioral experiments relating to food, addressing emotional triggers, targeting body image work through surveys and exposure, and relapse prevention. Interventions are centered on Socratic questioning, inhibitory learning through exposure, and structured behavioral experiments (Waller et al, 2018). Participants completed the ED-15 at pre-treatment and prior to the start of every session. To ensure consistent delivery of CBT-T and adherence to the treatment protocol, co-author and co-developer of CBT-T, Dr. Glenn Waller, provided therapist training and ongoing supervision, serving as the same supervisor across both sites. We defined adverse events as hospital admissions and emergency department visits unrelated to seeking a higher level of care for an ED. We had six adverse events, three per BMI group, and none were severe or related to the study. Adverse events included hospitalizations for surgical procedures, urinary tract infections, nausea and vomiting secondary to oral antibiotic use, foot and vaginal cyst pain, pharyngitis, and evaluation for possible sexually transmitted infections.

Statistical Analyses

Aim 1 – Acceptability of CBT-T by BMI Category (Sample 1—USA only)

We conducted analyses in SPSS Version 28 (IBM Corporation, 2021). To test the hypothesis that treatment would be less acceptable to individuals with BMIs ≥ 30 kg/m2 compared to those with BMIs < 30 kg/m2, we compared treatment drop-out rates between groups. Discontinuation of or pausing treatment at Session 4, as discussed between patient and clinician, is part of the CBT-T protocol and is intended to capitalize on rapid response, a unique feature that helps distinguish CBT-T from other CBT protocols (Waller et al., 2019). We categorized patient dropout as mutual agreement to pause or end treatment, patient-initiated dropout, which for some included logistical barriers, or referrals to a higher level of care (Kambanis et al., 2025). We operationalized acceptability as completion of the treatment protocol, which for some participants was more or less than 10 treatment sessions. For participants who completed treatment in <10 sessions (n = 14), missing data at Session 10 reflected early completion rather than attrition (Kambanis et al., 2025). As such, these participants’ final available session ED-15 score was used to represent their endpoint. Likewise, for individuals whose treatment extended beyond 10 sessions (n = 4), the ED-15 score from the last session they attended was treated as their final session score. This method ensured that all treatment completers had an endpoint value. We used a chi-square test of independence to examine whether drop-out rates differed significantly by BMI category (BMI ≥ 30 kg/m2 vs. BMI < 30 kg/m2).

Aim 2 – Effectiveness of CBT-T by BMI Category (Sample 1—USA and Sample 2—UK)

To compare effectiveness of CBT-T by BMI category, we conducted separate regression analyses using Mplus (Muthén & Muthén, 1998–2017) in Samples 1—USA and 2—UK with full information maximum likelihood, which estimates model parameters using all observed data. Each model included BMI category as the predictor variable and change in ED behaviors and cognitions at the dependent variables. Since all analyses were hypothesis-driven and derived from the same parent scale (the ED-15), we did not apply a correction for multiple comparisons. We did not stratify analyses by clinical diagnosis as CBT-T is effective and established treatment for non.

Behaviors

To test our hypothesis that individuals with BMIs ≥ 30 kg/m2 would show smaller reductions in behavioral symptoms than those with BMIs < 30 kg/m2, we conducted linear regression analyses with BMI group (BMI ≥ 30 kg/m2 vs. BMI < 30 kg/m2) as the predictor. The outcome variable included change scores for each individual ED-15 behavior, including binge eating, purging (which included both vomiting and laxative use), restriction, and excessive exercise. We calculated behavioral change as the difference between scores at Session 1 and the final treatment session.

Cognitions

To test the hypothesis that individuals with BMIs ≥ 30 kg/m2 would show smaller reductions in cognitive symptoms than those with BMIs < 30 kg/m2, we repeated the linear regression analyses described above, this time using the ED-15 Global Score to index cognitive symptoms. We also conducted separate analyses for the ED-15 subscales (Eating Concern and Shape/Weight Concern).

Secondary Follow-Up Analyses

To better understand our pattern of findings, we conducted secondary follow-up analyses to examine whether baseline differences in symptom severity across the weight spectrum could account for any observed differences in symptom reduction between BMI categories. We used an independent sample t-test to examine the effect of the independent variable: BMI category (BMI ≥ 30 kg/m2 vs. BMI < 30 kg/m2) on the dependent variables: change in ED behaviors and cognitions.

Results

Aim 1 – Acceptability of CBT-T by BMI Category (Sample 1—USA only)

Contrary to our first hypothesis, results of the chi-square analyses indicated no significant difference in treatment drop-out rates between individuals with BMIs ≥ 30 kg/m2 compared to those with BMIs < 30 kg/m2 (χ2 = 0.59, p = .444, Cramer’s V = .10). Specifically, 75% (n = 18) of participants with BMIs ≥ 30 kg/m2 completed CBT-T, whereas 64% (n = 25) of those with BMIs < 30 kg/m2 completed it. The direction of difference did not indicate any trend towards supporting the hypothesis as the completion level was in higher in the ≥ 30 kg/m2 group.

Aim 2 – Effectiveness of CBT-T by BMI Category (Sample 1—USA and Sample 2—UK)

Sample 1—USA

Results are presented in Table 2 and Figures 1 and 2.

Table 2.

Sample 1. Linear Regression Results Predicting Change in Behaviors and Cognitions from Body Mass Index (BMI) Group (BMI < 30 kg/m2 compared to BMI ≥ 30 kg/m2) in Sample 1 (United States)

B SE z-value 95% CI
Lower, Upper		 p-value
Behavioral outcomes
Objective binge eating −.22 .47 −.47 −.98, .55 .640
Purging −.62 .41 −1.51 −1.30, .05 .130
Restriction −.98 .82 −1.19 −2.33, .37 .234
Excessive exercise −.50 .51 −.97 −1.34, .35 .331
Cognitive outcomes
Global Score −.40 .42 −.95 −1.09, .29 .344
Eating Concerns subscale .68 .44 1.54 −.05, 1.41 .123
Shape/Weight Concerns subscale −2.32 1.39 −1.67 −4.61, −.03 .096
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Note. B – unstandardized coefficient; SE – standard error; CI – confidence interval. We entered BMI as a dichotomous predictor. Outcome variables reflect change scores calculated as Session 1 minus Final Session values. BMI < 30 kg/m2 is the reference group. Bolded p-values are statistically significant.

Figure 1.

Figure 1

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Change in Eating Disorder Behaviors by Body Mass Index Group (BMI ≥ 30kg/m2 vs. BMI < 30kg/m2) in Sample 1 (United States)

Figure 2.

Figure 2

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Change in Eating Disorder Behaviors by Body Mass Index Group (BMI ≥ 30kg/m2 vs. BMI < 30kg/m2) in Sample 2 (United Kingdom)

Behaviors.

At baseline, individuals with BMIs ≥ 30 kg/m2 reported significantly lower levels (p <.001) of purging (M = .06, SD = .24) and restrictive eating (M =1.2, SD = 2.0, p = .007) compared to those with BMIs < 30 kg/m2 (purging: M = .68, SD = 1.8; restrictive eating: M = 2.2, SD = 3.1). We observed no significant differences in binge eating or excessive exercise across groups. Contrary to hypotheses, in Sample 1, individuals with BMIs ≥ 30 kg/m2 did not demonstrate smaller reductions in behavioral symptoms compared to those with BMIs < 30 kg/m2. Indeed, both groups demonstrated large and significant reductions in objective binge eating, purging, restriction, and excessive exercise from pre- to post-treatment.

Cognitions.

At baseline, we observed no significant differences in ED cognitions, including Global scores (p = .950), Eating Concern subscale scores (p = .968), and Weight/Shape subscale scores (p = .996) between groups. Contrary to hypotheses, individuals with BMIs ≥ 30 kg/m2 did not demonstrate smaller reductions in cognitive symptoms to those with BMIs < 30 kg/m2. Indeed, both groups demonstrate large and significant reductions from pre- to post-treatment in Global Score, Eating Concern, and Shape/Weight Concern.

Sample 2—UK

Results are presented in Table 3 and Figures 3 and 4.

Table 3.

Sample 2. Linear Regression Results Predicting Change in Behaviors and Cognitions from Body Mass Index (BMI) Group (BMI < 30 kg/m2 compared to BMI ≥ 30 kg/m2) in Sample 2 (United Kingdom)

B SE z-value 95% CI
Lower, Upper		 p-value
Behavioral outcomes
Objective binge eating 1.70 1.03 1.65 .00, 3.41 .099
Purging −1.92 .95 −2.01 −3.48, −.35 .044
Restriction −1.77 .63 −2.79 −2.79, −.72 .005
Excessive exercise −.59 .44 −1.33 −1.32, .14 .183
Cognitive outcomes
Global Score .54 .41 1.30 −.14, 1.22 .194
Eating Concerns subscale .39 .42 .93 −.30, 1.09 .352
Shape/Weight Concerns subscale .66 .43 1.55 −.04, 1.37 .122
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Note. B – unstandardized coefficient; SE – standard error; CI – confidence interval. We entered BMI as a dichotomous predictor. Outcome variables reflect change scores calculated as Session 1 minus Final Session values. BMI < 30 kg/m2 is the reference group. Bolded p-values are statistically significant.

Figure 3.

Figure 3

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Changes in Eating Disorder Cognitions by Body Mass Index Group (BMI ≥ 30kg/m2vs. BMI < 30 kg/m2) in Sample 1 (United States)

Figure 4.

Figure 4

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Changes in Eating Disorder Cognitions by Body Mass Index Group (BMI ≥ 30kg/m2vs. BMI < 30 kg/m2) in Sample 2 (United Kingdom)

Behaviors.

At baseline, individuals with BMIs ≥ 30 kg/m2 reported significantly higher levels of purging (M = 2.5, SD = 5.5, p =.009) and restrictive eating (M = 3.2, SD = 2.8, p = .021) compared to those with BMIs < 30 kg/m2 (purging: M = .64, SD = 1.8, p =.009; restrictive eating: M = 1.4, SD = 2.0, p = .021). Additionally, individuals with BMI ≥ 30 kg/m2 also reported significantly higher levels of excessive exercise (M = 1.0, SD = 2.0, p = .038) compared to the BMI < 30 kg/m2 group (M = .41, SD = 1.3, p = .038). We observed no significant differences in binge eating between groups (p = .167). In partial support of hypotheses, individuals with BMIs ≥ 30 kg/m2 demonstrated significantly smaller reductions from pre- to post-treatment compared to those with BMIs < 30 kg/m2 in two behavioral symptoms: restricting and purging. However, post-hoc comparisons demonstrated significantly lower pre-treatment frequencies of both restriction and purging in the BMI ≥ 30 kg/m2 category, such that those with BMIs ≥ 30 kg/m2 were restricting only half as frequently and purging only one-fifth as frequently as those with BMIs < 30 kg/m2 Session 1. Contrary to hypotheses, individuals with BMIs ≥ 30 kg/m2 did not demonstrate smaller reductions in objective binge eating and excessive exercise than those with BMIs < 30 kg/m2.

Cognitions.

At baseline, we observed no significant differences in ED cognitions, including Global scores (p = .836), Eating Concern subscale scores (p = .855), and Weight/Shape subscale scores (p = .856) between groups. Contrary to hypotheses, individuals with BMIs ≥ 30 kg/m2 individuals did not demonstrate smaller reductions in cognitive symptoms to those with BMIs < 30 kg/m2. Indeed, both groups demonstrated large and significant reductions from pre- to post-treatment on Global Score, Eating Concern, and Weight/Shape Concern.

Discussion

This is the first study, to our knowledge, to compare the acceptability and effectiveness of CBT-T for non-underweight patients with EDs who have BMIs ≥ 30 kg/m2 versus BMIs < 30 kg/m2. Our exploratory multisite study across two samples in the USA and UK found no evidence that CBT-T was less acceptable or effective for patients in higher weight bodies. Contrary to our first hypothesis, those in the USA sample with BMIs ≥ 30 kg/m2 did not drop out of treatment more frequently than those with BMIs < 30 kg/m2, suggesting no group differences in treatment acceptability. Similarly, and contrary to our second hypothesis, we found no evidence that individuals with BMIs ≥ 30kg/m2 did less well in CBT-T than those with BMIs < 30 kg/m2 in both the USA and UK samples, suggesting no differences in treatment effectiveness across groups.

While individuals in the BMI ≥ 30 kg/m2 group in the UK sample reported smaller reductions in restricting and purging from pre- to post-treatment, secondary analyses demonstrated a floor effect in which smaller reductions in the higher-weight group were fully explained by their significantly lower pre-treatment symptom frequencies. Furthermore, in the USA sample, the magnitude of reductions in ED behaviors did not differ across BMI categories.. These findings may reflect baseline symptom severity differences between BMI groups rather than differences in treatment response. It is also possible that individuals with lower BMI in our non-underweight sample may have presented with greater ambivalence about recovery, which could theoretically limit treatment response. However, our findings did not support differential treatment effectiveness across BMI groups, suggesting that if such differences in ambivalence existed, they did not substantially impact treatment outcomes in CBT-T. Additionally, the similar magnitude of reductions in ED behaviors may further support that CBT-T addresses maintaining mechanisms independent of BMI group. Overall, our findings provide preliminary evidence that CBT-T may be just as appropriate for participants with BMIs ≥ 30 kg/m2 as it is for participants with BMIs < 30 kg/m2.

At baseline, individuals in the BMI ≥ 30kg/m2 group did not present to treatment with more severe baseline psychopathology than the BMI < 30kg/m2 group. In sample 1 (USA), individuals in the BMI ≥ 30kg/m2 group actually presented with lower levels of ED psychopathology at baseline. These findings show that individuals with higher weight did not inherently experience more severe ED psychopathology compared to individuals with lower weight and, observed group differences in the current study’s treatment outcomes cannot be explained by higher baseline ED severity in the higher weight group. Additionally, this suggests that ED severity cannot be inferred by BMI alone.

Our results align with prior naturalistic research showing that higher BMI does not necessarily predict higher dropout rates (Vroling et al., 2016) or poorer treatment response (Melisse et al., 2023) among individuals with binge-type EDs. For example, in a naturalistic sample of 376 patients receiving intensive outpatient CBT for BED, baseline BMI measured continuously was not associated with treatment dropout (Vroling et al., 2016), and in a separate sample of 294 patients receiving outpatient CBT for non-underweight eating disorders, BMI measured continuously did not predict treatment outcomes (Melisse et al., 2023). Consistent with these findings, a recent meta-analysis of CBT-T for non-underweight EDs demonstrated that individuals at higher weights, including those with BMIs above 30, achieve meaningful reductions in ED symptoms (Keegan et al., 2022). Our findings are notable in light of evidence that individuals in the general population with BMI ≥ 30 kg/m2 report greater weight discrimination than individuals with a BMI between 25 kg/m2 and 30 kg/m2 (Hatzenbuehler et al., 2009), and also in light of recent concerns about possible iatrogenic effects of CBT for individuals in higher-weight bodies (Milner & Mulheim, 2021).

To our knowledge, this is the first study to specifically examine differences in treatment outcomes with CBT among non-underweight individuals across BMI categories, resulting in limited prior empirical data for direct comparison. Importantly, earlier studies examined BMI continuously and did not stratify outcomes by BMI groups, which underscores how our study advances the existing literature. Overall, our findings reinforce and extend previous research by confirming that CBT-T is an effective treatment option for non-underweight patients with EDs regardless of BMI.

A potential explanation for the lack of differential acceptability and effectiveness between BMI categories observed in the current study is that CBT-T was specifically designed for individuals with non-underweight EDs (Waller et al., 2019), a group that has traditionally been neglected and even stigmatized in ED treatment (Harrop et al., 2023). Importantly, CBT-T focuses on addressing maintaining mechanisms such as dietary restraint, binge-purge cycles, body image disturbance, and maladaptive cognitions that may be experienced similarly across non-underweight weight spectrum. CBT-T also incorporates a distinctive approach to collaborative weighing that specifically highlights the patient’s uncertainty about relative weight change rather than absolute weight. Instead of treating weight as a fixed or meaningful number, CBT-T helps patients see how much weight fluctuates by including weighing at different times during the day and after different behavioral challenges (e.g., eating feared foods), highlighting the numerous confounding contributors to weight, while challenging the idea that weight and shape should hold so much importance. In doing so, it reinforces the idea that weight is inherently subjective and variable, making it an unreliable measure on which to base self-worth or progress. Importantly, the CBT-T clinician takes a neutral stance towards the patients’ absolute weight and merely helps the patient evaluate whether the magnitude of cumulative changes across treatment are ultimately as large as they had predicted. This allows for targeting a primary ‘broken cognition’ that dietary restriction is needed to prevent rapid and uncontrollable weight gain.

Another unique and key strategy to CBT-T is body image surveys, during which patients make predictions about how other people evaluate them. Through body image surveys, patients and clinicians work together to challenge negative stereotypes associated with overweight and obesity that tackle maladaptive core beliefs (e.g., being not good enough, unlovable, undesirable, unhealthy), rather than focusing on absolute body size. The CBT-T manual outlines how to conduct these exposures with an emphasis on challenging weight stigma versus invalidating lived experiences of weight stigma (Waller et al., 2019). Clinicians are encouraged to support patients in creating surveys using open-ended questions such as “What is the first thing you notice about this person?” rather than confirmatory questions such as “Is this person overweight?” that shift focus away from a patient’s body size and can instead counteract common negative stereotypes associated with overweight and obesity (e.g., laziness, poor health). Lastly, CBT-T focuses specifically decreasing ED behaviors and cognitions as measured by the ED-15, rather than evaluating weight change as an outcome.

There has recently been a renaissance of increased awareness of the harmful impact of weight stigma in the development, maintenance, and treatment of EDs, as evidenced by the publication of recent critiques in the field (Levinson et al., 2024). It is also now well accepted that EDs occur in all body sizes, and therefore weight biases must be addressed to ensure equitable assessment and access to high-quality care (Schaumberg et al., 2017). Notably, it has been more than thirty years since the original manual for BN was published (Fairburn & Wilson, 1993) and nearly twenty years since the CBT-E manual was published (Fairburn, 2008). More recent CBT manuals, including CBT-T, have moved away from stigmatizing concepts such as helping patients achieve a “normal” weight range, implying that individuals at higher weights have a “distorted” body image, or normalizing post-treatment weight loss. This shift reflects the field’s evolving understanding of weight stigma and body diversity. In recent years, there has been careful attention to avoiding the pathologization of weight gain, shifting the focus of treatment on symptom reduction as opposed changes in weight, and including body image interventions that can be adapted across the weight spectrum (McEntee et al., 2023). Furthermore, CBT for EDs has recently taken a more weight-inclusive approach that that specifically targets weight stigma and internalized weight bias in higher-weight EDs (Mulheim et al., in press).

Our limited understanding of patients’ lived experiences with CBT makes it challenging to address potential experienced or perceived weight stigma. Qualitative studies could provide valuable insights not captured in the current study. Indeed, recent qualitative interviews of individuals in higher-weight bodies who have participated in higher levels of care for EDs has uncovered problems, such as providers not taking patient’s ED symptoms seriously, setting inappropriate weight goals for treatment, and demonstrating disordered eating behaviors in front of the patient (Harrop et al., 2025) Interestingly, qualitative studies that have examined patient (Hoskins et al., 2019) and clinician (Hewitt et al., 2025) experiences of CBT-T did not mention weight or weighing procedures as potential barriers to successful treatment. However, future qualitative studies could point toward areas where CBT-T could continue to be improved to be most beneficial to individuals with higher-weight EDs.

Our findings should be interpreted in light of study limitations, including the small sample size in Sample 1 (USA, n = 63), which included a relatively small proportion of participants with BMIs ≥ 30 kg/m2 (n = 24, 35%) compared to those with BMIs < 30 kg/m2. These results are strengthened by replication in the UK sample, where the BMI >30 kg/m2 group included 39 of 58 participants (67%), a larger proportion than in the USA sample. In the future, larger and more diverse sample sizes could facilitate the detection of even small effect sizes should they be present. We recognize our acceptability for this study is narrowly defined and does not include participants’ subjective appraisal. Qualitative data collections could uncover lived experiences (e.g., weight stigma during treatment) that are not represented on the ED-15. Replications in different countries are needed as cultural norms around weight, body image, and treatment expectations may influence treatment outcomes.

In conclusion, this study provides preliminary evidence that CBT-T may be appropriate for the full weight spectrum of non-underweight EDs, particularly for individuals with a BMI ≥ 30 kg/m2. Findings also highlight the importance of disseminating empirically-supported interventions to individuals across all non-underweight BMI categories, so that individuals in traditionally stigmatized groups are given full access to best care practices. Additionally, the findings point to the need for future qualitative work to explore the lived experience of CBT-T among individuals in higher-weight bodies, including perceived weight stigma. Such research could help the treatment continue to evolve and meet the needs of the increasingly diverse group of individuals seeking ED treatment.

Highlights:

  • As body mass index (BMI) increases across the population, the eating disorders field is seeing a rise in concerns regarding the appropriateness of CBT for individuals in higher weight bodies. We evaluated the acceptability (Sample 1—United States) and effectiveness (Sample 2—United States, United Kingdom) of CBT-T by BMI category in an exploratory multisite study.

  • In Sample 1, acceptability, as measured by dropout rate, did not differ significantly by BMI category (BMI ≥ 30 kg/m2 vs. BMI < 30 kg/m2).

  • In both Samples 1 and 2, individuals in both BMI (BMI ≥ 30 kg/m2 and BMI < 30 kg/m2) categories showed large and significant reductions in eating-disorder behaviors and cognitions from pre- to post- CBT-T.

  • Our exploratory multisite study found no evidence that CBT-T was less acceptable or effective for patients in higher weight bodies.

Funding:

Funding from K24MH135189 (Thomas); K23MH125143 (Becker); K23MH139989 (Kambanis), K23MH127465 (Breithaupt). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Conflicts of Interest:

Drs. Thomas, Becker, and Eddy receive royalties from Cambridge University Press for their books on avoidant/restrictive food intake disorder. Drs. Thomas, Eddy, Turner, and Waller receive royalties from Routledge for their books on cognitive-behavioral therapy for eating disorders. Drs. Thomas, Eddy, and Kambanis receive consulting fees from Equip Health.

Footnotes

Ethics Approval and Consent to Participate: The study was conducted according to the Declaration of Helsinki and study protocol was approved by the Mass General Brigham Institutional Review Board. Written informed consent or waiver of informed consent as approved by the IRB was obtained for all participants.

Consent for Publication: The authors consent for this manuscript to be published. There are no other parties involved in the decision to publish.

Availability of Data and Materials:

The data that support the findings of this study are available from the corresponding author upon request.

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Associated Data

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon request.

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