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Binge eating, weight gain and psychosocial adjustment in patients with bipolar disorder
Psychiatry Research 169 (2009) 88–90
Contents lists available at ScienceDirect
Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s
Brief report
Binge eating, weight gain and psychosocial adjustment in patients with bipolar disorder Silvia Castrogiovanni a, Isabella Soreca b,c,⁎, Daniela Troiani a, Mauro Mauri a a b c
Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies, School of Medicine, University of Pisa, Pisa, Italy Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Department of Neuroscience, School of Applied Neurological Sciences, University of Siena, Italy
A R T I C L E
I N F O
Article history: Received 13 February 2007 Received in revised form 25 September 2007 Accepted 12 June 2008 Keywords: Mood disorders Eating disorders BMI Self-esteem
A B S T R A C T Binge Eating (BE) is a common eating pattern in patients with Bipolar Disorder (BD). BE may confer an increased risk for obesity, morbidity, mortality and poorer quality of life. We assessed the presence of BE and its impact on body weight, body image and self-esteem in 50 patients with BD and 50 age- and gendermatched controls. The presence and severity of BE was assessed with the Binge Eating Scale (BES). The Body Image and Self-Esteem Evaluation Scale (B-WISE) was used to assess the psychosocial impact of weight gain. Body Mass Index (BMI) was calculated. Nine (18%) patients had a score N 27, indicating a likely diagnosis of BE. None of the control subjects had a BES score N 17. No association between BES score and the medications was found. Patients had a significantly higher BES score, significantly higher BMI, waist circumference and fasting blood glucose. Although the B-Wise score was higher in the controls, the difference was not statistically significant. This study suggests that BE is prevalent in patients with BD. The presence of BE eating is a predictor of higher BMI, indicating that the disruption of eating behavior may be a pathway to weight gain. © 2008 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Binge Eating Disorder (BED) is a common eating pattern in obese subjects (Yanovski, 2003; Bulik et al., 2002) and is frequently reported by patients with Bipolar Disorder (BD) (Ramacciotti et al., 2005; Kruger et al., 1996). McElroy et al. (2002) reported that 13.5% of obese patients with BD and 50% of extremely obese patients with BD had a current or lifetime history of BED, compared with 4.9% of normal weight bipolar subjects, suggesting that the engagement in abnormal eating behavior may be a pathway to obesity for patients with BD. On the other hand, treatment-seeking obese binge eaters reported a high prevalence of mood disorder (Yanovski et al., 1993; Bulik et al., 2002) and binge eating is associated with increased medical comorbidity independently from Body Mass Index (BMI) (Bulik and ReichbomKjennerud, 2003). Obesity seems to be a proxy for medical burden in patients with mood disorders. The pathways between obesity and mood disorders may include dysregulation of neural systems, medications and lifestyle (McElroy et al., 2005). Bipolar Disorder may be a risk factor for obesity (Simon et al., 2006): physical inactivity and altered eating pattern during the depressive phase of BD confer an increased risk for overweight and
⁎ Corresponding author. Western Psychiatric Institute and Clinic, room BT 807A, 3811 O'Hara Street, Pittsburgh, PA 15213, USA. Tel.: +1 412 2466945; fax: +1 412 2465520. E-mail address: [email protected] (I. Soreca). 0165-1781/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2008.06.016
obesity (Katon, 2003), and long term treatment with psychotropic medication is also associated with weight gain (Keck and McElroy, 2003; Allison and Casey, 2001; Ganguli, 1999). In this report we assessed the presence of BED and its impact on body weight, body image and self-esteem in patients with BD. 2. Methods 2.1. Subjects and procedures Fifty patients with Bipolar I and II Disorder, aged 18–65, and 50 ageand gender-matched controls were consecutively recruited from the psychiatric outpatient facility of the University Hospital of Pisa from September 2005 to July 2007. Exclusion criteria were the presence of current substance abuse, current psychotic symptoms, high suicidal risk, and presence of an episode requiring hospitalization. The diagnosis of BD and the presence of clinical conditions that would result in subjects being excluded from the study were determined according to the DSMIVTR criteria with an interview by the treating psychiatrist. Controls were screened with a medical, psychiatric and medication history by a physician; being currently treated for any medical or psychiatric condition was considered a criterion for exclusion. All participants gave written informed consent, and the study was approved by the local Ethics Committee. For each subject, body weight (kg), height (m) and waist circumference (cm) were measured and BMI (kg/m2) was calculated.
S. Castrogiovanni et al. / Psychiatry Research 169 (2009) 88–90 Table 1 Subjects' characteristics.
89
Table 3 Means BES and B-WISE score and the distribution of the BES scores in the two groups.
Variable (mean, S.D.)
Patients
Controls
P
Variable
Patients
Controls
P
Males (n) Females (n) Age Body weight (kg) BMI (kg/m2) Waist circumference (cm) Fasting serum glucose (mg/dl) Serum triglycerides (mg/dl) Total cholesterol (mg/dl) Smoking (n)
15 35 38.48 (12.48) 72.27 (18.14) 25.64 (6.69) 90.75 (15.7) 109.76 (14.62) 121.28 (46.86) 182.26 (32.64) 21
15 35 36.61 (12.64) 65.75 (12.96) 22.04 (3.18) 79.52 (11.56) 82.81 (13.53) 104.16 (26.97) 182.42 (67.63) 12
– – 0.510 0.042 0.014 0.000 0.000 0.154 0.989 –
B-WISE total score (mean, S.D.) BES total score (mean, S.D.) BES N 27 (n) BES N 17 b27 (n) BES b 17 (n, %)
16.32 (19.93) 14.83 (10.57) 9 (18%) 11 (22%) 30 (60%)
18.73 (3.18) 3.28 (3.8) – – 50 (100%)
0.419 0.000
Blood chemistry results were available for 42 bipolar patients and 22 controls. The presence and severity of BE were assessed with the Binge Eating Scale (BES) (Gormally et al., 1982). The BES is a 16-item selfadministered questionnaire that measures the presence and severity of bulimic behaviors in obese subjects. Psychometric studies have shown that a score of 27 or higher on the BES has a good correlation with the diagnosis of binge eating assessed with the clinicianadministered Eating Disorder Examination (EDE) (Celio et al., 2004), while a score of 17 or lower is the cut-off value for the presence of mild or no binge eating. The Body Image and Self-Esteem Evaluation Scale (B-WISE) (Awad and Voruganti, 2004) was used to assess the psychosocial impact of weight gain. The B-WISE is a 12-item self-administered instrument that evaluates psychological consequences of weight gain in patients with severe mental illness. The validation study of the scale has shown a high internal consistency, good split-half reliability, and good discriminant validity (Awad and Voruganti, 2004). Higher scores in the B-WISE are indicative of better adjustment. 2.2. Statistical analyses Continuous variables were summarized with mean and standard deviations (S.D.), and frequencies in % were used to summarize dichotomous variables. Linear logistic regression was used to explore the relationship between the variables. BMI was used as the dependent variable and BES score, age and gender were entered as predictors. Then patients were divided into three groups according to the BES score: BES N 27 or high probability of binge eating, BES N 17 b27 or intermediate probability of having binge eating, BES b 17 or low probability of binge eating. We compared the B-Wise scores among the three groups by oneway analysis of variance (ANOVA). All the analyses were conducted with the SPSS statistical package, version 14.0 (SPSS, Chicago, IL). 3. Results A total of 50 patients and 50 age- and gender-matched controls (15 males and 35 females in each group) were evaluated. The mean age was 38.48 (±12.48) for bipolar patients and 36.61 (±12.64) for the control subjects; in the group of patients, 29 subjects had a diagnosis of Bipolar I Disorder, and 21 had a diagnosis of Bipolar II Disorder. The mean body weight of the patients was 72.27 kg (±18.14), and the mean body weight for the controls was 65.75 (±12.96); the mean BMI was 25.64 kg/m2 (±6.69) for patients and 22.04 (±3.18) for controls, and
waist circumference was 90.75 cm (±15.7) for patients and 79.52 cm (±11.56) for controls. Twenty-one patients and 12 controls were currently smokers (Table 1). Results of the blood chemistry were available for 42 patients and for 22 controls and are shown in Table 1. All the patients with BD and none of the controls (by design) were being treated with psychotropic medication (see Table 2): 22 (44%) were on anticonvulsants (mainly valproate) or lithium, 41 (83%) were on antidepressants, and 10 (20%) were on atypical antipsychotics (Table 2). Thirty patients (60%) had a BES score b17, 11 (22%) patients scored between 17 and 27, and nine (18%) patients had a score N27.None of the control subjects had a BES score N17 (Table 3). No association between BES score category and the medications was found (Table 4). Overall, patients had a significantly higher BES score, significantly higher BMI, waist circumference and fasting blood glucose (Table 1). Although the B-Wise score was higher in the controls, the difference was not statistically significant (Table 3). No significant difference was found in age (by design), serum triglycerides and total cholesterol between patients and controls (Table 1). In the regression model, the BMI was entered as dependent variable and age, gender, group (patients/controls) and BES score as independent predictors. The BES score showed a significant correlation with the BMI (Beta = 0.304, P = 0.002). We then compared the B-WISE total scores among subjects who had a BES score N27 (high probability of binge eating), BES score N 17 b27 (moderate probability of binge eating) and BES score b 17 (low probability of binge eating). The B-WISE score was lower in the BES N 27 group than in the other two groups, but this result did not reach statistical significance (F = 3.08; P = 0.051). 4. Discussion Consistent with results from other reports, this study suggests that binge eating is highly prevalent in patients with BD. Our sample, albeit small, represents a picture of the actual clinical population that is seen in an outpatient facility for mood disorders. Nineteen percent of these subjects had a BES score higher than 27, which has been shown to be highly correlated with a diagnosis of BED (Celio et al., 2004). Prevalence of binge eating in non-clinical populations ranges from 1% to 2% (Smith et al., 1998; Dingemans et al., 2002), while it rises to 8–17% among patients with BD (Ramacciotti et al., 2005; MacQueen et al., 2003). It is also noteworthy that 22% of our sample fell in the subthreshold score range, indicating the presence of some degree of eating pathology, although not meeting full criteria for the diagnosis.
Table 4 Association between BES score and medications. Medications (yes/no)
Table 2 Medications used in the BD patients sample. Medication
N
%
Anticonvulsants and lithium Antidepressants Atypical antipsychotics
22 41 10
44 82 20
Anticonvulsants and lithium Antidepressants Atypical antipsychotics
BES score b 17
BES score N 17 b27
BES score N 27
Pearson Chi-square
Yes
No
Yes
No
Yes
12
18
4
4
6
6
0.70
25 5
5 25
6 3
3 6
10 2
1 9
0.35 0.54
No
90
S. Castrogiovanni et al. / Psychiatry Research 169 (2009) 88–90
The prevalence of binge eating did not differ significantly between males and females. The likely diagnosis of binge eating according to the BES total score was observed in the patients with BD and was not present in any of the gender and age- and gender-matched control subjects. Some of the medications that are used to treat BD may cause increased appetite, thus triggering overeating and binge eating. The emergence of binge eating with the use of certain psychotropic medications, especially olanzapine and clozapine (Theisen et al., 2003), has been reported. We did not observe any association between the presence of binge eating and the use of psychotropic medications (anticonvulsants or lithium, antidepressants, atypical antipsychotics). Nevertheless, our data do not allow us to draw conclusions as to whether the differences between patients and controls are solely driven by the presence of BD or by the use of medications by the patients. A sample of non-medicated, or nevermedicated subjects with BD would be needed to address this question. Not surprisingly, the presence of binge eating is a predictor of higher BMI in our sample, suggesting that the disruption of eating behavior during the course of a mood disorder is an important pathway to weight gain, especially in women. Weight gain, on the other hand, is associated with worse outcome (Fagiolini et al., 2003) and with poorer treatment adherence (Kurzthaler and Fleischhacker, 2001; Masand, 1999). In our sample, psychosocial adjustment, measured by means of the B-WISE, was lower in the patients with a probable diagnosis of binge eating, but this result did not reach statistical significance. It is noteworthy that the subjects in our sample are on average only slightly overweight (mean BMI = 25.6). However, women, but not men, show a mean waist circumference of 90.5 cm, exceeding the threshold for abdominal obesity according to the ATP III criteria (Grundy et al., 2005). Another result worthy of discussion is the fact that mean fasting glucose levels in this sample were 109.7 mg/dl (Table 2), exceeding the new upper limit (100 mg/dl) recommended by the American Diabetes Association (http://www.diabetes.org) and suggesting the need for more systematic screening for metabolic syndrome components in patients with BD. While our study revealed significant results, we must acknowledge various limitations in the present report. The small sample size, the use of self-rating instruments for the measurement of binge eating, without a cross-control with a clinician-administered interview and the lack of controlling results for clinical status may limit our findings. The presence of atypical depression, for example, may have contributed to the altered eating pattern reported by our patients (Moller, 1992). Despite these limitations, we believe that this report contributed information that may be useful to clinicians treating patients with BD. First, the high prevalence of binge eating and subthreshold binge eating in patients with BD is something that clinicians should be aware of when assessing and treating patients with BD; the presence of a disordered eating pattern seems to be accompanied by a cluster of medical risk factors, such as overweight, abdominal obesity, and reduced glucose tolerance that are related to poorer psychiatric outcome (Fagiolini et al., 2003, 2005) and increased mortality (Angst et al., 2002). References Allison, D.B., Casey, D.E., 2001. Antipsychotic induced weight gain: a review of the literature. Journal of Clinical Psychiatry 62 (suppl.7), 22–31.
American Diabetes Association, 2003: http://www.diabetes.org. Angst, F., Stassen, H.H., Clayton, P.J., Angst, J., 2002. Mortality of patients with mood disorders: follow-up over 34–38 years. Journal of Affective Disorders 68, 167–171. Awad, A.G., Voruganti, L.N., 2002. Body weight, image and self esteem evaluation questionnaire: development and validation of a new scale. Schizophrenia Research 70 (1), 63–67. Bulik, C.M., Reichbom-Kjennerud, T., 2003. Medical comorbidity in binge eating disorder. International Journal of Eating Disorders 34 (suppl 39), 39–46. Bulik, C.M., Sullivan, P.F., Kendler, K.S., 2002. Medical and psychiatric comorbidity in obese women with and without binge eating. International Journal of Eating Disorders 32, 72–78. Celio, A.A., Wilfley, D.E., Crow, S.J., Mitchell, J., Walsh, B.T., 2004. A comparison of the binge eating scale, questionnaire for eating patterns-revised, and eating disorder examination questionnaire with instructions with the eating disorder examination in the assessment of binge eating disorder and its symptoms. International Journal of Eating Disorders 36 (4), 434–444. Dingemans, A.E., Bruna, M.J., van Furth, E.F., 2002. Binge eating disorder: a review. International Journal of Obesity and Related Metabolic Disorders 26 (3), 299–307. Fagiolini, A., Kupfer, D.J., Houck, P.R., Novick, D.M., Frank, E., 2003. Obesity as a correlate of outcome in patients with bipolar I disorder. American Journal of Psychiatry 160 (1), 112–117. Fagiolini, A., Frank, E., Scott, J.A., Turkin, S., Kupfer, D.J., 2005. Metabolic syndrome in bipolar disorder: findings from the Bipolar Disorder Center for Pennsylvanians. Bipolar Disorders 7 (5), 424–430. Ganguli, R., 1999. Weight gain associated with antipsychotic drugs. Journal of Clinical Psychiatry 60 (suppl. 21), 20–24. Gormally, J., Blank, S., Daston, S., Radin, D., 1982. The assessment of binge eating severity among obese persons. Addictive Behaviors 7 (1), 47–55. Grundy, S.M., Cleeman, J.I., Daniels, S.R., Donato, K.A., Eckel, R.H., Franklin, B.A., Gordon, D.J., Krauss, R.M., Savage, P.J., Smith, S.C., Spertus, J.A., Costa, F., 2005. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute scientific statement. Circulation 112 (17), 2735–2752. Katon, W.J., 2003. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry 54, 216–226. Keck, P.E., McElroy, S.L., 2003. Bipolar disorder, obesity, and pharmacotherapyassociated weight gain. Journal of Clinical Psychiatry 64 (12), 1426–1435. Kruger, S., Shugar, G., Cooke, R.G., 1996. Comorbidity of binge eating disorder and the partial binge eating syndrome with bipolar disorder. International Journal of Eating Disorders 19, 45–52. Kurzthaler, I., Fleischhacker, W.W., 2001. The clinical implications of weight gain in schizophrenia. Journal of Clinical Psychiatry 62 (suppl 7), 32–37. MacQueen, G.M., Marriott, M., Begin, H., Robb, J., Joffe, R.T., Young, L.T., 2003. Subsyndromal symptoms assessed in longitudinal, prospective follow-up of a cohort of patients with bipolar disorder. Bipolar Disorders 5 (5), 349–355. Masand, P.S., 1999. Wight gain and antipsychotic medication. Journal of Clinical Psychiatry 60, 336–337. McElroy, S.L., Frye, M.A., Suppes, T., 2002. Correlates of overweight and obesity in 644 patients with bipolar disorder. Journal of Clinical Psychiatry 63, 207–211. McElroy, S.L., Kotwal, R., Keck Jr., P.E., Akiskal, H.S., 2005. Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations? Journal of Affective Disorders 86 (2–3), 107–127. Moller, S.E., 1992. Serotonin, carbohydrates, and atypical depression. Pharmacology and Toxicology 71 (Suppl 1), 61–71. Ramacciotti, C.A., Paoli, R.A., Marcacci, G., Piccini, A., Burgalassi, A., Dell'Osso, L., Garfinkel, P.E., 2005. Relationship between bipolar illness and binge eating disorders. Psychiatry Research 135 (2), 165–170. Simon, G.E., Von Korff, M., Saunders, K., Miglioretti, D.L., Crane, P.K., van Belle, G., Kessler, R.C., 2006. Association between obesity and psychiatric disorders in the US adult population. Archives of General Psychiatry 63, 824–830. Smith, D.E., Marcus, M.D., Lewis, C.E., Fitzgibbon, M., Schreiner, P., 1998. Prevalence of binge eating disorder, obesity, and depression in a biracial cohort of young adults. Annals of Behavioral Medicine 20 (3), 227–232. Theisen, F.M., Linden, A., Koning, I.P., Martin, M., Remschmidt, H., Hebebrand, J., 2003. Spectrum of binge eating symptomatology in patients treated with clozapine and olanzapine. Journal of Neural Transmission 110 (1), 111–121. Yanovski, S.Z., 2003. Binge eating disorder and obesity in 2003: could treating an eating disorder have a positive effect on the obesity epidemic? International Journal of Eating Disorders 34, 117–120 (suppl). Yanovski, S.Z., Nelson, J.E., Dubbert, B.K., Spitzer, R.L., 1993. Association of binge eating disorder and psychiatric comorbidity in obese subjects. American Journal of Psychiatry 150 (10), 1472–1479.
Contents lists available at ScienceDirect
Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s
Brief report
Binge eating, weight gain and psychosocial adjustment in patients with bipolar disorder Silvia Castrogiovanni a, Isabella Soreca b,c,⁎, Daniela Troiani a, Mauro Mauri a a b c
Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies, School of Medicine, University of Pisa, Pisa, Italy Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Department of Neuroscience, School of Applied Neurological Sciences, University of Siena, Italy
A R T I C L E
I N F O
Article history: Received 13 February 2007 Received in revised form 25 September 2007 Accepted 12 June 2008 Keywords: Mood disorders Eating disorders BMI Self-esteem
A B S T R A C T Binge Eating (BE) is a common eating pattern in patients with Bipolar Disorder (BD). BE may confer an increased risk for obesity, morbidity, mortality and poorer quality of life. We assessed the presence of BE and its impact on body weight, body image and self-esteem in 50 patients with BD and 50 age- and gendermatched controls. The presence and severity of BE was assessed with the Binge Eating Scale (BES). The Body Image and Self-Esteem Evaluation Scale (B-WISE) was used to assess the psychosocial impact of weight gain. Body Mass Index (BMI) was calculated. Nine (18%) patients had a score N 27, indicating a likely diagnosis of BE. None of the control subjects had a BES score N 17. No association between BES score and the medications was found. Patients had a significantly higher BES score, significantly higher BMI, waist circumference and fasting blood glucose. Although the B-Wise score was higher in the controls, the difference was not statistically significant. This study suggests that BE is prevalent in patients with BD. The presence of BE eating is a predictor of higher BMI, indicating that the disruption of eating behavior may be a pathway to weight gain. © 2008 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Binge Eating Disorder (BED) is a common eating pattern in obese subjects (Yanovski, 2003; Bulik et al., 2002) and is frequently reported by patients with Bipolar Disorder (BD) (Ramacciotti et al., 2005; Kruger et al., 1996). McElroy et al. (2002) reported that 13.5% of obese patients with BD and 50% of extremely obese patients with BD had a current or lifetime history of BED, compared with 4.9% of normal weight bipolar subjects, suggesting that the engagement in abnormal eating behavior may be a pathway to obesity for patients with BD. On the other hand, treatment-seeking obese binge eaters reported a high prevalence of mood disorder (Yanovski et al., 1993; Bulik et al., 2002) and binge eating is associated with increased medical comorbidity independently from Body Mass Index (BMI) (Bulik and ReichbomKjennerud, 2003). Obesity seems to be a proxy for medical burden in patients with mood disorders. The pathways between obesity and mood disorders may include dysregulation of neural systems, medications and lifestyle (McElroy et al., 2005). Bipolar Disorder may be a risk factor for obesity (Simon et al., 2006): physical inactivity and altered eating pattern during the depressive phase of BD confer an increased risk for overweight and
⁎ Corresponding author. Western Psychiatric Institute and Clinic, room BT 807A, 3811 O'Hara Street, Pittsburgh, PA 15213, USA. Tel.: +1 412 2466945; fax: +1 412 2465520. E-mail address: [email protected] (I. Soreca). 0165-1781/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2008.06.016
obesity (Katon, 2003), and long term treatment with psychotropic medication is also associated with weight gain (Keck and McElroy, 2003; Allison and Casey, 2001; Ganguli, 1999). In this report we assessed the presence of BED and its impact on body weight, body image and self-esteem in patients with BD. 2. Methods 2.1. Subjects and procedures Fifty patients with Bipolar I and II Disorder, aged 18–65, and 50 ageand gender-matched controls were consecutively recruited from the psychiatric outpatient facility of the University Hospital of Pisa from September 2005 to July 2007. Exclusion criteria were the presence of current substance abuse, current psychotic symptoms, high suicidal risk, and presence of an episode requiring hospitalization. The diagnosis of BD and the presence of clinical conditions that would result in subjects being excluded from the study were determined according to the DSMIVTR criteria with an interview by the treating psychiatrist. Controls were screened with a medical, psychiatric and medication history by a physician; being currently treated for any medical or psychiatric condition was considered a criterion for exclusion. All participants gave written informed consent, and the study was approved by the local Ethics Committee. For each subject, body weight (kg), height (m) and waist circumference (cm) were measured and BMI (kg/m2) was calculated.
S. Castrogiovanni et al. / Psychiatry Research 169 (2009) 88–90 Table 1 Subjects' characteristics.
89
Table 3 Means BES and B-WISE score and the distribution of the BES scores in the two groups.
Variable (mean, S.D.)
Patients
Controls
P
Variable
Patients
Controls
P
Males (n) Females (n) Age Body weight (kg) BMI (kg/m2) Waist circumference (cm) Fasting serum glucose (mg/dl) Serum triglycerides (mg/dl) Total cholesterol (mg/dl) Smoking (n)
15 35 38.48 (12.48) 72.27 (18.14) 25.64 (6.69) 90.75 (15.7) 109.76 (14.62) 121.28 (46.86) 182.26 (32.64) 21
15 35 36.61 (12.64) 65.75 (12.96) 22.04 (3.18) 79.52 (11.56) 82.81 (13.53) 104.16 (26.97) 182.42 (67.63) 12
– – 0.510 0.042 0.014 0.000 0.000 0.154 0.989 –
B-WISE total score (mean, S.D.) BES total score (mean, S.D.) BES N 27 (n) BES N 17 b27 (n) BES b 17 (n, %)
16.32 (19.93) 14.83 (10.57) 9 (18%) 11 (22%) 30 (60%)
18.73 (3.18) 3.28 (3.8) – – 50 (100%)
0.419 0.000
Blood chemistry results were available for 42 bipolar patients and 22 controls. The presence and severity of BE were assessed with the Binge Eating Scale (BES) (Gormally et al., 1982). The BES is a 16-item selfadministered questionnaire that measures the presence and severity of bulimic behaviors in obese subjects. Psychometric studies have shown that a score of 27 or higher on the BES has a good correlation with the diagnosis of binge eating assessed with the clinicianadministered Eating Disorder Examination (EDE) (Celio et al., 2004), while a score of 17 or lower is the cut-off value for the presence of mild or no binge eating. The Body Image and Self-Esteem Evaluation Scale (B-WISE) (Awad and Voruganti, 2004) was used to assess the psychosocial impact of weight gain. The B-WISE is a 12-item self-administered instrument that evaluates psychological consequences of weight gain in patients with severe mental illness. The validation study of the scale has shown a high internal consistency, good split-half reliability, and good discriminant validity (Awad and Voruganti, 2004). Higher scores in the B-WISE are indicative of better adjustment. 2.2. Statistical analyses Continuous variables were summarized with mean and standard deviations (S.D.), and frequencies in % were used to summarize dichotomous variables. Linear logistic regression was used to explore the relationship between the variables. BMI was used as the dependent variable and BES score, age and gender were entered as predictors. Then patients were divided into three groups according to the BES score: BES N 27 or high probability of binge eating, BES N 17 b27 or intermediate probability of having binge eating, BES b 17 or low probability of binge eating. We compared the B-Wise scores among the three groups by oneway analysis of variance (ANOVA). All the analyses were conducted with the SPSS statistical package, version 14.0 (SPSS, Chicago, IL). 3. Results A total of 50 patients and 50 age- and gender-matched controls (15 males and 35 females in each group) were evaluated. The mean age was 38.48 (±12.48) for bipolar patients and 36.61 (±12.64) for the control subjects; in the group of patients, 29 subjects had a diagnosis of Bipolar I Disorder, and 21 had a diagnosis of Bipolar II Disorder. The mean body weight of the patients was 72.27 kg (±18.14), and the mean body weight for the controls was 65.75 (±12.96); the mean BMI was 25.64 kg/m2 (±6.69) for patients and 22.04 (±3.18) for controls, and
waist circumference was 90.75 cm (±15.7) for patients and 79.52 cm (±11.56) for controls. Twenty-one patients and 12 controls were currently smokers (Table 1). Results of the blood chemistry were available for 42 patients and for 22 controls and are shown in Table 1. All the patients with BD and none of the controls (by design) were being treated with psychotropic medication (see Table 2): 22 (44%) were on anticonvulsants (mainly valproate) or lithium, 41 (83%) were on antidepressants, and 10 (20%) were on atypical antipsychotics (Table 2). Thirty patients (60%) had a BES score b17, 11 (22%) patients scored between 17 and 27, and nine (18%) patients had a score N27.None of the control subjects had a BES score N17 (Table 3). No association between BES score category and the medications was found (Table 4). Overall, patients had a significantly higher BES score, significantly higher BMI, waist circumference and fasting blood glucose (Table 1). Although the B-Wise score was higher in the controls, the difference was not statistically significant (Table 3). No significant difference was found in age (by design), serum triglycerides and total cholesterol between patients and controls (Table 1). In the regression model, the BMI was entered as dependent variable and age, gender, group (patients/controls) and BES score as independent predictors. The BES score showed a significant correlation with the BMI (Beta = 0.304, P = 0.002). We then compared the B-WISE total scores among subjects who had a BES score N27 (high probability of binge eating), BES score N 17 b27 (moderate probability of binge eating) and BES score b 17 (low probability of binge eating). The B-WISE score was lower in the BES N 27 group than in the other two groups, but this result did not reach statistical significance (F = 3.08; P = 0.051). 4. Discussion Consistent with results from other reports, this study suggests that binge eating is highly prevalent in patients with BD. Our sample, albeit small, represents a picture of the actual clinical population that is seen in an outpatient facility for mood disorders. Nineteen percent of these subjects had a BES score higher than 27, which has been shown to be highly correlated with a diagnosis of BED (Celio et al., 2004). Prevalence of binge eating in non-clinical populations ranges from 1% to 2% (Smith et al., 1998; Dingemans et al., 2002), while it rises to 8–17% among patients with BD (Ramacciotti et al., 2005; MacQueen et al., 2003). It is also noteworthy that 22% of our sample fell in the subthreshold score range, indicating the presence of some degree of eating pathology, although not meeting full criteria for the diagnosis.
Table 4 Association between BES score and medications. Medications (yes/no)
Table 2 Medications used in the BD patients sample. Medication
N
%
Anticonvulsants and lithium Antidepressants Atypical antipsychotics
22 41 10
44 82 20
Anticonvulsants and lithium Antidepressants Atypical antipsychotics
BES score b 17
BES score N 17 b27
BES score N 27
Pearson Chi-square
Yes
No
Yes
No
Yes
12
18
4
4
6
6
0.70
25 5
5 25
6 3
3 6
10 2
1 9
0.35 0.54
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The prevalence of binge eating did not differ significantly between males and females. The likely diagnosis of binge eating according to the BES total score was observed in the patients with BD and was not present in any of the gender and age- and gender-matched control subjects. Some of the medications that are used to treat BD may cause increased appetite, thus triggering overeating and binge eating. The emergence of binge eating with the use of certain psychotropic medications, especially olanzapine and clozapine (Theisen et al., 2003), has been reported. We did not observe any association between the presence of binge eating and the use of psychotropic medications (anticonvulsants or lithium, antidepressants, atypical antipsychotics). Nevertheless, our data do not allow us to draw conclusions as to whether the differences between patients and controls are solely driven by the presence of BD or by the use of medications by the patients. A sample of non-medicated, or nevermedicated subjects with BD would be needed to address this question. Not surprisingly, the presence of binge eating is a predictor of higher BMI in our sample, suggesting that the disruption of eating behavior during the course of a mood disorder is an important pathway to weight gain, especially in women. Weight gain, on the other hand, is associated with worse outcome (Fagiolini et al., 2003) and with poorer treatment adherence (Kurzthaler and Fleischhacker, 2001; Masand, 1999). In our sample, psychosocial adjustment, measured by means of the B-WISE, was lower in the patients with a probable diagnosis of binge eating, but this result did not reach statistical significance. It is noteworthy that the subjects in our sample are on average only slightly overweight (mean BMI = 25.6). However, women, but not men, show a mean waist circumference of 90.5 cm, exceeding the threshold for abdominal obesity according to the ATP III criteria (Grundy et al., 2005). Another result worthy of discussion is the fact that mean fasting glucose levels in this sample were 109.7 mg/dl (Table 2), exceeding the new upper limit (100 mg/dl) recommended by the American Diabetes Association (http://www.diabetes.org) and suggesting the need for more systematic screening for metabolic syndrome components in patients with BD. While our study revealed significant results, we must acknowledge various limitations in the present report. The small sample size, the use of self-rating instruments for the measurement of binge eating, without a cross-control with a clinician-administered interview and the lack of controlling results for clinical status may limit our findings. The presence of atypical depression, for example, may have contributed to the altered eating pattern reported by our patients (Moller, 1992). Despite these limitations, we believe that this report contributed information that may be useful to clinicians treating patients with BD. First, the high prevalence of binge eating and subthreshold binge eating in patients with BD is something that clinicians should be aware of when assessing and treating patients with BD; the presence of a disordered eating pattern seems to be accompanied by a cluster of medical risk factors, such as overweight, abdominal obesity, and reduced glucose tolerance that are related to poorer psychiatric outcome (Fagiolini et al., 2003, 2005) and increased mortality (Angst et al., 2002). References Allison, D.B., Casey, D.E., 2001. Antipsychotic induced weight gain: a review of the literature. Journal of Clinical Psychiatry 62 (suppl.7), 22–31.
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