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Eating patterns and breakfast consumption in obese patients with binge eating disorder
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Behaviour Research and Therapy 44 (2006) 1545–1553 www.elsevier.com/locate/brat
Eating patterns and breakfast consumption in obese patients with binge eating disorder$ Robin M. Masheb, Carlos M. Grilo a
Department of Psychiatry, Yale Psychiatric Research, Yale University School of Medicine, P.O. Box 208098, 301 Cedar Street (2nd floor), New Haven, CT 06520, USA Received 30 June 2005; received in revised form 20 October 2005; accepted 24 October 2005
Abstract This study examined eating patterns and breakfast consumption, and their relationships to weight and binge eating, in obese individuals with binge eating disorder (BED). One-hundred seventy-three consecutively evaluated men (n ¼ 46) and women (n ¼ 127) with BED were administered semi-structured interviews and self-report measures to assess the frequency of meals and snacks eaten, as well as binge eating and eating disorder features. Overall, those who consumed more frequent meals, particularly breakfast, and snacks, weighed less. Breakfast, which was eaten on a daily basis by less than half of participants (n ¼ 74; 43%), was the least frequently eaten meal of the day. Participants (n ¼ 56; 32%) who ate three meals per day weighed significantly less, and had significantly fewer binges, than participants (n ¼ 117; 68%) who did not regularly eat three meals per day. Thus, eating more frequently, having breakfast and consuming three meals every day, have potentially important clinical applications for the treatment of BED given that the effectiveness of specific interventions within treatments for BED are unknown, and that weight loss outcome for BED has been poor. r 2005 Elsevier Ltd. All rights reserved. Keywords: Binge eating disorder; Breakfast; Eating patterns; Obesity; Weight loss
Introduction In 1994, binge eating disorder (BED) was included as a new research criteria set in the DSM-IV (American Psychiatric Association (APA), 1994) following two large-scale multi-site trials conducted by Spitzer et al. (1992, 1993). Since that time, a considerable body of research has accumulated regarding the prevalence, validity, and importance of this clinical problem (Johnson, Spitzer, & Williams, 2001; National Task Force on the Prevention and Treatment of Obesity (NTF), 2000; Wilfley, Wilson, & Agras, 2003). BED, as defined by the DSM-IV (APA, 1994), includes recurrent episodes of binge eating in the absence of inappropriate compensatory weight control methods found in bulimia nervosa (BN). The binge eating must be associated with emotional distress, occur regularly (2 days per week or more), and be persistent (minimum of 6-month duration). Utilizing these research criteria, it is now known that considerable psychological distress and eating $
This research was supported by Grants R01 DK49587 and K24 DK070052 from the National Institute of Health.
Corresponding author.
E-mail address: [email protected] (R.M. Masheb). 0005-7967/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2005.10.013
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disorder symptomatology is associated with BED (Grilo, 1998), and that overweight or obesity is commonly found in these individuals (Spitzer et al., 1992, 1993). Patients with BED, unlike patients with BN, are also at increased risk for morbidity and mortality associated with obesity (NTF, 2000), and unlike obese individuals without BED, have elevated comorbid psychopathology and eating disorder symptomatology (Mussell et al., 1996). A number of psychotherapies and pharmacotherapies have been shown to produce significant and substantial reductions in binge eating among BED patients. Of these treatments, cognitive-behavioral therapy (CBT) has demonstrated efficacy (Carter, & Fairburn, 1998; Grilo, Masheb, & Wilson, 2005; Wilfley et al., 1993) for BED and its effects are well-maintained at least through 12 months (Wilfley et al., 2002). The superiority of various methods of CBT over waitlist control groups (Carter & Fairburn, 1998; Grilo & Masheb, 2005; Wilfley et al., 1993), and behavioral weight loss treatment (Grilo & Masheb, 2005), and pharmacotherapy (i.e., fluoxetine; Grilo, Masheb, & Wilson, 2005) make it the best-established intervention for BED to date (National Institute for Clinical Excellence (NICE), 2004; Wilson, 2005). However, CBT, and other treatments for BED, suffer from two major problems: (1) treatments have not resulted in clinically meaningful weight loss outcomes, and (2) factors within treatments that may be associated with binge remission, and reduction in eating disorder and psychological sequelae, are relatively unknown. In fact, the only known predictor of binge remission and weight loss in BED patients is ‘‘rapid response’’ (i.e., substantial reduction of binge eating that occurs early in treatment; Grilo, Masheb, & Wilson, 2004). To advance the treatment of BED, the next wave of studies needs to identify the specific interventions within treatments for BED that are effective, particularly interventions that may be associated with weight loss. Tanofsky-Kraff and Yanovski (2004) have advocated for the examination of non-normative eating behaviors (e.g., irregular eating patterns) and their potential implications for informing treatments designed for overweight and obese populations. At the core of the CBT treatment for BED, is the prescription of a pattern of regular eating such that the patient is asked to restrict eating to three planned meals per day, and two or three planned snacks (Fairburn, Marcus, & Wilson, 1993). Inherent in this prescription is the assumption that these patients engage in irregular eating schedules such that the pattern of eating (i.e., the number and order of meals and snacks) varies from day-to-day. Clinically it has been assumed that patients with BED engage in irregular eating patterns, perhaps going long periods of time without eating that are followed by binge episodes. This assumption seems to have emerged based upon the knowledge that individuals with BN, patients for whom this CBT treatment was designed for, do not regularly eat three, or even two, normal meals per day (Mitchell, Hatsukami, Eckert, & Pyle, 1985). However, it has been shown that individuals with BED eat more frequently than individuals who are overweight or obese and do not binge eat (Allison, Grilo, Masheb, & Stunkard, 2005). Also of particular interest, is the association of breakfast consumption with weight and binge eating given it’s documented importance for weight control in obesity (Cho, Dietrich, Brown, Clark, & Block, 2003; Ruxton & Kirk, 1997), and overall food intake and diet quality (Morgan, Zabik, & Stampley, 1986; Ruxton & Kirk, 1997; Schlundt, Hill, Sbrocco, Pope-Cordle, & Sharp, 1992). More specifically, it seems that skipping breakfast may lead to more frequent snacking (Schlundt et al., 1992; Sjoberg, Hallberg, Hoglund, & Hulthen, 2003). Thus, the purpose of the present study is to explore the frequency, regularity, and associations of meals and snacks eaten by patients with BED. We hypothesize that eating patterns and breakfast consumption will be related to weight and binge eating. Exploratory analyses will be conducted with additional eating disorder features to investigate whether these features may be related to eating patterns and breakfast consumption as well. Methods Participants Participants were 173 consecutively evaluated men (n ¼ 46) and women (n ¼ 127) who responded to advertisements seeking individuals for treatment studies at a medical school. Inclusion criteria required age between 18 and 60 years, body mass index (BMI) of 30 or greater, and DSM-IV (APA, 1994) research criteria
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for BED. Excluded were potential participants who were receiving concurrent treatment for eating, weight or psychiatric illness; had medical conditions (e.g., diabetes or thyroid problems, as determined by laboratory findings) that influence weight or eating; had severe current psychiatric conditions requiring different treatments (i.e., psychosis, bipolar disorder, suicidality or current substance dependence); or were pregnant or nursing. The study received approval by the Human Investigation Committee at the Yale University School of Medicine, and written informed consent was obtained from all participants. Participants were aged 18–59 years (M ¼ 45.2, SD ¼ 8.8), 73.4% (n ¼ 127) were female, 68.2% (n ¼ 118) were married, and 81.5% (n ¼ 141) attended or finished college. The participant group was 79.8% (n ¼ 138) Caucasian, 13.3% (n ¼ 23) African American, 4.6% (n ¼ 8) Hispanic American, and 2.3% (n ¼ 4) of other ethnicity. BMI (weight (kg)/height (m2)) ranged from 30.0 to 53.5 (M ¼ 37.9, SD ¼ 5.6), and was calculated with actual measurements obtained with a medical balance-beam scale. Procedures and assessments Assessments were performed by trained and monitored doctoral-level research clinicians. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P; First, Spitzer, Gibbon, & Williams, 1996) was used to determine DSM-IV (APA, 1994) BED diagnoses. The Eating Disorder Examination Interview: 12th Edition version (EDE; Fairburn & Cooper, 1993), a semistructured investigator-based interview, was administered at baseline to assess eating patterns, eating behaviors and eating disorder features. The EDE focuses on the previous 28 days except for the diagnostic items, which were modified to include questions to assess the DSM-IV (APA, 1994) duration requirement of 6 months for the presence of regular binge eating (minimum of 2 days per week). To measure eating patterns, the EDE assesses the frequency of meals (breakfast, lunch, dinner), snacks (mid-morning, mid-afternoon, evening), and nocturnal eating (eating after having gone to sleep) over the previous 28 days. The response set is based on the following 7-point scale: 0 denotes absence of the eating behavior, 1 denotes 1–5 days, 2 denotes 6–12 days, 3 denotes 13–15 days, 4 denotes 16–22 days, 5 denotes 23–27 days, and 6 denotes every day of the previous 28 days. In addition, the EDE assesses the frequency of different forms of overeating, including objective bulimic episodes (OBEs; binge eating defined as unusually large quantities of food with a subjective sense of loss of control), and objective bulimic days (the number of days in which OBEs occurred), for the previous month. The EDE also assesses eating disorder features as measured by the following four subscales: dietary restraint, eating concern, shape concern, and weight concern. Items are rated on a 7-point scale (0–6), with higher scores reflecting greater severity or frequency. The EDE is used widely in the assessment of binge eating and eating disorders (Grilo, Masheb, & Wilson, 2001a, b; Wilfley, Schwartz, Spurrell, & Fairburn, 2000). The EDE subscales have demonstrated adequate internal consistency and good discriminative validity (Cooper, Cooper, & Fairburn, 1989; Rosen, Vara, Wendt, & Leitenberg, 1990). Studies of the EDE have reported good inter-rater and test–retest reliability for binge eating behaviors and for the subscales measuring the features of eating disorders (Grilo, Lozano, & Elder, 2005; Grilo, Masheb, Lozano-Blanco, & Barry, 2004; Rizvi, Peterson, Crow, & Agras, 2000). There are no published reports on the reliability of the eating pattern items from the EDE. Thus, we examined the reliability of these items using archival EDE data from the same sample of 18 patients for whom reliability of binge eating behaviors and the EDE subscales have been reported (Grilo et al., 2004). Participants in the present study and the reliability sample were recruited for outpatient treatment studies of BED by the same research group, with the same recruitment strategies. Thus, the two study groups had similar characteristics. The time interval between the first and second administrations of the EDE was 1–2 weeks (M ¼ 10.5 days, SD ¼ 3.2 days, range ¼ 6–14 days). For test–retest reliability of the seven eating pattern items (i.e., items corresponding to breakfast, mid-morning snack, lunch, mid-afternoon snack, dinner, evening snack, and nocturnal eating), intraclass correlaion coefficients (ICCs), ranging from .46 to .90 (po.02), demonstrated adequate to very good test–retest reliability. For inter-rater reliability of the eating pattern items, a third sample of 42 patients with BED, with similar characteristics to the other two samples, was recruited. Pearson product moment correlation coefficients (PPMCs) were calculated on each of the seven items and ranged from .99 to 1.00 (po.0001) demonstrating excellent inter-rater reliability.
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The Three Factor Eating Questionnaire (TFEQ; Stunkard, & Messick, 1985) is a widely used self-report measure (Allison, Kalinsky, & Gorman, 1992), with subscales reflecting three key eating domains: cognitive restraint, disinhibition, and hunger. Higher scores reflect greater levels. Studies of the TFEQ have reported adequate psychometric properties and construct validity (Allison et al., 1992; Stunkard & Messick, 1985). Results How frequently do patients with BED eat? Table 1 shows the frequency for how often each meal (breakfast, lunch and dinner), snack (mid-morning, mid-afternoon, and evening), and nocturnal eating episode was eaten in the previous 28 days. Breakfast was eaten every day by fewer than half of the participants (n ¼ 74; 42.8%). Among meals, a daily breakfast was also eaten less frequently than a daily lunch (n ¼ 111; 64.2%) and a daily dinner (n ¼ 144; 83.2%). Small numbers of participants reported never eating breakfast (n ¼ 4; 2.3%), lunch (n ¼ 1; 0.6%) or dinner (n ¼ 1; 0.6%). Among snacks, an evening snack was eaten every day by about half the participants (n ¼ 88; 50.9%). A daily evening snack was reported more frequently than a daily mid-morning snack (n ¼ 27; 15.6%) and a daily mid-afternoon snack (n ¼ 52; 30.1%). Most participants (n ¼ 124; 71.7%) did not have any nocturnal snacks, and only a small number (n ¼ 6; 3.5%) reported nocturnal snacking on a daily basis. Men and women ate meals and snacks at similar frequencies, with the exception of mid-morning snacking. Men reported more frequent mid-morning snacking than women (M ¼ 3.17, SD ¼ 2.01 vs. M ¼ 2.40, SD ¼ 2.07; F(1, 172) ¼ 4.78, p ¼ .030). Is meal, snack and breakfast consumption related to weight, binge eating, and eating disorder features among BED patients? Table 2 shows Pearson product moment correlations (PPMCs) for each of the meals, snacks, and nocturnal eating episodes, as well as the combined meals and combined snacks, to BMI, binge eating and eating disorder features. All three meals combined (i.e., the frequency of breakfast, lunch and dinner in the past 28 days) was significantly and negatively correlated with BMI (r ¼ .24, p ¼ .001), such that more frequent meals was related to lower weight. A low, but significant negative correlation (r ¼ .15, p ¼ .048) was also found for the three snacks (i.e., the frequency of mid-morning, mid-afternoon, and evening snacks in the past 28 days), such that more frequent snacking was also related to lower weight. Among the meals, both breakfast (r ¼ .24, p ¼ .001) and lunch (.18, p ¼ .020) frequency, but not dinner frequency, were significantly and negatively correlated with BMI. Among the snacks, only the frequency of the evening snack (r ¼ .19, p ¼ .017) was significantly and negatively correlated with BMI. Thus, more frequent breakfast and lunch eating, and evening snacking, were associated with lower weight.
Table 1 Frequency of meals and snacks Frequency
0 1 2 3 4 5 6
(Absence) (1–5 days) (6–12 days) (13–15 days) (16–22 days) (23–27 days) (28 days)
Breakfast
Mid-morning snack
Lunch
n
(%)
n
(%)
n
4 21 19 12 19 24 74
(2.3) (12.1) (11.0) (6.9) (11.0) (13.9) (42.8)
38 23 32 18 27 8 27
(22.0) (13.3) (18.5) (10.4) (15.6) (4.6) (15.6)
1 1 9 5 28 18 111
Mid-afternoon snack
Dinner
Evening snack
Nocturnal eating
(%)
n
(%)
n
(%)
n
(%)
n
(%)
(0.6) (0.6) (5.2) (2.9) (16.2) (10.4) (64.2)
20 22 19 18 31 11 52
(11.6) (12.7) (11.0) (10.4) (17.9) (6.4) (30.1)
1 0 2 5 5 16 144
(0.6) (0.0) (1.2) (2.9) (2.9) (9.2) (83.2)
9 4 11 9 25 27 88
(5.2) (2.3) (6.4) (5.2) (14.5) (15.6) (50.9)
124 15 12 9 5 2 6
(71.7) (8.7) (6.9) (5.2) (2.9) (1.2) (3.5)
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Table 2 Correlation coefficients for the eating pattern variables with eating-related measures (n ¼ 173) Eating-related measures
Meals Snacks Breakfast Midcombined combined morning snack
Lunch
MidDinner afternoon snack
Evening snack
BMI
.24
.18
EDE binge eating Objective bulimic days Objective bulimic episodes
.11 .14
Eating disorder features EDE restraint EDE eating concern EDE shape concern EDE weight concern TFEQ cognitive restraint TFEQ disinhibition TFEQ hunger
.02 .03 .01 .01 .07 .14 .07
.15
Nocturnal eating
.24
.02
.18
.14
.01
.05 .07
.09 .13
.04 .02
.11 .12
.03 .01
.02 .01
.20 .20
.08 .08
.01 .04 .15 .15 .15 .05 .11
.01 .07 .05 .07 .03 .17 .04
.10 .01 .14 .10 .14 .04 .02
.03 .05 .02 .01 .02 .06 .02
.04 .11 .11 .10 .09 .06 .04
.01 .13 .05 .10 .13 .00 .11
.05 .04 .07 .13 .09 .01 .20
.04 .04 .12 .10 .03 .03 .04
.03
Note: BMI ¼ body mass index; EDE ¼ Eating Disorder Examination; TFEQ ¼ Three-Factor Eating Questionnaire; meals combined ¼ frequency of breakfast, lunch and dinner in the past 28 days; snacks combined ¼ frequency of mid-morning, mid-afternoon and evening snacks in the past 28 days. po.05. po.01.
None of the meal frequencies were associated with binge eating (i.e., objective bulimic days or episodes). Among the snacks, only the frequency of the evening snack was significantly correlated with objective bulimic days (r ¼ .20, p ¼ .008) and episodes (r ¼ .20, p ¼ .009), such that more frequent evening snacking was associated with more frequent binge eating. Evening snacking was also significantly related to more hunger (r ¼ .20, p ¼ .008). Participants who ate breakfast every day (n ¼ 74; 42.8%) had significantly lower BMIs than participants who did not eat a daily breakfast (n ¼ 99; 57.2%; M ¼ 36.4, SD ¼ 4.3 vs. M ¼ 39.1, SD ¼ 6.1; F(1, 172) ¼ 10.75, p ¼ .001). Participants who ate breakfast every day also reported greater cognitive restraint as measured by the TFEQ subscale (M ¼ 7.04, SD ¼ 3.22 vs. M ¼ 8.06, SD ¼ 3.46; F(1, 170) ¼ 3.95, p ¼ .049).
What percentage of patients with BED regularly eat three meals per day, and is meal regularity associated with weight and binge eating? Participants were categorized based on whether they reported eating three meals per day, every day, in the past 28 days (i.e., reported a 6 on each of the three EDE items corresponding to breakfast, lunch and dinner) or not. Participants who ate three meals per day, every day, comprised about one-third of the sample (n ¼ 56; 32.4%) and participants who did not regularly eat three meals per day comprised about two-thirds of the sample (n ¼ 117; 67.6%). A comparison of these two groups on BMI, binge eating and the eating disorder features was performed. The means and standard deviations for the overall sample and the two subgroups, as well as the results from the ANOVA, are displayed in Table 3. Participants who ate three meals per day, every day, weighed significantly less than those who did not (M ¼ 36.2, SD ¼ 4.3 vs. M ¼ 38.7, SD ¼ 5.9; F(1, 172) ¼ 7.95, p ¼ .005). In addition, those who ate three meals per day reported significantly fewer objective bulimic days in the past 28 days than those who did not (M ¼ 12.7, SD ¼ 5.7 vs. M ¼ 14.7, SD ¼ 6.0; F(1, 172) ¼ 4.24, p ¼ .041). The two groups reported similarly on eating disorder features other than weight and binge eating.
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Table 3 Means, standard deviations, and ANOVA for eating-related measures by three-meal per day eaters vs. non-three-meal per day eaters Eating-related measures
Overall sample (n ¼ 173)
Three-meal per day eaters (n ¼ 56)
Non-three-meal per day eaters (n ¼ 117)
ANOVA
Mean
(SD)
Mean
(SD)
Mean
(SD)
F
p
37.9
(5.6)
36.2
(4.2)
38.7
(6.0)
8.13
.005
EDE binge eating Objective bulimic days 14.0 Objective bulimic episodes 15.7
(5.9) (8.3)
12.7 14.2
(5.7) (8.5)
14.7 16.4
(6.0) (8.1)
4.24 2.58
.041 .110
Eating disorder features EDE restraint EDE eating concern EDE shape concern EDE weight concern TFEQ cognitive restraint TFEQ disinhibition TFEQ hunger
(6.6) (6.8) (7.4) (4.6) (3.4) (2.2) (3.3)
9.0 11.6 26.5 16.4 7.1 13.4 9.8
(6.2) (7.2) (7.2) (4.8) (3.2) (2.1) (3.3)
8.9 10.8 26.5 16.2 7.9 13.3 9.5
(6.8) (6.6) (7.5) (4.5) (3.5) (2.3) (3.3)
0.01 0.55 0.00 0.04 2.00 0.03 0.31
.943 .458 .983 .840 .159 .861 .581
BMI
8.9 11.0 26.5 16.3 7.6 13.3 9.6
Note: BMI ¼ body mass index; EDE ¼ Eating Disorder Examination; TFEQ ¼ Three-Factor Eating Questionnaire.
Discussion CBT is currently the best-established treatment for BED (NICE, 2004; Wilson, 2005). At the core of the CBT treatment for BED, and what distinguishes this treatment from CBT treatment for other disorders, is the prescription of a pattern of regular eating (i.e., three meals per day, alternating with two or three planned snacks; Fairburn et al., 1993). Inherent in this prescription is the assumption that these patients engage in erratic eating schedules, and that in turn, erratic eating schedules lead to and/or maintain binge eating. Little is known, however, about the relationship between eating patterns, and binge eating and weight (TanofskyKraff & Yanovski, 2004), although some laboratory studies found that individuals with BED eat larger quantities of food than individuals without BED (see review, Walsh & Boudreau, 2003). Furthermore, a variety of research studies have found that breakfast consumption is important for weight control (Ruxton & Kirk, 1997; Schlundt et al., 1992; Wyatt et al., 2002). The present study explored the frequency and regularity of meals and snacks eaten by obese patients with BED, and investigated whether eating patterns and breakfast consumption are related to weight and binge eating. In this consecutively evaluated series of obese patients with BED, eating patterns and breakfast consumption were found to have an important relationship with weight based upon findings from the EDE. Participants who ate more frequently, both in terms of meals and snacks, weighed less. In particular, breakfast and lunch, but not dinner, were related to weight with breakfast having a stronger relationship to weight than lunch. This extends the well-established relationship between breakfast eating and lower weight (see review, Ruxton & Kirk, 1997) to individuals with BED. Interestingly, breakfast was the least frequently eaten meal in this sample, with less than half (43%) of participants consuming breakfast on a daily basis, in contrast to two epidemiologic studies of adults in the US of which approximately 75% reported regularly eating breakfast (Haines, Guilkey, & Popkin, 1996; Morgan et al., 1986). Data from the present study also seem to support that generally eating earlier in the day is related to lower weight, a finding consistent with a previous study comparing obese and non-obese Swedish women (Berteus Forslund, Lindroos, Sjostrom, & Lissner, 2002). Among the BED participants, those who ate three meals per day weighed less than those who did not regularly eat three meals per day. Thus, eating more frequently, particularly having breakfast and three meals every day, has potentially important clinical applications for obese BED patients with regard to weight. We also examined the associations between eating patterns and binge eating. While there were no relationships between binge eating and specific meals of the day, eating three meals per day was related to
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binge eating. Those who ate three meals per day (about one-third of the sample) reported fewer binge days than those individuals who did not regularly eat three meals per day (about two-thirds of the sample). In addition, daily evening snacking occurred in about one-half of the sample, and occurred more frequently than mid-morning snacking (16%) and mid-afternoon snacking (30%). Evening snacking was related to hunger and binge eating, suggesting that eating in the evening may be a way to control satiety but may also represent a particularly vulnerable time for binge eating. Surprisingly, evening snacking was related to not higher, but lower, weight. One area not examined in the present study was whether a proportion of evening eating episodes began as snacks and developed into binge episodes. A more detailed examination of evening eating and its relationship to weight and binge eating may help to explain these seemingly contradictory findings and provide important insights about the role of evening snacking. These data leave unanswered many important questions. Comparisons of BED patients with other samples would provide a context for understanding the eating patterns of this population. While findings from this study seem to support the importance of frequent food consumption, a study by Allison et al. (2005) found that individuals with BED already eat more frequently than overweight individuals without BED. Beyond eating three meals per day and consuming breakfast, little is known about other aspects of eating behavior (e.g., the timing of meals and snacks, the speed of eating, objective overeating episodes, and continual grazing) and their relations to binge eating and weight. Tanofsky-Kraff and Yanovski (2004) have highlighted the need for a better understanding of ‘‘non-normative’’ eating behaviors and their role in energy balance for individuals at risk for overweight or obesity. Knowing whether changes in eating patterns and breakfast consumption lead to changes in weight and binge eating may be critical in identifying effective components within treatments, particularly CBT treatment, for BED. For example, one treatment study (Schlundt et al., 1992) demonstrated that eating breakfast helped to reduce dietary fat intake and minimize impulsive snacking among obese women. We note potential limitations to consider. First, participants were overweight individuals with BED seeking treatment to stop binge eating and lose weight at a university medical center. Thus, results may not be generalizable to non-treatment seeking patients, or to patients seeking treatments for other reasons (Fitzgibbon, Stolley, & Kirschenbaum, 1993). Second, the EDE is based on retrospective recall of the past 28 days, and reliance on self-report of food consumption may be misleading because it is known that obese individuals underestimate their food intake (Buhl, Gallagher, Hoy, Matthews, & Heymsfield, 1995; Lichtman et al., 1992). Third, there were aspects of eating patterns that were not captured in this assessment and analysis. For example, the assessment of eating patterns in the present study did not include times when participants may have eaten more than three meals and three snacks per day. Fourth, our assessment did not include a nutritional or caloric assessment. Future studies should include detailed food record assessments to provide such needed information as we cannot speak to the size or nutritional characteristics of the meals and snacks reported here. Lastly, and most importantly, the present study was correlational in design and did not include a comparison sample. Thus, the results do not provide evidence for the effectiveness of establishing regular eating patterns in individuals with BED. Studies using experimental designs (e.g., Schlundt et al., 1992) are needed to determine the utility of specific meal prescriptions for managing weight in this obese patient group.
Conclusion In this consecutively evaluated series of BED individuals, eating three meals per day and breakfast consumption were significantly associated with BMI. We hypothesize that these eating behaviors help to reduce overall daily energy intake, thus suppressing weight. Data from this study also support the notion that frequent eating episodes serve to interrupt the cycle of binge eating. Our findings have important clinical implications given that the effectiveness of specific interventions within treatments for BED are unknown, and that weight loss outcome for BED has been poor. Whether changes in eating patterns and breakfast consumption are associated with changes in weight and binge eating remains unknown. Future investigations are also needed to assess the nutritional composition of meals and snacks consumed by these patients.
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Wilson (Eds.), Binge eating: Nature, assessment, and treatment (12th ed., pp. 317–360). New York: Guilford Press. Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn, & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 361–404). New York: Guilford Press. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured clinical interview for DSM-IV axis I disorders—Patient version (SCID-I/P Version 2.0). New York: New York State Psychiatric Institute. Fitzgibbon, M. L., Stolley, M. R., & Kirschenbaum, D. S. (1993). Obese people who seek treatment have different characteristics than those who do not seek treatment. Health Psychology, 12, 342–345. Grilo, C. M. (1998). The assessment and treatment of binge eating disorder. Journal of Practical Psychiatry and Behavioral Health, 4, 191–201. Grilo, C., & Masheb, R. (2005). A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge eating disorder. Behaviour Research and Therapy, 43, 1509–1525. Grilo, C. M., Lozano, C., & Elder, K. A. (2005). Inter-rater and test–retest reliability of the Spanish language version of the eating disorder examination interview: Clinical and research implications. Journal of Psychiatric Practice, 11, 231–240. Grilo, C. M., Masheb, R. M., Lozano-Blanco, C., & Barry, D. T. (2004). Reliability of the eating disorder examination in patients with binge eating disorder. International Journal of Eating Disorders, 35, 80–85. Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2001a). A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 317–322. Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2001b). Different methods for assessing the features of eating disorders in patients with binge eating disorder: A replication. Obesity Research, 9, 418–422. Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2004). Outcome predictors for the treatment of binge eating disorder. Paper presented at the meeting of the American Psychological Association, Honolulu, HI Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2005). Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: A randomized double-blind placebo-controlled comparison. Biological Psychiatry, 57, 301–309. Haines, P. S., Guilkey, D. K., & Popkin, B. M. (1996). Trends in breakfast consumption of US adults between 1965 and 1991. Journal of the American Dietetic Association, 96, 464–470. Johnson, J. G., Spitzer, R. L., & Williams, J. B. W. (2001). Health problems, impairment and illness associated with bulimia nervosa and binge eating disorder among primary care and obstetric gynecology patients. Psychological Medicine, 31, 1455–1466. Lichtman, S. W., Pisarska, K., Berman, E. R., Pestone, M., Dowling, H., Offenbacher, E., et al. (1992). Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. New England Journal of Medicine, 327, 1893–1898. Mitchell, J. E., Hatsukami, D., Eckert, E. D., & Pyle, R. L. (1985). Characteristics of 275 patients with bulimia. American Journal of Psychiatry, 142, 482–485. Morgan, K. J., Zabik, M. E., & Stampley, G. L. (1986). The role of breakfast in diet adequacy of the US adult population. Journal of the American College of Nutrition, 5, 551–563. Mussell, M. P., Mitchell, J. E., de Zwaan, M., Crosby, R. D., Seim, H. C., & Crow, S. J. (1996). Clinical characteristics associated with binge eating in obese females: A descriptive study. International Journal of Obesity, 20, 324–331. National Institute for Clinical Excellence. (2004). Eating Disorders—Core Interventions in the treatment and management of anorexia nervosa, bulimia nervosa, related eating disorders. NICE Clinical Guideline No. 9. London, England: National Institute for Clinical Excellence.
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National Task Force on the Prevention and Treatment of Obesity. (2000). Dieting and the development of eating disorders in overweight and obese adults. Archives of Internal Medicine, 160, 2581–2589. Rizvi, S. L., Peterson, C. B., Crow, S. J., & Agras, W. S. (2000). Test–retest reliability of the eating disorder examination. International Journal of Eating Disorders, 28, 311–316. Rosen, J. C., Vara, L., Wendt, S., & Leitenberg, H. (1990). Validity studies of the eating disorder examination. International Journal of Eating Disorders, 9, 519–528. Ruxton, C. H., & Kirk, T. R. (1997). Breakfast: A review of associations with measures of dietary intake, physiology and biochemistry. British Journal of Nutrition, 78, 199–213. Schlundt, D. G., Hill, J. O., Sbrocco, T., Pope-Cordle, J., & Sharp, T. (1992). The role of breakfast in the treatment of obesity: A randomized clinical trial. American Journal of Clinical Nutrition, 55, 645–651. Sjoberg, A., Hallberg, L., Hoglund, D., & Hulthen, L. (2003). Meal pattern, food choice, nutrient intake and lifestyle factors in the Goteborg adolescence study. European Journal of Clinical Nutrition, 57, 1569–1578. Spitzer, R. L., Devlin, M., Walsh, B. T., Hasin, D., Wing, R., Marcus, M., et al. (1992). Binge eating disorder: A multisite field trial of the diagnostic criteria. International Journal of Eating Disorders, 11, 191–203. Spitzer, R. L., Yanovski, S., Wadden, T., Wing, R., Marcus, M., Stunkard, A., et al. (1993). Binge eating disorder: Its further validation in a multisite study. International Journal of Eating Disorders, 13, 137–153. Stunkard, A. J., & Messick, S. (1985). The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. Journal of Psychosomatic Research, 29, 71–83. Tanofsky-Kraff, M., & Yanovski, S. Z. (2004). Eating disorder or disordered eating? Non-normative eating patterns in obese individuals. Obesity Research, 12, 1361–1366. Walsh, B. T., & Boudreau, G. (2003). Laboratory studies of binge eating disorder. International Journal of Eating Disorders, 34, S30–S38. Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A. G., et al. (1993). Group cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic individual: A controlled comparison. Journal of Consulting and Clinical Psychology, 61, 296–305. Wilfley, D. E., Schwartz, M. B., Spurrell, E. B., & Fairburn, C. G. (2000). Using the eating disorder examination to identify the specific psychopathology of binge eating disorder. International Journal of Eating Disorders, 27, 259–269. Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., et al. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge eating disorder. Archives of General Psychiatry, 59, 713–721. Wilfley, D. E., Wilson, G. T., & Agras, W. S. (2003). The clinical significance of binge eating disorder. International Journal of Eating Disorders, 34, S96–S106. Wilson, G. T. (2005). Psychological treatment of eating disorders. Annual Review of Clinical Psychology, 1, 439–465. Wyatt, H. R., Grunwald, G. K., Mosca, C. L., Klem, M. L., Wing, R. R., & Hill, J. O. (2002). Long-term weight loss and breakfast in subjects in the national weight control registry. Obesity Research, 10, 78–82.
Behaviour Research and Therapy 44 (2006) 1545–1553 www.elsevier.com/locate/brat
Eating patterns and breakfast consumption in obese patients with binge eating disorder$ Robin M. Masheb, Carlos M. Grilo a
Department of Psychiatry, Yale Psychiatric Research, Yale University School of Medicine, P.O. Box 208098, 301 Cedar Street (2nd floor), New Haven, CT 06520, USA Received 30 June 2005; received in revised form 20 October 2005; accepted 24 October 2005
Abstract This study examined eating patterns and breakfast consumption, and their relationships to weight and binge eating, in obese individuals with binge eating disorder (BED). One-hundred seventy-three consecutively evaluated men (n ¼ 46) and women (n ¼ 127) with BED were administered semi-structured interviews and self-report measures to assess the frequency of meals and snacks eaten, as well as binge eating and eating disorder features. Overall, those who consumed more frequent meals, particularly breakfast, and snacks, weighed less. Breakfast, which was eaten on a daily basis by less than half of participants (n ¼ 74; 43%), was the least frequently eaten meal of the day. Participants (n ¼ 56; 32%) who ate three meals per day weighed significantly less, and had significantly fewer binges, than participants (n ¼ 117; 68%) who did not regularly eat three meals per day. Thus, eating more frequently, having breakfast and consuming three meals every day, have potentially important clinical applications for the treatment of BED given that the effectiveness of specific interventions within treatments for BED are unknown, and that weight loss outcome for BED has been poor. r 2005 Elsevier Ltd. All rights reserved. Keywords: Binge eating disorder; Breakfast; Eating patterns; Obesity; Weight loss
Introduction In 1994, binge eating disorder (BED) was included as a new research criteria set in the DSM-IV (American Psychiatric Association (APA), 1994) following two large-scale multi-site trials conducted by Spitzer et al. (1992, 1993). Since that time, a considerable body of research has accumulated regarding the prevalence, validity, and importance of this clinical problem (Johnson, Spitzer, & Williams, 2001; National Task Force on the Prevention and Treatment of Obesity (NTF), 2000; Wilfley, Wilson, & Agras, 2003). BED, as defined by the DSM-IV (APA, 1994), includes recurrent episodes of binge eating in the absence of inappropriate compensatory weight control methods found in bulimia nervosa (BN). The binge eating must be associated with emotional distress, occur regularly (2 days per week or more), and be persistent (minimum of 6-month duration). Utilizing these research criteria, it is now known that considerable psychological distress and eating $
This research was supported by Grants R01 DK49587 and K24 DK070052 from the National Institute of Health.
Corresponding author.
E-mail address: [email protected] (R.M. Masheb). 0005-7967/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2005.10.013
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disorder symptomatology is associated with BED (Grilo, 1998), and that overweight or obesity is commonly found in these individuals (Spitzer et al., 1992, 1993). Patients with BED, unlike patients with BN, are also at increased risk for morbidity and mortality associated with obesity (NTF, 2000), and unlike obese individuals without BED, have elevated comorbid psychopathology and eating disorder symptomatology (Mussell et al., 1996). A number of psychotherapies and pharmacotherapies have been shown to produce significant and substantial reductions in binge eating among BED patients. Of these treatments, cognitive-behavioral therapy (CBT) has demonstrated efficacy (Carter, & Fairburn, 1998; Grilo, Masheb, & Wilson, 2005; Wilfley et al., 1993) for BED and its effects are well-maintained at least through 12 months (Wilfley et al., 2002). The superiority of various methods of CBT over waitlist control groups (Carter & Fairburn, 1998; Grilo & Masheb, 2005; Wilfley et al., 1993), and behavioral weight loss treatment (Grilo & Masheb, 2005), and pharmacotherapy (i.e., fluoxetine; Grilo, Masheb, & Wilson, 2005) make it the best-established intervention for BED to date (National Institute for Clinical Excellence (NICE), 2004; Wilson, 2005). However, CBT, and other treatments for BED, suffer from two major problems: (1) treatments have not resulted in clinically meaningful weight loss outcomes, and (2) factors within treatments that may be associated with binge remission, and reduction in eating disorder and psychological sequelae, are relatively unknown. In fact, the only known predictor of binge remission and weight loss in BED patients is ‘‘rapid response’’ (i.e., substantial reduction of binge eating that occurs early in treatment; Grilo, Masheb, & Wilson, 2004). To advance the treatment of BED, the next wave of studies needs to identify the specific interventions within treatments for BED that are effective, particularly interventions that may be associated with weight loss. Tanofsky-Kraff and Yanovski (2004) have advocated for the examination of non-normative eating behaviors (e.g., irregular eating patterns) and their potential implications for informing treatments designed for overweight and obese populations. At the core of the CBT treatment for BED, is the prescription of a pattern of regular eating such that the patient is asked to restrict eating to three planned meals per day, and two or three planned snacks (Fairburn, Marcus, & Wilson, 1993). Inherent in this prescription is the assumption that these patients engage in irregular eating schedules such that the pattern of eating (i.e., the number and order of meals and snacks) varies from day-to-day. Clinically it has been assumed that patients with BED engage in irregular eating patterns, perhaps going long periods of time without eating that are followed by binge episodes. This assumption seems to have emerged based upon the knowledge that individuals with BN, patients for whom this CBT treatment was designed for, do not regularly eat three, or even two, normal meals per day (Mitchell, Hatsukami, Eckert, & Pyle, 1985). However, it has been shown that individuals with BED eat more frequently than individuals who are overweight or obese and do not binge eat (Allison, Grilo, Masheb, & Stunkard, 2005). Also of particular interest, is the association of breakfast consumption with weight and binge eating given it’s documented importance for weight control in obesity (Cho, Dietrich, Brown, Clark, & Block, 2003; Ruxton & Kirk, 1997), and overall food intake and diet quality (Morgan, Zabik, & Stampley, 1986; Ruxton & Kirk, 1997; Schlundt, Hill, Sbrocco, Pope-Cordle, & Sharp, 1992). More specifically, it seems that skipping breakfast may lead to more frequent snacking (Schlundt et al., 1992; Sjoberg, Hallberg, Hoglund, & Hulthen, 2003). Thus, the purpose of the present study is to explore the frequency, regularity, and associations of meals and snacks eaten by patients with BED. We hypothesize that eating patterns and breakfast consumption will be related to weight and binge eating. Exploratory analyses will be conducted with additional eating disorder features to investigate whether these features may be related to eating patterns and breakfast consumption as well. Methods Participants Participants were 173 consecutively evaluated men (n ¼ 46) and women (n ¼ 127) who responded to advertisements seeking individuals for treatment studies at a medical school. Inclusion criteria required age between 18 and 60 years, body mass index (BMI) of 30 or greater, and DSM-IV (APA, 1994) research criteria
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for BED. Excluded were potential participants who were receiving concurrent treatment for eating, weight or psychiatric illness; had medical conditions (e.g., diabetes or thyroid problems, as determined by laboratory findings) that influence weight or eating; had severe current psychiatric conditions requiring different treatments (i.e., psychosis, bipolar disorder, suicidality or current substance dependence); or were pregnant or nursing. The study received approval by the Human Investigation Committee at the Yale University School of Medicine, and written informed consent was obtained from all participants. Participants were aged 18–59 years (M ¼ 45.2, SD ¼ 8.8), 73.4% (n ¼ 127) were female, 68.2% (n ¼ 118) were married, and 81.5% (n ¼ 141) attended or finished college. The participant group was 79.8% (n ¼ 138) Caucasian, 13.3% (n ¼ 23) African American, 4.6% (n ¼ 8) Hispanic American, and 2.3% (n ¼ 4) of other ethnicity. BMI (weight (kg)/height (m2)) ranged from 30.0 to 53.5 (M ¼ 37.9, SD ¼ 5.6), and was calculated with actual measurements obtained with a medical balance-beam scale. Procedures and assessments Assessments were performed by trained and monitored doctoral-level research clinicians. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P; First, Spitzer, Gibbon, & Williams, 1996) was used to determine DSM-IV (APA, 1994) BED diagnoses. The Eating Disorder Examination Interview: 12th Edition version (EDE; Fairburn & Cooper, 1993), a semistructured investigator-based interview, was administered at baseline to assess eating patterns, eating behaviors and eating disorder features. The EDE focuses on the previous 28 days except for the diagnostic items, which were modified to include questions to assess the DSM-IV (APA, 1994) duration requirement of 6 months for the presence of regular binge eating (minimum of 2 days per week). To measure eating patterns, the EDE assesses the frequency of meals (breakfast, lunch, dinner), snacks (mid-morning, mid-afternoon, evening), and nocturnal eating (eating after having gone to sleep) over the previous 28 days. The response set is based on the following 7-point scale: 0 denotes absence of the eating behavior, 1 denotes 1–5 days, 2 denotes 6–12 days, 3 denotes 13–15 days, 4 denotes 16–22 days, 5 denotes 23–27 days, and 6 denotes every day of the previous 28 days. In addition, the EDE assesses the frequency of different forms of overeating, including objective bulimic episodes (OBEs; binge eating defined as unusually large quantities of food with a subjective sense of loss of control), and objective bulimic days (the number of days in which OBEs occurred), for the previous month. The EDE also assesses eating disorder features as measured by the following four subscales: dietary restraint, eating concern, shape concern, and weight concern. Items are rated on a 7-point scale (0–6), with higher scores reflecting greater severity or frequency. The EDE is used widely in the assessment of binge eating and eating disorders (Grilo, Masheb, & Wilson, 2001a, b; Wilfley, Schwartz, Spurrell, & Fairburn, 2000). The EDE subscales have demonstrated adequate internal consistency and good discriminative validity (Cooper, Cooper, & Fairburn, 1989; Rosen, Vara, Wendt, & Leitenberg, 1990). Studies of the EDE have reported good inter-rater and test–retest reliability for binge eating behaviors and for the subscales measuring the features of eating disorders (Grilo, Lozano, & Elder, 2005; Grilo, Masheb, Lozano-Blanco, & Barry, 2004; Rizvi, Peterson, Crow, & Agras, 2000). There are no published reports on the reliability of the eating pattern items from the EDE. Thus, we examined the reliability of these items using archival EDE data from the same sample of 18 patients for whom reliability of binge eating behaviors and the EDE subscales have been reported (Grilo et al., 2004). Participants in the present study and the reliability sample were recruited for outpatient treatment studies of BED by the same research group, with the same recruitment strategies. Thus, the two study groups had similar characteristics. The time interval between the first and second administrations of the EDE was 1–2 weeks (M ¼ 10.5 days, SD ¼ 3.2 days, range ¼ 6–14 days). For test–retest reliability of the seven eating pattern items (i.e., items corresponding to breakfast, mid-morning snack, lunch, mid-afternoon snack, dinner, evening snack, and nocturnal eating), intraclass correlaion coefficients (ICCs), ranging from .46 to .90 (po.02), demonstrated adequate to very good test–retest reliability. For inter-rater reliability of the eating pattern items, a third sample of 42 patients with BED, with similar characteristics to the other two samples, was recruited. Pearson product moment correlation coefficients (PPMCs) were calculated on each of the seven items and ranged from .99 to 1.00 (po.0001) demonstrating excellent inter-rater reliability.
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The Three Factor Eating Questionnaire (TFEQ; Stunkard, & Messick, 1985) is a widely used self-report measure (Allison, Kalinsky, & Gorman, 1992), with subscales reflecting three key eating domains: cognitive restraint, disinhibition, and hunger. Higher scores reflect greater levels. Studies of the TFEQ have reported adequate psychometric properties and construct validity (Allison et al., 1992; Stunkard & Messick, 1985). Results How frequently do patients with BED eat? Table 1 shows the frequency for how often each meal (breakfast, lunch and dinner), snack (mid-morning, mid-afternoon, and evening), and nocturnal eating episode was eaten in the previous 28 days. Breakfast was eaten every day by fewer than half of the participants (n ¼ 74; 42.8%). Among meals, a daily breakfast was also eaten less frequently than a daily lunch (n ¼ 111; 64.2%) and a daily dinner (n ¼ 144; 83.2%). Small numbers of participants reported never eating breakfast (n ¼ 4; 2.3%), lunch (n ¼ 1; 0.6%) or dinner (n ¼ 1; 0.6%). Among snacks, an evening snack was eaten every day by about half the participants (n ¼ 88; 50.9%). A daily evening snack was reported more frequently than a daily mid-morning snack (n ¼ 27; 15.6%) and a daily mid-afternoon snack (n ¼ 52; 30.1%). Most participants (n ¼ 124; 71.7%) did not have any nocturnal snacks, and only a small number (n ¼ 6; 3.5%) reported nocturnal snacking on a daily basis. Men and women ate meals and snacks at similar frequencies, with the exception of mid-morning snacking. Men reported more frequent mid-morning snacking than women (M ¼ 3.17, SD ¼ 2.01 vs. M ¼ 2.40, SD ¼ 2.07; F(1, 172) ¼ 4.78, p ¼ .030). Is meal, snack and breakfast consumption related to weight, binge eating, and eating disorder features among BED patients? Table 2 shows Pearson product moment correlations (PPMCs) for each of the meals, snacks, and nocturnal eating episodes, as well as the combined meals and combined snacks, to BMI, binge eating and eating disorder features. All three meals combined (i.e., the frequency of breakfast, lunch and dinner in the past 28 days) was significantly and negatively correlated with BMI (r ¼ .24, p ¼ .001), such that more frequent meals was related to lower weight. A low, but significant negative correlation (r ¼ .15, p ¼ .048) was also found for the three snacks (i.e., the frequency of mid-morning, mid-afternoon, and evening snacks in the past 28 days), such that more frequent snacking was also related to lower weight. Among the meals, both breakfast (r ¼ .24, p ¼ .001) and lunch (.18, p ¼ .020) frequency, but not dinner frequency, were significantly and negatively correlated with BMI. Among the snacks, only the frequency of the evening snack (r ¼ .19, p ¼ .017) was significantly and negatively correlated with BMI. Thus, more frequent breakfast and lunch eating, and evening snacking, were associated with lower weight.
Table 1 Frequency of meals and snacks Frequency
0 1 2 3 4 5 6
(Absence) (1–5 days) (6–12 days) (13–15 days) (16–22 days) (23–27 days) (28 days)
Breakfast
Mid-morning snack
Lunch
n
(%)
n
(%)
n
4 21 19 12 19 24 74
(2.3) (12.1) (11.0) (6.9) (11.0) (13.9) (42.8)
38 23 32 18 27 8 27
(22.0) (13.3) (18.5) (10.4) (15.6) (4.6) (15.6)
1 1 9 5 28 18 111
Mid-afternoon snack
Dinner
Evening snack
Nocturnal eating
(%)
n
(%)
n
(%)
n
(%)
n
(%)
(0.6) (0.6) (5.2) (2.9) (16.2) (10.4) (64.2)
20 22 19 18 31 11 52
(11.6) (12.7) (11.0) (10.4) (17.9) (6.4) (30.1)
1 0 2 5 5 16 144
(0.6) (0.0) (1.2) (2.9) (2.9) (9.2) (83.2)
9 4 11 9 25 27 88
(5.2) (2.3) (6.4) (5.2) (14.5) (15.6) (50.9)
124 15 12 9 5 2 6
(71.7) (8.7) (6.9) (5.2) (2.9) (1.2) (3.5)
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Table 2 Correlation coefficients for the eating pattern variables with eating-related measures (n ¼ 173) Eating-related measures
Meals Snacks Breakfast Midcombined combined morning snack
Lunch
MidDinner afternoon snack
Evening snack
BMI
.24
.18
EDE binge eating Objective bulimic days Objective bulimic episodes
.11 .14
Eating disorder features EDE restraint EDE eating concern EDE shape concern EDE weight concern TFEQ cognitive restraint TFEQ disinhibition TFEQ hunger
.02 .03 .01 .01 .07 .14 .07
.15
Nocturnal eating
.24
.02
.18
.14
.01
.05 .07
.09 .13
.04 .02
.11 .12
.03 .01
.02 .01
.20 .20
.08 .08
.01 .04 .15 .15 .15 .05 .11
.01 .07 .05 .07 .03 .17 .04
.10 .01 .14 .10 .14 .04 .02
.03 .05 .02 .01 .02 .06 .02
.04 .11 .11 .10 .09 .06 .04
.01 .13 .05 .10 .13 .00 .11
.05 .04 .07 .13 .09 .01 .20
.04 .04 .12 .10 .03 .03 .04
.03
Note: BMI ¼ body mass index; EDE ¼ Eating Disorder Examination; TFEQ ¼ Three-Factor Eating Questionnaire; meals combined ¼ frequency of breakfast, lunch and dinner in the past 28 days; snacks combined ¼ frequency of mid-morning, mid-afternoon and evening snacks in the past 28 days. po.05. po.01.
None of the meal frequencies were associated with binge eating (i.e., objective bulimic days or episodes). Among the snacks, only the frequency of the evening snack was significantly correlated with objective bulimic days (r ¼ .20, p ¼ .008) and episodes (r ¼ .20, p ¼ .009), such that more frequent evening snacking was associated with more frequent binge eating. Evening snacking was also significantly related to more hunger (r ¼ .20, p ¼ .008). Participants who ate breakfast every day (n ¼ 74; 42.8%) had significantly lower BMIs than participants who did not eat a daily breakfast (n ¼ 99; 57.2%; M ¼ 36.4, SD ¼ 4.3 vs. M ¼ 39.1, SD ¼ 6.1; F(1, 172) ¼ 10.75, p ¼ .001). Participants who ate breakfast every day also reported greater cognitive restraint as measured by the TFEQ subscale (M ¼ 7.04, SD ¼ 3.22 vs. M ¼ 8.06, SD ¼ 3.46; F(1, 170) ¼ 3.95, p ¼ .049).
What percentage of patients with BED regularly eat three meals per day, and is meal regularity associated with weight and binge eating? Participants were categorized based on whether they reported eating three meals per day, every day, in the past 28 days (i.e., reported a 6 on each of the three EDE items corresponding to breakfast, lunch and dinner) or not. Participants who ate three meals per day, every day, comprised about one-third of the sample (n ¼ 56; 32.4%) and participants who did not regularly eat three meals per day comprised about two-thirds of the sample (n ¼ 117; 67.6%). A comparison of these two groups on BMI, binge eating and the eating disorder features was performed. The means and standard deviations for the overall sample and the two subgroups, as well as the results from the ANOVA, are displayed in Table 3. Participants who ate three meals per day, every day, weighed significantly less than those who did not (M ¼ 36.2, SD ¼ 4.3 vs. M ¼ 38.7, SD ¼ 5.9; F(1, 172) ¼ 7.95, p ¼ .005). In addition, those who ate three meals per day reported significantly fewer objective bulimic days in the past 28 days than those who did not (M ¼ 12.7, SD ¼ 5.7 vs. M ¼ 14.7, SD ¼ 6.0; F(1, 172) ¼ 4.24, p ¼ .041). The two groups reported similarly on eating disorder features other than weight and binge eating.
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Table 3 Means, standard deviations, and ANOVA for eating-related measures by three-meal per day eaters vs. non-three-meal per day eaters Eating-related measures
Overall sample (n ¼ 173)
Three-meal per day eaters (n ¼ 56)
Non-three-meal per day eaters (n ¼ 117)
ANOVA
Mean
(SD)
Mean
(SD)
Mean
(SD)
F
p
37.9
(5.6)
36.2
(4.2)
38.7
(6.0)
8.13
.005
EDE binge eating Objective bulimic days 14.0 Objective bulimic episodes 15.7
(5.9) (8.3)
12.7 14.2
(5.7) (8.5)
14.7 16.4
(6.0) (8.1)
4.24 2.58
.041 .110
Eating disorder features EDE restraint EDE eating concern EDE shape concern EDE weight concern TFEQ cognitive restraint TFEQ disinhibition TFEQ hunger
(6.6) (6.8) (7.4) (4.6) (3.4) (2.2) (3.3)
9.0 11.6 26.5 16.4 7.1 13.4 9.8
(6.2) (7.2) (7.2) (4.8) (3.2) (2.1) (3.3)
8.9 10.8 26.5 16.2 7.9 13.3 9.5
(6.8) (6.6) (7.5) (4.5) (3.5) (2.3) (3.3)
0.01 0.55 0.00 0.04 2.00 0.03 0.31
.943 .458 .983 .840 .159 .861 .581
BMI
8.9 11.0 26.5 16.3 7.6 13.3 9.6
Note: BMI ¼ body mass index; EDE ¼ Eating Disorder Examination; TFEQ ¼ Three-Factor Eating Questionnaire.
Discussion CBT is currently the best-established treatment for BED (NICE, 2004; Wilson, 2005). At the core of the CBT treatment for BED, and what distinguishes this treatment from CBT treatment for other disorders, is the prescription of a pattern of regular eating (i.e., three meals per day, alternating with two or three planned snacks; Fairburn et al., 1993). Inherent in this prescription is the assumption that these patients engage in erratic eating schedules, and that in turn, erratic eating schedules lead to and/or maintain binge eating. Little is known, however, about the relationship between eating patterns, and binge eating and weight (TanofskyKraff & Yanovski, 2004), although some laboratory studies found that individuals with BED eat larger quantities of food than individuals without BED (see review, Walsh & Boudreau, 2003). Furthermore, a variety of research studies have found that breakfast consumption is important for weight control (Ruxton & Kirk, 1997; Schlundt et al., 1992; Wyatt et al., 2002). The present study explored the frequency and regularity of meals and snacks eaten by obese patients with BED, and investigated whether eating patterns and breakfast consumption are related to weight and binge eating. In this consecutively evaluated series of obese patients with BED, eating patterns and breakfast consumption were found to have an important relationship with weight based upon findings from the EDE. Participants who ate more frequently, both in terms of meals and snacks, weighed less. In particular, breakfast and lunch, but not dinner, were related to weight with breakfast having a stronger relationship to weight than lunch. This extends the well-established relationship between breakfast eating and lower weight (see review, Ruxton & Kirk, 1997) to individuals with BED. Interestingly, breakfast was the least frequently eaten meal in this sample, with less than half (43%) of participants consuming breakfast on a daily basis, in contrast to two epidemiologic studies of adults in the US of which approximately 75% reported regularly eating breakfast (Haines, Guilkey, & Popkin, 1996; Morgan et al., 1986). Data from the present study also seem to support that generally eating earlier in the day is related to lower weight, a finding consistent with a previous study comparing obese and non-obese Swedish women (Berteus Forslund, Lindroos, Sjostrom, & Lissner, 2002). Among the BED participants, those who ate three meals per day weighed less than those who did not regularly eat three meals per day. Thus, eating more frequently, particularly having breakfast and three meals every day, has potentially important clinical applications for obese BED patients with regard to weight. We also examined the associations between eating patterns and binge eating. While there were no relationships between binge eating and specific meals of the day, eating three meals per day was related to
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binge eating. Those who ate three meals per day (about one-third of the sample) reported fewer binge days than those individuals who did not regularly eat three meals per day (about two-thirds of the sample). In addition, daily evening snacking occurred in about one-half of the sample, and occurred more frequently than mid-morning snacking (16%) and mid-afternoon snacking (30%). Evening snacking was related to hunger and binge eating, suggesting that eating in the evening may be a way to control satiety but may also represent a particularly vulnerable time for binge eating. Surprisingly, evening snacking was related to not higher, but lower, weight. One area not examined in the present study was whether a proportion of evening eating episodes began as snacks and developed into binge episodes. A more detailed examination of evening eating and its relationship to weight and binge eating may help to explain these seemingly contradictory findings and provide important insights about the role of evening snacking. These data leave unanswered many important questions. Comparisons of BED patients with other samples would provide a context for understanding the eating patterns of this population. While findings from this study seem to support the importance of frequent food consumption, a study by Allison et al. (2005) found that individuals with BED already eat more frequently than overweight individuals without BED. Beyond eating three meals per day and consuming breakfast, little is known about other aspects of eating behavior (e.g., the timing of meals and snacks, the speed of eating, objective overeating episodes, and continual grazing) and their relations to binge eating and weight. Tanofsky-Kraff and Yanovski (2004) have highlighted the need for a better understanding of ‘‘non-normative’’ eating behaviors and their role in energy balance for individuals at risk for overweight or obesity. Knowing whether changes in eating patterns and breakfast consumption lead to changes in weight and binge eating may be critical in identifying effective components within treatments, particularly CBT treatment, for BED. For example, one treatment study (Schlundt et al., 1992) demonstrated that eating breakfast helped to reduce dietary fat intake and minimize impulsive snacking among obese women. We note potential limitations to consider. First, participants were overweight individuals with BED seeking treatment to stop binge eating and lose weight at a university medical center. Thus, results may not be generalizable to non-treatment seeking patients, or to patients seeking treatments for other reasons (Fitzgibbon, Stolley, & Kirschenbaum, 1993). Second, the EDE is based on retrospective recall of the past 28 days, and reliance on self-report of food consumption may be misleading because it is known that obese individuals underestimate their food intake (Buhl, Gallagher, Hoy, Matthews, & Heymsfield, 1995; Lichtman et al., 1992). Third, there were aspects of eating patterns that were not captured in this assessment and analysis. For example, the assessment of eating patterns in the present study did not include times when participants may have eaten more than three meals and three snacks per day. Fourth, our assessment did not include a nutritional or caloric assessment. Future studies should include detailed food record assessments to provide such needed information as we cannot speak to the size or nutritional characteristics of the meals and snacks reported here. Lastly, and most importantly, the present study was correlational in design and did not include a comparison sample. Thus, the results do not provide evidence for the effectiveness of establishing regular eating patterns in individuals with BED. Studies using experimental designs (e.g., Schlundt et al., 1992) are needed to determine the utility of specific meal prescriptions for managing weight in this obese patient group.
Conclusion In this consecutively evaluated series of BED individuals, eating three meals per day and breakfast consumption were significantly associated with BMI. We hypothesize that these eating behaviors help to reduce overall daily energy intake, thus suppressing weight. Data from this study also support the notion that frequent eating episodes serve to interrupt the cycle of binge eating. Our findings have important clinical implications given that the effectiveness of specific interventions within treatments for BED are unknown, and that weight loss outcome for BED has been poor. Whether changes in eating patterns and breakfast consumption are associated with changes in weight and binge eating remains unknown. Future investigations are also needed to assess the nutritional composition of meals and snacks consumed by these patients.
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