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Replacing the term “binge eating” with “loss of control over eating” affects eating disorder screening in clinical care
Obesity Research & Clinical Practice (2015) 9, 531—532
RESEARCH LETTER Replacing the term ‘‘binge eating’’ with ‘‘loss of control over eating’’ affects eating disorder screening in clinical care
Table 1 Results from screening instruments and clinical interviews (n = 338). Interview by psychologists
Having episodes of binge eating is central to the binge eating disorder (BED) and bulimia nervosa (BN) diagnoses but may be difficult to assess accurately through self-report instruments and estimates of prevalence varies [1,2]. Some researchers have reported lower levels of binge eating in clinical interviews where interviewers may use follow up questions and correct misunderstandings, compared with self-report questionnaires [3]. Another reason for mixed results may be the negative stigma of binge eating behaviours and thus the embarrassment of admitting having binge eating episodes [4,5]. Having episodes of binge eating is associated with shame and guilt which might hamper report even in clinical settings [6—8]. It may thus be important to investigate whether using the more neutral term ‘‘loss of control over eating’’ instead of ‘‘binge eating’’ may lead to more valid responses in self-report instruments. In a recent study at an obesity clinic, 338 participants were randomized to either answer the original self-report instrument EDO (EDO BE) or an alternative version of the EDO (EDO LOC) where the term ‘‘binge eating’’ had been replaced with ‘‘loss of control over eating’’ [9]. In subsequent interviews made by nurses, 94 (28%) participants reported symptoms of disordered eating and were referred to psychological assessment where 46 (14%) participants were diagnosed as having an eating disorder, see Table 1. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and diagnostic odds ratio (DOR) were calculated for each instrument [10]. The EDO LOC provided higher sensitivity but lower specificity than the EDO BE while the DOR, an overall measure of test quality, was higher for the EDO BE than the EDO LOC, see Table 2.
No ED diagnosis
BED diagnosis
EDO BE Positive 10 screening Negative 136 screening EDO LOC Positive 23 screening Negative 123 screening
BN diagnosis
14
6
2
0
10
13
1
0
Note: EDO BE = eating disorder in obesity binge eating version, EDO LOC = eating disorder in obesity loss of control version, ED = eating disorder, BED = binge eating disorder, BN = bulimia nervosa.
Table 2 Diagnostic test indicators for the two versions of the instrument (n = 338).
Sensitivity Specificity PPV NPV Accuracy DOR
EDO BE
EDO LOC
.91 .93 .67 .99 .93 136
.96 .84 .50 .99 .86 123
Note: PPV = positive predictive value, NPV = negative predictive value, DOR = diagnostic odds ratio, EDO BE = eating disorder in obesity binge eating version, EDO LOC = eating disorder in obesity loss of control version.
These results indicate that a higher proportion of people agree to having episodes where they ‘‘lose control over eating’’ than having ‘‘binge eating’’. Some of those who reported losing control did not full fill other criteria for eating disorders and were not diagnosed in the interviews. Using
http://dx.doi.org/10.1016/j.orcp.2015.05.006 1871-403X/© 2015 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
532
Research Letter
the term ‘‘loss of control’’ in the screening instrument may thus result in a larger proportion of positive screening which also leads to more false positive cases and in the end to a higher work load for clinicians who have to perform the confirmatory interviews. The lower DOR of the EDO LOC indicates that this tradeoff may not be beneficiary for the instrument. The importance placed on sensitivity and specificity is however dependent on the circumstances and purpose of using a screening instrument. In a clinical setting where patients with potential eating disorders need to be identified, for example prior to bariatric surgery, a high sensitivity may well offset a lower specificity [11].
Conflict of interest The author reports no conflicts of interest.
References [1] Grilo CM, Masheb RM, Wilson GT. Different methods for assessing the features of eating disorders in patients with binge eating disorder: a replication. Obes Res 2001;9(7):418—22. [2] Striegel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eat Disord 2003;34(S1):S19—29. [3] De Zwaan M, Mitchell JE, Specker SM, Pyle RL, Mussell MP, Seim HC. Diagnosing binge eating disorder: level of agreement between self-report and expert-rating. Int J Eat Disord 1993;14(3):289—95.
[4] Bannon KL, Hunter-Reel D, Wilson GT, Karlin RA. The effects of causal beliefs and binge eating on the stigmatization of obesity. Int J Eat Disord 2009;42(2):118—24. [5] Jambekar SA, Masheb RM, Grilo CM. Gender differences in shame in patients with binge-eating disorder. Obes Res 2003;11(4):571—7. [6] Sanftner JL, Barlow DH, Marschall DE, Tangney JP. The relation of shame and guilt to eating disorder symptomatology. J Soc Clin Psychol 1995;14(4):315—24. [7] Burney J, Irwin HJ. Shame and guilt in women with eatingdisorder symptomatology. J Clin Psychol 2000;56(1):51—61. [8] Swan S, Andrews B. The relationship between shame, eating disorders and disclosure in treatment. Br J Clin Psychol 2003;42(4):367—78. [9] de Man J, Ghaderi A, Halvarsson-Edlund K, Norring C. Psychometric properties of the eating disorders in obesity questionnaire: validating against the Eating Disorder Examination interview. Eat Weight Disord — Stud Anorex Bulim Obes 2007;12(4):168—75. [10] Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM. The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol 2003;56(11):1129—35. [11] Mitchell J, Steffen K, de Zwaan M, Ertelt T, Marino J, Mueller A. Congruence between clinical and research-based psychiatric assessment in bariatric surgical candidates. Surg Obes Relat Dis 2010;6(6):628—34.
Sven Alfonsson ∗ Department of Public Health and Caring Sciences, Uppsala University, Sweden ∗ Correspondence to: Department of Public Health and Caring Sciences, Uppsala University, Husargatan 3, Box 564, 752 37 Uppsala, Sweden. Tel.: +46 184716194; fax: +46 184716675. E-mail address: [email protected]
Available online at www.sciencedirect.com
ScienceDirect
7 April 2015
RESEARCH LETTER Replacing the term ‘‘binge eating’’ with ‘‘loss of control over eating’’ affects eating disorder screening in clinical care
Table 1 Results from screening instruments and clinical interviews (n = 338). Interview by psychologists
Having episodes of binge eating is central to the binge eating disorder (BED) and bulimia nervosa (BN) diagnoses but may be difficult to assess accurately through self-report instruments and estimates of prevalence varies [1,2]. Some researchers have reported lower levels of binge eating in clinical interviews where interviewers may use follow up questions and correct misunderstandings, compared with self-report questionnaires [3]. Another reason for mixed results may be the negative stigma of binge eating behaviours and thus the embarrassment of admitting having binge eating episodes [4,5]. Having episodes of binge eating is associated with shame and guilt which might hamper report even in clinical settings [6—8]. It may thus be important to investigate whether using the more neutral term ‘‘loss of control over eating’’ instead of ‘‘binge eating’’ may lead to more valid responses in self-report instruments. In a recent study at an obesity clinic, 338 participants were randomized to either answer the original self-report instrument EDO (EDO BE) or an alternative version of the EDO (EDO LOC) where the term ‘‘binge eating’’ had been replaced with ‘‘loss of control over eating’’ [9]. In subsequent interviews made by nurses, 94 (28%) participants reported symptoms of disordered eating and were referred to psychological assessment where 46 (14%) participants were diagnosed as having an eating disorder, see Table 1. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and diagnostic odds ratio (DOR) were calculated for each instrument [10]. The EDO LOC provided higher sensitivity but lower specificity than the EDO BE while the DOR, an overall measure of test quality, was higher for the EDO BE than the EDO LOC, see Table 2.
No ED diagnosis
BED diagnosis
EDO BE Positive 10 screening Negative 136 screening EDO LOC Positive 23 screening Negative 123 screening
BN diagnosis
14
6
2
0
10
13
1
0
Note: EDO BE = eating disorder in obesity binge eating version, EDO LOC = eating disorder in obesity loss of control version, ED = eating disorder, BED = binge eating disorder, BN = bulimia nervosa.
Table 2 Diagnostic test indicators for the two versions of the instrument (n = 338).
Sensitivity Specificity PPV NPV Accuracy DOR
EDO BE
EDO LOC
.91 .93 .67 .99 .93 136
.96 .84 .50 .99 .86 123
Note: PPV = positive predictive value, NPV = negative predictive value, DOR = diagnostic odds ratio, EDO BE = eating disorder in obesity binge eating version, EDO LOC = eating disorder in obesity loss of control version.
These results indicate that a higher proportion of people agree to having episodes where they ‘‘lose control over eating’’ than having ‘‘binge eating’’. Some of those who reported losing control did not full fill other criteria for eating disorders and were not diagnosed in the interviews. Using
http://dx.doi.org/10.1016/j.orcp.2015.05.006 1871-403X/© 2015 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
532
Research Letter
the term ‘‘loss of control’’ in the screening instrument may thus result in a larger proportion of positive screening which also leads to more false positive cases and in the end to a higher work load for clinicians who have to perform the confirmatory interviews. The lower DOR of the EDO LOC indicates that this tradeoff may not be beneficiary for the instrument. The importance placed on sensitivity and specificity is however dependent on the circumstances and purpose of using a screening instrument. In a clinical setting where patients with potential eating disorders need to be identified, for example prior to bariatric surgery, a high sensitivity may well offset a lower specificity [11].
Conflict of interest The author reports no conflicts of interest.
References [1] Grilo CM, Masheb RM, Wilson GT. Different methods for assessing the features of eating disorders in patients with binge eating disorder: a replication. Obes Res 2001;9(7):418—22. [2] Striegel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eat Disord 2003;34(S1):S19—29. [3] De Zwaan M, Mitchell JE, Specker SM, Pyle RL, Mussell MP, Seim HC. Diagnosing binge eating disorder: level of agreement between self-report and expert-rating. Int J Eat Disord 1993;14(3):289—95.
[4] Bannon KL, Hunter-Reel D, Wilson GT, Karlin RA. The effects of causal beliefs and binge eating on the stigmatization of obesity. Int J Eat Disord 2009;42(2):118—24. [5] Jambekar SA, Masheb RM, Grilo CM. Gender differences in shame in patients with binge-eating disorder. Obes Res 2003;11(4):571—7. [6] Sanftner JL, Barlow DH, Marschall DE, Tangney JP. The relation of shame and guilt to eating disorder symptomatology. J Soc Clin Psychol 1995;14(4):315—24. [7] Burney J, Irwin HJ. Shame and guilt in women with eatingdisorder symptomatology. J Clin Psychol 2000;56(1):51—61. [8] Swan S, Andrews B. The relationship between shame, eating disorders and disclosure in treatment. Br J Clin Psychol 2003;42(4):367—78. [9] de Man J, Ghaderi A, Halvarsson-Edlund K, Norring C. Psychometric properties of the eating disorders in obesity questionnaire: validating against the Eating Disorder Examination interview. Eat Weight Disord — Stud Anorex Bulim Obes 2007;12(4):168—75. [10] Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM. The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol 2003;56(11):1129—35. [11] Mitchell J, Steffen K, de Zwaan M, Ertelt T, Marino J, Mueller A. Congruence between clinical and research-based psychiatric assessment in bariatric surgical candidates. Surg Obes Relat Dis 2010;6(6):628—34.
Sven Alfonsson ∗ Department of Public Health and Caring Sciences, Uppsala University, Sweden ∗ Correspondence to: Department of Public Health and Caring Sciences, Uppsala University, Husargatan 3, Box 564, 752 37 Uppsala, Sweden. Tel.: +46 184716194; fax: +46 184716675. E-mail address: [email protected]
Available online at www.sciencedirect.com
ScienceDirect
7 April 2015