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Published in final edited form as: Int J Eat Disord. 2024 Feb 2;57(3):745–751. doi: 10.1002/eat.24153

The Children of Parents who Receive Treatment for Binge-Eating Disorder Experience Improvements in Disordered Eating

Janet A Lydecker 1, Elise V Ozbardakci 1, Carlos M Grilo 1
PMCID: PMC10947894  NIHMSID: NIHMS1961174  PMID: 38308384

Abstract

Objective:

Parental eating disorders are associated with disordered eating behaviors and psychopathology in their children, but it is not known whether parent treatment for binge-eating disorder is associated with changes in child disordered eating behaviors and weight. Benefits or the “ripple” effect of treatment on untreated family members has been described in the obesity literature but not for binge-eating disorder.

Method:

Participants evaluated for two randomized clinical trials for binge-eating disorder were screened for whether they had children. 76 parents completed baseline assessments about a school-aged child; 62 were randomized to treatment, of whom 41 completed end-of-treatment assessments about their child’s eating behaviors and weight (which were not targeted in the parent treatments).

Results:

Analyses revealed a significant effect of time on children’s binge-eating frequency and perceived weight category and a significant effect of parent medication on perceived weight category. Parental change in binge eating was associated significantly with changes in child secretive eating and food hoarding. Parental change in weight was not associated significantly with change in age/sex-normed child BMI percentile, but had some associations with parent-perceived child weight category.

Conclusions:

Parent changes during their treatment were associated with changes in their children. Future longitudinal research is needed to examine when disordered eating emerges and clarify critical intervention timing related to children’s age and parental binge-eating disorder. Further clinical research is also needed to assess the effectiveness of treating disordered eating at the family level.

Keywords: parents, binge-eating disorder, eating disorders, treatment

INTRODUCTION

Binge-eating disorder (BED) is influenced by environmental and genetic factors (Javaras et al., 2008; Mitchell et al., 2010; Reichborn-Kjennerud et al., 2004). Minimal research, however, has focused on how parental BED influences offspring (Tanofsky-Kraff et al., 2020). Parents with BED are more likely to have children who binge eat than parents without BED (Goldschmidt et al., 2014; Lydecker & Grilo, 2017; Zocca et al., 2011). Parents with BED engage in more restriction of their child’s diet than parents who do not have eating disorders and feel greater responsibility and concern about their children’s weight than parents with obesity (no BED), even though weight does not differ between offspring groups (Agras et al., 1999; Lydecker & Grilo, 2017). Parents seek to prevent passing eating psychopathology on to their offspring (Agras et al., 1999; Bryant-Waugh et al., 2007; Mazzeo et al., 2005). As an alternative to a parenting intervention, a fruitful avenue for investigation is the “ripple” effect of parental treatment on untreated children (Albright et al., 2020; Gorin et al., 2018; Gorin et al., 2008; Pratt et al., 2023). Conceptually, improvements in parental psychopathology and behaviors could involve “whole-of-family” behavior change, modeling healthy lifestyle behaviors, and improved parent-child interactions (Boutelle et al., 2017; Golan, 2006; Mazzeo et al., 2014).

In this study, we addressed two knowledge gaps. First, we characterized disordered eating of children of treatment-seeking parents with BED. Second, we explored whether children experienced a ripple effect when their parents participated in BED treatment studies. We hypothesized that children whose parents received weight-focused interventions (medication, behavioral weight loss [BWL]) would lose weight, and children whose parents received eating-focused interventions (BWL) would have less disordered eating at the end of the parent’s treatment program.

METHODS

Participants

Parents were enrolled in two randomized clinical trials (RCTs) evaluating BED treatments (12–16 weeks; testing naltrexone/bupropion and/or BWL). Parents provided informed consent as part of the larger studies (Grilo et al., 2022; Grilo et al., 2023). The current study, a secondary analysis, characterizes 76 parents with school-aged children (5–18 years old; N=76) and a subset of those parents randomized to the RCTs—i.e., 41 of 62 parents randomized to treatments who completed assessments about the same child at both timepoints (Supplemental Figure 1). We selected school-aged children because they live at home.

Assessments

RCT participants were screened to identify parents. Parents completed assessments about their own and their child’s disordered eating and weight at baseline and end-of-treatment. Parents with multiple children were asked to choose one child about whom they would answer questions. Parents who answered surveys about different children at baseline and end-of-treatment were only included in baseline analyses.

The Eating Disorder Examination-Questionnaire, which has good test-retest reliability (Berg et al., 2012), assessed binge-eating frequency (objectively-large binge-eating episodes) during the past 28 days. The Eating Disorder Examination-Questionnaire, Parent Version (Kamody & Lydecker, 2021), obtained parent-reported frequencies of child binge-eating episodes, loss-of-control-eating episodes, and secretive-eating episodes during the past 28 days. We added food-hoarding episodes given relevance to child binge eating (Fiechtner et al., 2018).

Parents reported weight and height for themselves and their child. We calculated BMI percentiles for children (age/sex-normed)(Ogden et al., 2002). Parents also reported their perception of their child’s weight category (underweight, normal weight, overweight, very overweight). Prior work has shown a moderate correlation between parent-perceived child weight category and BMI percentile (Anderson et al., 2005).

Statistical Analysis

Baseline data are described for all parents and school-aged children (N=76). ANOVAs, performed with 41 parents who participated in treatments and provided end-of-treatment data for themselves and their child, evaluated whether child outcomes (binge eating, loss-of-control eating, secretive eating, food hoarding, BMI percentile, perceived weight category) changed when parents received treatments. Time was within-subject factor; treatments (BWL versus no; naltrexone/bupropion versus placebo) were between-subjects factors. ANCOVAs for child outcomes (binge eating, loss-of-control eating, secretive eating, food hoarding, perceived weight category, BMI percentile) included time as a within-subject factor, and parent-weight change and parent-binge change as covariates. Because there were four disordered-eating outcomes, we included a sensitivity analysis using Bonferroni-corrected α=0.0125 to determine whether results remained significant.

RESULTS

Participant Characteristics

Table 1 summarizes parent and child demographic characteristics and child clinical characteristics. Parents had a mean age of 42.9y (SD=7.2). Parents were 73% (N=56) mothers, 71% (N=54) white, 87% (N=66) non-Hispanic, 67% (N=51) married, 12% (N=9) single parents, and 88% (N=67) attended/finished college. Children had a mean age of 11.9y (SD=4.1); 54% (N=41) were daughters.

Table 1.

Baseline Characteristics of Parents, Families, and Children

Parents of School-Aged Children Parents who Completed Pre and Post Assessments
N=76 N=41
Parent Characteristics
Age, M (SD) 42.89 (7.18) 44.24 (6.98)
Gender, n (%)
 Men 18 (23.7%) 6 (14.6%)
 Women 56 (73.7%) 34 (82.9%)
 Another gender 2 (2.7%) 1 (2.4%)
Race, n (%)
 Asian 2 (2.6%) 1 (2.4%)
 Black 14 (18.4%) 9 (22.0%)
 White 54 (71.1%) 28 (68.3%)
 Multiracial 4 (5.3%) 1 (2.4%)
 Another race 2 (2.6%) 2 (4.9%)
Ethnicity, n (%)
 Not Hispanic/Latinx 66 (86.8%) 36 (87.8%)
 Hispanic/Latinx 10 (13.2%) 5 (12.2%)
Education, n (%)
 High school or less 9 (11.8%) 3 (7.3%)
 Some college 24 (31.6%) 12 (29.3%)
 College 14 (18.4%) 10 (24.4%)
 Post college 29 (38.2%) 16 (39.0%)
Sexual Orientation, n (%)
 Heterosexual 71 (93.4%) 37 (90.2%)
 Homosexual 1 (1.3%) 1 (2.4%)
 Bisexual 2 (2.6%) 2 (4.9%)
 Another sexuality 2 (2.6%) 1 (2.4%)
Family Characteristics
Parents Married, n (%) 51 (67.1%) 28 (68.3%)
Single Parents, n (%) 9 (11.8%) 6 (14.6%)
Number of Children, M (SD) 2.16 (1.01) 1.88 (0.75)
Child Characteristics
Age, M (SD) 11.70 (4.39) 12.56 (4.04)
Gender, n (%)
 Boy 35 (46.1%) 19 (46.3%)
 Girl 41 (53.9%) 22 (53.7%)
 Another gender 0 (0.0%) 0 (0.0%)
Child Clinical Variables
Disordered Eating Episodes
 Binge eating, M (SD) 4.16 (7.87) 1.90 (4.58)
 Loss-of-control eating, M (SD) 6.83 (13.39) 3.02 (7.93)
 Secretive eating, M (SD) 3.80 (9.32) 2.49 (5.87)
 Food hoarding, M (SD) 1.79 (5.46) 1.49 (4.82)
BMI percentile, M (SD) 73.11 (28.40) 70.81 (28.57)
BMI-z, M (SD) 0.94 (1.19) 0.77 (1.07)
Perceived weight category, M (SD) 3.45 (0.79) 3.20 (0.84)
 Very underweight, n (%) 0 (0.0%) 0 (0.0%)
 Somewhat underweight, n (%) 6 (7.9%) 6 (14.6%)
 Normal weight, n (%) 38 (50.0%) 17 (41.5%)
 Somewhat overweight, n (%) 24 (31.6%) 13 (31.7%)
 Very overweight, n (%) 8 (10.5%) 5 (12.2%)
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BMI percentile = age/sex-normed body mass index percentile; BMI-z = age/sex-normed body mass index z score.

Baseline Clinical Characteristics of Children

In the previous 28 days, children had 4.16 (SD=7.87) binge-eating episodes, 6.82 (SD=13.39) loss-of-control-eating episodes, 3.80 (SD=9.32) secretive-eating episodes, and 1.78 (SD=5.46) food-hoarding episodes. 29% (N=22) of children had at least weekly binge-eating episodes and 37% (N=28) of children had at least biweekly loss-of-control-eating episodes (American Psychiatric Association, 2013; Tanofsky-Kraff et al., 2008). 22% (N=17) of children were eating secretively at least weekly, and 11% (N=8) of children were hoarding food at least weekly.

At baseline, children had an average age/sex-normed BMI percentile of 73% (SD=28.4). 50% of parents (n=38) perceived their child’s weight category to be normal, 8% (n=6) somewhat underweight, 32% (n=24) somewhat overweight, and 11% (n=8) very overweight.

Effects of Parental BED Treatment

Table 2 shows ANOVA and ANCOVA results for child outcomes. Child binge eating (F(1,39)=6.92, p=0.012, ηp2=0.151) and perceived child weight category (F(1,39)=13.45, p<0.001, ηp2=0.256) differed significantly with time. There were no significant effects of BWL-by-time, medication-by-time, or BWL-by-medication-by-time on children’s outcomes, with one exception. Perceived child weight category differed significantly by medication-by-time (F(1,39)=4.91, p=0.03, ηp2=0.112). Parents who received placebo perceived greater decrease in their child’s weight category at end-of-treatment compared to parents who received naltrexone/bupropion. With the more conservative Bonferroni-corrected alpha for disordered-eating analyses, results remained significant.

Table 2.

Child Change with Parent Treatment

Child Outcome ANOVAs and ANCOVAs
Time Med*Time BWL*Time Med*BWL*Time
Disordered Eating Episodes
 Binge eating F(1,39)=6.92, p=0.012, η p2 =0.151 F(1,39)=0.00, p=0.98, ηp2<0.001 F(1,24)=0.86, p=0.36, ηp2=0.035 F(1,22)=0.16, p=0.69, ηp2=0.007
 Loss-of-control eating F(1,39)=2.86, p=0.10, ηp2=0.068 F(1,39)=0.48, p=0.49, ηp2=0.012 F(1,24)=0.14, p=0.71, ηp2=0.006 F(1,22)=0.57, p=0.46, ηp2=0.025
 Secretive eating F(1,39)=0.02, p=0.89, ηp2=0.001 F(1,39)=0.13, p=0.72, ηp2=0.003 F(1,24)=0.30, p=0.59, ηp2=0.012 F(1,22)=0.08, p=0.78, ηp2=0.004
 Food hoarding F(1,39)=0.02, p=0.88, ηp2=0.001 F(1,39)=1.11, p=0.30, ηp2=0.028 F(1,24)=0.08, p=0.38, ηp2=0.032 F(1,22)=0.00, p=0.99, ηp2<0.001
BMI percentile F(1,33)=0.02, p=0.90, ηp2<0.001 F(1,33)=0.60, p=0.45, ηp2=.018 F(1,20)=0.47, p=0.50, ηp2=0.023 F(1,18)=1.17, p=0.29, ηp2=0.061
Perceived weight category F(1,39)=13.45, p<0.001, η p2 =0.256 F(1,39)=4.91, p=0.03, η p2 =0.112 F(1,24)=0.49, p=0.49, ηp2=0.020 F(1,22)=0.00, p=0.97, ηp2<.001
Time*Parent Binge Change Time*Parent Weight Change
Disordered Eating Episodes
 Binge eating F(1,39)=0.62, p=0.44, ηp2=0.016 F(1,39)=0.45, p=0.51, ηp2=0.011
 Loss-of-control eating F(1,39)=0.10, p=0.75, ηp2=0.003 F(1,39)=0.14, p=0.71, ηp2=0.004
 Secretive eating F(1,39)=8.22, p=0.007, ηp2=0.174 F(1,39)=0.17, p=0.68, ηp2=0.004
 Food hoarding F(1,39)=6.09, p=0.018, ηp2=0.135 F(1,39)=0.65, p=0.42, ηp2=0.017
BMI percentile F(1,33)=0.57, p=0.46, ηp2=0.017 F(1,33)=0.04, p=0.85, ηp2=0.001
Perceived weight category F(1,39)=0.09, p=0.77, ηp2=0.002 F(1,39)=5.89, p=0.02, ηp2=0.131
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Note. Bolded results indicate significant findings. ηp2 = partial eta squared; considered small at .01, medium at .06, and large at .14 (Cohen, 1988). Med=medication (naltrexone/bupropion or placebo); BWL=behavioral weight loss therapy; BMI=body mass index. Time (within-subjects variable) by med (between-subjects variable) indicates the effect of the medication intervention on each dependent variable; BWL by time indicates the effect of the behavioral weight loss intervention. Med by BWL by time indicates the effect of the combination of treatments; time by parent binge change (covariate) indicates the effect of parental change in binge eating episodes over the course of the treatment on each child dependent variable; time by parent weight change (covariate) indicates the effect of parental change in weight over the course of their treatment on each child dependent variable. Bonferroni corrections to the disordered eating analyses adjusted the significant alpha level to .0125. With this more conservative criterion, time by parent change in binge eating was no longer a significant predictor of child food hoarding, but other analyses remained significant.

When change in parents’ binge eating from baseline to end-of-treatment was included as a covariate, children’s secretive eating (F(1,39)=8.22, p=0.007, ηp2=0.174) and food hoarding (F(1,39)=6.09, p=0.018, ηp2=0.135) both decreased (i.e., fewer disordered-eating episodes at end-of-treatment than baseline). Simple effects are depicted in Supplemental Figure 2. When parents experienced greater change in binge eating (greater reduction in frequency from baseline), children experienced greater reduction in secretive-eating and food-hoarding episodes; when parents experienced less change in binge eating (less reduction or increase in frequency from baseline), children had more secretive-eating and food-hoarding episodes. With the more conservative Bonferroni-corrected alpha for disordered-eating analyses, secretive eating remained significant, but food hoarding was no longer significant.

When change in parent weight from baseline to end-of-treatment was included as a covariate, perceived child weight category (F(1,39)=5.89, p=0.02, ηp2=0.131) decreased. Simple effects are depicted in Supplemental Figure 3. Surprisingly, when parent weight changed the most (greater decrease in weight from baseline), perceived child weight category changed the least; parents whose weight changed less (smaller decrease from baseline or weight gain) perceived greater decreases in child weight category.

DISCUSSION

This study was an initial exploration of a “ripple” effect in child eating behaviors and weight when parents receive BED treatment for themselves. As this was an initial exploration of a potential, novel treatment-related phenomenon, future research will be critical to improve our understanding about how to potentially mitigate disordered eating in youth (see Supplemental Table 1). Overall, there was a limited effect of parental treatment. However, change in parent binge eating was related to changes in some child disordered-eating behaviors, suggesting a possible “ripple” effect of parents’ treatment on their children’s eating behaviors.

Prior work suggests that children of parents with BED are more likely to engage in binge eating than children of parents who do not have BED. The current study found that some children of treatment-seeking parents are engaging in disordered eating, although our findings were exploratory and future work should identify factors influencing which children of parents with BED develop disordered eating themselves. Prevention efforts targeting children who have parents who binge eat need to be explored. Targeting families where parents self-identify as needing binge-eating treatment could yield a potential source of participants who would engage in and might benefit from prevention efforts.

Although the children of parents with BED had a broad age range (6m to 50y), this study focused on school-aged children because they live at home. Further research needs to examine other aspects of children’s experiences, including whether they are participating in treatment themselves. Future longitudinal research examining when disordered eating emerges among children of parents with BED and examining age as a potential moderator of the effects of parent treatment might clarify critical prevention/intervention windows.

The association of change in parental binge eating with child secretive eating has implications for early interventions. Secretive eating is associated with but distinct from binge eating (Fiechtner et al., 2018; Tanofsky-Kraff et al., 2020). Conceptually, it is possible that change in parental binge eating could reduce children’s risk of developing binge eating, as secretive eating appears to be a precursor to binge eating (Fairburn et al., 2005; Kass et al., 2017; Marcus & Kalarchian, 2003; Tanofsky-Kraff et al., 2020). Alternatively, it is possible that change in parent binge eating improved family-wide eating behavior and improvement in children’s non-disordered eating decreased secretive eating. Longitudinal research is needed to clarify relationships between parent and child disordered eating.

In our study, perceived child weight category, but not child BMI percentile, decreased with time, as did parent weight. However, when parents experienced less decrease in their own weight, they perceived more decrease in their child’s weight category. It is possible that this reflects a change in parental awareness of child weight category rather than a true change in child body size. Conceptually, parent awareness of child body size could change because of treatment participation. However, parent perception likely reflects more than an assessment of their child’s body size. Prior work has shown a significant, moderate correlation between perceived weight category and measured BMI percentile (Anderson et al., 2005), but also a link between parent-perceived child weight category and child eating behaviors (Robinson & Sutin, 2017), suggesting perceived weight category reflects more than body size. Future research needs to examine how treatment might influence perceived weight category and how treatment influences both perception and measured child body size.

This study was a first exploration of a ripple effect of parental treatment for BED. As this was an initial effort, results of the current study should be interpreted with caution and within the context of the study’s limitations, including the use of self-report and parent-report data. We did not assess whether children were receiving any mental health treatment, pharmacotherapy, or had any medical conditions. Development of parent-report eating psychopathology measures is in an early stage. Psychometric studies have shown acceptable agreement between parent-reported, child-reported, and child-interview measures of binge-eating episodes, yet importantly, parents were better at knowing when children were not binge eating than when it was happening (Elliott et al., 2013; Johnson et al., 1999; Tanofsky-Kraff et al., 2005). It is possible that in the current study, associations between parent and child change reflect a change in parents’ perceptions, rather than true change. Additional research using multiple sources is essential to clarify the longitudinal relationship of parent and child binge eating and the extent to which changes in parental binge eating and weight ripple through children. Despite the overall limitation of relying on parent-reported data, there is also clinical utility. Parenting is interpersonal and parents make decisions about their parenting practices based on their perceptions. Additionally, parent-report measures are commonly used in clinical practice, in part because of their low cost. Despite these limitations, the current study had noteworthy strengths: inclusion of fathers (in addition to mothers) (Khandpur et al., 2014; Morgan et al., 2017), focus on a treatment-seeking sample of parents with BED, and exploration of child disordered eating.

Examining health requires looking at multiple levels of influence across multiple domains of influence, including family factors (National Institute on Minority Health and Health Disparities, 2017). Our findings describe a potential relationship between parents’ BED treatment and children’s disordered eating, which warrants further examination in larger and controlled studies, as prevention and early intervention efforts have the potential to improve the health and wellbeing of patients and their children.

Supplementary Material

1

Public Significance.

Prior cross-sectional work has found that parents with binge-eating disorder are more likely to have children who engage in binge eating compared to parents without eating-disorder psychopathology. This study was an initial exploration of change in children when parents received treatment in randomized controlled trials for binge-eating disorder. In this study, parent changes in binge eating were associated with reduced child secretive eating and food hoarding.

Funding:

This research was supported, in part, by National Institutes of Health grant K23 DK115893 (Lydecker), R01 DK112771 (Grilo), R01 DK049587 (Grilo), and UL1 TR001863. Funders played no role in the content of this paper.

Footnotes

Disclosure: The authors declare no conflict of interest relevant to this article. Dr. Grilo reports broader interests, which did not influence this research, including Honoraria for lectures, and Royalties from Guilford Press and Taylor & Francis Publishers for academic books.

Clinical Trials: Randomization procedures and treatments for BED have been described in the manuscripts for the main trials and information is also available on Clinicaltrials.gov (NCT03045341, NCT03539900).

Data availability statement:

Data from the larger trials, including study protocols, statistical analysis plans, and informed consent forms are available on Clinicaltrials.gov. Deidentified participant data (including data dictionaries) will be made available to 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.

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Associated Data

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

Supplementary Materials

1
NIHMS1961174-supplement-1.pdf (560.7KB, pdf)

Data Availability Statement

Data from the larger trials, including study protocols, statistical analysis plans, and informed consent forms are available on Clinicaltrials.gov. Deidentified participant data (including data dictionaries) will be made available to 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.

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