Symptoms of ‘food addiction’ in binge eating disorder using the Yale Food Addiction Scale version 2.0

Accepted Manuscript Symptoms of ‘food addiction’ in binge eating disorder using the Yale Food Addiction Scale version 2.0 Jacqueline C. Carter, Megan Van Wijk, Marsha Rowsell PII:

S0195-6663(18)30949-8

DOI:

https://doi.org/10.1016/j.appet.2018.11.032

Reference:

APPET 4108

To appear in:

Appetite

Received Date: 27 June 2018 Revised Date:

14 November 2018

Accepted Date: 29 November 2018

Please cite this article as: Carter J.C., Van Wijk M. & Rowsell M., Symptoms of ‘food addiction’ in binge eating disorder using the Yale Food Addiction Scale version 2.0, Appetite (2018), doi: https:// doi.org/10.1016/j.appet.2018.11.032. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT 1 1 2 3 Symptoms of ‘Food Addiction’ in Binge Eating Disorder

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Using the Yale Food Addiction Scale Version 2.0

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Running head: ‘FOOD ADDICTION’ AND BINGE EATING DISORDER

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Jacqueline C. Carter, D.Phil.

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Megan Van Wijk, B.Sc.

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Marsha Rowsell, M.Sc.

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Department of Psychology

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Memorial University of Newfoundland

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St. John’s, NL, Canada

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Correspondence: Dr. J.C. Carter, Department of Psychology, Memorial University of

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Newfoundland, St. John’s, NL, A1C 5S7, Canada, email: [email protected]

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Abstract

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‘Food addiction’ refers to the idea that certain highly palatable foods can trigger an addictive-like process in susceptible individuals. The aim of this study was to assess the

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prevalence and clinical significance of ‘food addiction’ symptoms in binge eating disorder

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(BED) using the second version of the Yale Food Addiction Scale (YFAS 2.0). Participants were

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71 individuals with BED and 79 individuals with no history of an eating disorder (NED). The

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Eating Disorder Examination (EDE) was used to diagnose BED and to measure binge eating.

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Participants completed self-report measures of eating disorder psychopathology, psychological

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distress, and the YFAS 2.0. Results indicated that the BED group reported significantly higher

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‘food addiction’ scores compared to the NED group after controlling for relevant covariates. In

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fact, 92% of the BED group met YFAS 2.0 criteria for at least mild ‘food addiction’ compared to

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only 6% of the NED group. BED participants who met criteria for Moderate/Severe ‘food

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addiction’ reported significantly higher eating disorder psychopathology (except dietary

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restraint) as well as higher levels of anxiety and depression than BED participants with No/Mild

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‘food addiction’. Scores on the YFAS 2.0 positively predicted binge frequency, but not global

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eating disorder psychopathology, in the BED group after controlling for body mass index (BMI),

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depression and anxiety. The high rate of ‘food addiction’ symptoms in the BED group may

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reflect overlap between the symptoms assessed by the YFAS 2.0 and the clinical features of

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BED. A focus on identifying overlapping and distinctive underlying mechanisms rather than

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similarities and differences in clinical features might be a more fruitful avenue for future

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research on BED and ‘food addiction’.

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Keywords: binge eating disorder, food addiction

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1. Introduction Scientific evidence for the concept of ‘food addiction’ has grown over the past decade. However, the idea that certain highly palatable foods (or certain ingredients added to foods such

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as fat, sugar or salt) can trigger an addictive-like process among susceptible individuals

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continues to be controversial. Evidence of clinical, psychological, and neurobiological parallels

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between compulsive overeating and addictive disorders has accumulated (for a review see

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Carter, Kenny & Davis 2018). Initial evidence came from animal models of feeding behavior

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(e.g., Avena, Rada & Hoebel, 2008) and subsequent neuroscience research showed that highly

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palatable food and addictive drugs activate the same reward systems (e.g., dopamine and

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endogenous opioid systems) in the brain (Gearhardt, et al., 2011; Johnson & Kenny, 2010). In

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addition, repeated consumption of highly palatable foods or addictive drugs produce similar

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neuroadaptations that promote an escalation of food or drug intake (Bello & Hajnal, 2010).

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Further evidence comes from clinical and behavioral similarities between binge eating disorder

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(BED) and substance use disorders (SUD) including loss of control, cravings, inability to cut

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down, and continued “use” despite negative consequences (Carter et al., 2018; Davis & Carter,

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2014). BED is characterized by recurrent binge eating (i.e., eating an abnormally large amount of

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food, given the context, accompanied by a sense of loss of control) in the absence of extreme

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compensatory behavior such as purging (American Psychiatric Association [APA], 2013). There

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is also evidence of shared underlying mechanisms in BED and SUD such as impulsivity, reward

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dysfunction, decision-making deficits and emotion regulation deficits (Kenny, Singleton &

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Carter, 2017; Manasse et al., 2015; Manwaring, Green, Myerson, Strube & Wilfley, 2011;

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Schulte, Grilo & Gearhardt, 2016). While BED and ‘food addiction’ also have unique clinical

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features, such as overconcern about shape and weight in BED (Schulte et al., 2016), some

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ACCEPTED MANUSCRIPT 4 researchers have argued that an addiction perspective might be relevant for a subset of

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individuals with BED (Davis, 2013; Davis & Carter, 2014). However, there has been little

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research on the prevalence or significance of ‘food addiction’ symptoms in individuals diagnosed

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with BED.

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The Yale Food Addiction Scale (YFAS; Gearhardt et al., 2012) was developed to

operationalize the “food addiction” construct by applying the 4th edition of the Diagnostic and

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Statistical Manual of Mental Disorders (DSM-IV; APA, 2000) diagnostic criteria for substance

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dependence to eating behavior. Using the YFAS, food addiction symptoms have been found to

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be elevated among individuals with BED, with 25-57% meeting the YFAS criteria for ‘food

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addiction’ (Gearhardt et al., 2012; Gearhardt, White, Masheb & Grilo, 2013). In another study,

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72% of obese individuals who met YFAS criteria for ‘food addiction’ also met criteria for BED

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(Davis et al., 2011) and these individuals reported more frequent binge eating, more intense food

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cravings, more emotional eating, as well as greater depression symptoms than those with BED

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who did not meet the YFAS criteria for ‘food addiction’ (Davis, 2013).

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To date, two studies have examined whether YFAS “food addiction” is predictive of the severity of eating disorder symptoms or general psychopathology in BED. In the first study,

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Gearhardt and colleagues (2012) reported that 57% of 81 obese BED patients presenting to a

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specialized eating disorder clinic met the YFAS criteria for ‘food addiction’. This subset of

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patients had significantly higher lifetime mood disorder diagnoses, higher scores on measures of

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depression and emotion dysregulation, as well as lower self-esteem compared to those who did

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not meet the YFAS criteria for ‘food addiction’. In addition, higher YFAS scores were associated

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with more severe eating disorder psychopathology including eating concern, shape concern and

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weight concern (except dietary restraint) and predicted more frequent binge eating after

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ACCEPTED MANUSCRIPT 5 controlling for mood and eating disorder psychopathology. In the second study, Gearhardt and

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colleagues (2013) studied 96 obese patients with BED who sought treatment in a primary care

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clinic. Of these, it was similarly found that the 42% of patients classified with YFAS ‘food

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addiction’ reported higher negative affect, more emotion dysregulation, lower self-esteem and

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earlier onset of overweight. In addition, higher YFAS symptom counts were associated with

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more frequent binge eating and greater eating disorder psychopathology (except dietary

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restraint). After controlling for global eating disorder psychopathology and negative affect,

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YFAS total score significantly predicted the frequency of binge eating.

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An updated version of the YFAS based on the DSM-5 diagnostic criteria for substance-

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related and addictive disorders (previously called substance use disorders) has recently been

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published (YFAS 2.0; Gearhardt, Corbin & Brownell, 2016). To reflect scientific progress in the

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field of addiction, a number of revisions were made to the diagnostic criteria for substance-

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related disorders in the DMS-5. First, substance abuse and substance dependence were merged to

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create a single substance-related disorder. Second, ‘craving’ or a strong desire to use a substance

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was added as a diagnostic criterion (Hasin et al., 2013). In addition, withdrawal and tolerance

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were no longer required for a diagnosis. Other changes included the addition of a diagnostic

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continuum of severity ranging from mild (2-3 symptoms) to severe (6+ symptoms) depending on

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the number of substance-related symptoms present. The YFAS 2.0 was designed to reflect these

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changes in the diagnostic criteria for substance use disorder and it has been demonstrated to have

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good psychometric properties (Gearhardt et al., 2016).

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To our knowledge there have only been two studies of the YFAS 2.0 in individuals

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identified as having binge eating problems. Gearhardt, Corbin & Brownell, (2016) reported that

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47.2% of 36 participants with BED met YFAS 2.0 criteria for ‘food addiction’ and that higher

ACCEPTED MANUSCRIPT 6 YFAS 2.0 symptom scores predicted more frequent binge eating. However, in this study, BED

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participants were obtained from a large sample of people recruited using the Mechanical Turk

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(MTurk) worker pool there and BED classification was made using an on-line self-report

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questionnaire which is considered to be less reliable method of diagnosis than interview-based

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diagnostic measures (Berg & Peterson, 2013). In the second study, it was reported that scores on

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the Binge Eating Scale (BES; Gormally, Black, Daston & Rardin, 1982), a continuous self-report

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measure of binge eating severity, were positively correlated with scores on the YFAS 2.0 in an

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on-line survey of a large community sample recruited through social media (Burrows, Skinner,

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McKenna & Rollo, 2017). To our knowledge, there have been no published studies to date of

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YFAS 2.0 ‘food addiction’ symptoms among individuals diagnosed with BED. Taken together, the research on BED and ‘food addiction’ suggests that the presence of ‘food addiction’ symptoms may indicate a more severe presentation in BED both in terms of

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eating disorder psychopathology (except dietary restraint) and psychological disturbances.

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However, to date, there have been no studies of YFAS 2.0 ‘food addiction’ symptoms among

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individuals diagnosed with BED. Thus, the current study had three aims. The first aim was to

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examine whether a community sample of individuals diagnosed with BED reported significantly

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more symptoms of ‘food addiction’ and were more likely to meet criteria for a classification of

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‘food addiction’ based on the YFAS 2.0 as compared with a community sample of individuals

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with no history of an eating disorder (NED). Findings based on community samples are likely to

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be more generalizable than studies of samples recruited from clinical settings since many people

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with BED do not seek or receive specialized treatment (Grilo, White, Gueorguieva, Barnes &

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Masheb, 2013). It was hypothesized that BED participants would report higher ‘food addiction’

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symptom counts and be more likely to meet the YFAS 2.0 criteria for ‘food addiction’ than the

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control group, after controlling for relevant covariates. The second aim was to extend previous findings by examining the significance of ‘food

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addiction’ symptoms in BED by comparing BED participants who did and did not meet YFAS

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2.0 criteria for ‘food addiction’ in terms of the severity of eating disorder symptoms and general

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psychopathology, after controlling for relevant covariates. It was hypothesized that those who

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met the YFAS 2.0 criteria for ‘food addiction’ would report significantly more severe eating

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disorder symptoms and significantly higher levels of general psychopathology than those who

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did not.

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The final aim was to determine whether YFAS 2.0 scores would predict unique variance in the severity of eating disorder psychopathology and the frequency of binge eating in BED

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after controlling for relevant covariates. Based on previous findings using the YFAS, it was

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hypothesized that higher YFAS 2.0 scores would be associated with more severe eating disorder

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psychopathology and higher binge frequency.

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2. Method

All study procedures were approved by the local Health Research Ethics Board.

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Individuals with BED and individuals with no history of an eating disorder (NED) were recruited

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from the community in a small city in eastern Canada as well as the surrounding rural areas of

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the province through advertisements on social media, websites of community organizations,

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local radio stations, newspapers, as well as posters in universities, hospitals, and medical clinics,

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looking for individuals who were “concerned about overeating” (BED group) or “interested in

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food and mood” (NED group). Both groups were recruited between October 2016 and November

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2017.

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2.1. Participants

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BED group

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Individuals in the BED group were recruited for a randomized controlled treatment trial (Carter et al., 2018). The current study focused on data collected at baseline. People were eligible

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to participate in the treatment trial if they met the DSM-5 diagnostic criteria for BED according

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to the Eating Disorder Examination 17.0 (EDE 17.0) interview (Fairburn, Cooper, & O’Connor,

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2014). Additional inclusion criteria for the trial included: (1) age between 19 and 65 years; (2)

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body mass index (BMI) of 18.5 kg/m2 or higher; (3) high school diploma or equivalent; (4)

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access to a device with a microphone and camera, as well as Wi-Fi1; (5) ability to read and write

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in English. The exclusion criteria for the trial were: (1) current treatment for binge eating from a

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registered psychologist, (2) major medical illness (e.g., type II diabetes), (3) current pregnancy,

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(4) current acute suicidal ideation or, (5) exceeding a cut-off of 5 on the Drug Abuse Screening

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Test (DAST-10; Skinner, 1982) or 16 on the Alcohol Use Disorders Identification Test (AUDIT;

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Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) indicating a likely substance use

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disorder. Individuals on a stable dose of antidepressants or sleep medication over the past three

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months were eligible to participate.

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NED group

Control group participants responded to an advertisement for people “interested in taking

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part in a study on food and mood”. Individuals were ineligible to participate in the NED group if

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they reported a current or previous ED diagnosis or exceeded a cut-off of 3 on the SCOFF, a

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five-item yes/no screening questionnaire for the identification of individuals at risk of an ED

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(Morgan, Reid, & Lacey, 1999). All other inclusion and exclusion criteria for the NED group

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were identical to those for the BED group in order to ensure the two groups were otherwise as 1

This was because the trial was evaluating a guided self-help treatment delivered via videoconferencing.

ACCEPTED MANUSCRIPT 9 similar as possible. Subsequently, the NED group was divided into two subgroups: those

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reporting a BMI between 18.5 and 25 kg/m2 (normal weight group [NW]) and those reporting a

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BMI of 25 kg/m2 or higher (overweight group [OW]).

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2.2. Procedure

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Potential participants completed an online screening questionnaire. Those who appeared to meet the study inclusion criteria (as described above) for the NED group based on their

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screening questionnaire results were sent a link to the study questionnaires. Individuals who

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appeared to meet the inclusion criteria (as described above) for the BED group were invited to

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participate in a brief version of the EDE 17.0 with a researcher over the telephone to confirm a

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DSM-5 BED diagnosis. Each case was closely supervised and reviewed by a licensed clinical

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psychologist with extensive experience with both the EDE interview and the diagnosis of BED

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(JCC). Only the BED diagnostic module and questions used to assess extreme compensatory

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behaviors (i.e., self-induced vomiting, laxative/diuretic misuse, excessive exercise, avoidance of

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eating) were administered. Prospective participants were classified as meeting BED criteria if

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they reported at least 12 objective binge episodes within the past three months in the absence

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regular extreme compensatory behaviors (i.e., conservatively defined as fewer than six episodes

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over the past six months). Eligible participants were then sent a link to the study questionnaires,

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which were identical to those completed by the NED group. With the exception of the telephone

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interview, all data were collected online via Qualtrics.

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2.3. Measures

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2.3.1. Demographics

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ACCEPTED MANUSCRIPT 10 Demographics, weight and height were assessed using a brief questionnaire designed for

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this study. Participants were asked to report their age, sex, ethnicity, marital status, highest level

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of education, employment status, as well as their current weight and height.

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2.3.2. Measure of binge eating frequency

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The Eating Disorder Examination 17.0 (EDE 17.0; Fairburn et al., 2014) was used to diagnose BED and to measure binge eating frequency. The EDE is a well validated (for review

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see Berg, Peterson, Frazier, & Crow, 2012), investigator-based interview of ED

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psychopathology. In the current study, only the items necessary to diagnose BED were

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administered. Individuals met the diagnostic criteria for BED if they reported: (1) at least weekly

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objective binge episodes (OBE; i.e., the amount of food was objectively large, and the individual

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experienced a sense of loss of control) over the past three months; (2) at least three binge

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characteristics such as consuming food faster than normal, consuming large amounts of food

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when not hungry, and feeling disgusted, depressed, or guilty after eating a large amount of food;

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(3) distress and/or impairment related to binge eating (APA, 2013). To ensure that we were not

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mistakenly including individuals with non-purging forms of bulimia nervosa, we developed a

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conservative operational definition of regular compensatory behavior. Specifically, “regular

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compensatory behavior” was defined as self-induced vomiting, laxative or diuretic misuse

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(taking at least twice the recommended dosage), excessive exercise (exercise that is excessive in

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terms of duration, intensity, and frequency, interferes with daily functioning, and may cause the

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person physical harm), or fasting (not eating anything for a period of eight or more waking

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hours) at least once per month over the past six months. Thus, individuals who reported engaging

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in any of these compensatory behaviors at least once per month over the past six months were

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excluded. Binge frequency was measured during the EDE 17.0 telephone interview. The total

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number of binge episodes over the previous three months (as this is the diagnostic period for

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BED) was recorded.

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2.3.3. Measure of eating disorder psychopathology The Eating Disorder Examination Questionnaire 6.0 (EDE-Q 6.0; Fairburn, 2008) was

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used to measure other aspects of eating disorder psychopathology. The EDE-Q is a self-report

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questionnaire based on the EDE interview (Fairburn et al., 2014). All items are rated on a 7-point

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scale with higher scores indicating more severe ED psychopathology. The reliability and validity

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of the EDE-Q 6.0 have been well established (for a review see Berg et al., 2012). However,

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factor analysis of the EDE-Q 6.0 has been more variable (Berg et al., 2012; Grilo et al., 2010). In

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the current study, we used a modified seven-item, three-factor version of the EDE-Q 6.0 as it has

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been validated in both men and women (Grilo, Reas, Hopwood, & Crosby, 2015), in bariatric

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surgery candidates (Grilo, Henderson, Bell, & Crosby, 2013), and in patients with BED (Grilo et

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al., 2010). This version of the EDE-Q 6.0 provides three subscales: (1) Dietary Restraint; (2)

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Body Dissatisfaction; (3) Overvaluation of shape and weight. A Global score is calculated by

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taking the average of the three subscale scores. In the current study, internal consistency was

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good for the Global (Cronbach’s alpha = .84), Dietary Restraint (Cronbach’s alpha = .89), and

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Body Dissatisfaction (Cronbach’s alpha = .89) scales, and excellent for the Overvaluation scale

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(Cronbach’s alpha = .97).

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2.3.4. Measure of depression and anxiety

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The Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) was used to assess

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symptoms of depression and anxiety. The BSI is a 53-item self-report questionnaire that

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measures how often an individual has been distressed by various symptoms over the past week.

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In the current study we adapted the time frame to four weeks (instead of one week) to correspond

ACCEPTED MANUSCRIPT 12 with the timeframe of our measure of eating disorder psychopathology (i.e., EDE-Q). BSI items

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are rated on a 5-point scale from “0” (not at all) to “4” (extremely). While the BSI assesses nine

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symptom groups, we only examined the depression and anxiety subscales in the current study.

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Each of these subscales is composed of six items. The validity and reliability of the BSI have

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been well established (Derogatis & Melisaratos, 1983). In the present study, internal consistency

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was good for both the anxiety (Cronbach’s alpha = .87) and depression (Cronbach’s alpha =

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.88) subscales.

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2.3.5. Measure of ‘food addiction’

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‘food addiction’ symptoms. The YFAS 2.0 is a self-report questionnaire based on the DSM-5

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diagnostic criteria for substance-related and addictive disorders modified for eating behaviors. It

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refers specifically to consumption of foods high in fat, sugar, salt or refined carbohydrates. The

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YFAS 2.0 consists of 35 items designed to assess symptoms related to the 11 diagnostic criteria

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for substance-related and addictive disorders applied to eating behavior. Each item is rated on an

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8-point rating scale related to symptom frequency ranging from 0 (never) to 7 (every day). Two

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scoring options are provided: (1) a continuous symptom count that reflects the number of

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symptoms endorsed by the respondent and; (2) a categorical scoring option that classifies

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respondents as having either no, mild, moderate or severe ‘food addiction’. If the participant’s

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ratings of one or more of the items (i.e., symptoms) relevant to the 11 diagnostic criteria meet the

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cut-off, then that criterion is considered to be present. A cut-off of 5 (i.e., 2-3 times per week) is

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used for determining whether a symptom is present. In order to be ‘diagnosed’ with food

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addiction, items measuring clinically significant distress and impairment must also be endorsed.

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Participants who meet the YFAS 2.0 criteria for ‘food addiction’ are classified as having either:

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ACCEPTED MANUSCRIPT 13 mild (2-3 symptoms), moderate (4-5 symptoms) or severe (6 or more symptoms) food addiction

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(Gearhardt et al., 2016). The YFAS has demonstrated good internal consistency, as well as

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convergent, discriminant and incremental validity (Gearhardt et al., 2016). In the present study,

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internal consistency was excellent (Cronbach’s alpha = .96).

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2.4. Statistical Analyses

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Data were analyzed using IBM SPSS Software (Armonk, NY) unless otherwise indicated and significance was determined at p < .05. First, in order to identify any covariates that should

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be controlled in the analysis, all demographic and clinical variables were compared between the

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BED and NED groups using independent t-tests for continuous variables and chi squared tests of

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independence for categorical variables. Then, in order to address our first study aim, an analysis

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of covariance (ANCOVA) was used to compare the BED and NED groups on mean total YFAS-

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2.0 symptom count scores, while controlling for relevant covariates. In addition, a chi square test

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of independence was conducted to compare the BED and NED groups in terms of percentage of

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participants who met criteria for the YFAS-2.0 ‘food addiction’ classifications (i.e., no ‘food

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addiction’, mild ‘food addiction’, moderate ‘food addiction’, and severe ‘food addiction’).

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Regarding our second study aim, the ‘food addiction’ classifications were merged into a

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‘no/mild food addiction’ group and a ‘moderate/severe food addiction’ group to increase group

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sample size and, accordingly, the statistical power of this analysis. Next, to identify any

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covariates that should be controlled in the comparison between the no/mild ‘food addiction’ and

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moderate/severe ‘food addiction’ groups, all demographic variables and BMI were compared

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between these two groups using independent t-tests for continuous variables and chi squared

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tests of independence for categorical variables. Since no relevant covariates were identified, a

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multivariate analysis of variance (MANOVA) was then conducted to compare BED participants

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ACCEPTED MANUSCRIPT 14 meeting YFAS 2.0 criteria for no/mild ‘food addiction’ with BED participants meeting YFAS 2.0

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criteria for moderate/severe ‘food addiction’ in terms of eating disorder and general

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psychopathology (i.e., EDE-Q subscales and Global scores, BSI Depression scores, and BSI

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Anxiety scores).

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Finally, to address the third research aim – to examine whether YFAS 2.0 symptom count predicted the level of eating disorder symptoms in the BED group – two hierarchical regression

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analyses were conducted. In the first, the criterion variable was the EDE-Q Global score, the

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predictor variable was YFAS 2.0 symptom count, and the covariates were BMI, BSI depression,

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and BSI anxiety since these variables have previously been shown to be related to severity of

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eating disorder psychopathology in BED (e.g., Kenny, Singleton & Carter, 2017). In the second,

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the criterion variable was binge frequency (as assessed by EDE interview), the predictor variable

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was YFAS 2.0 symptom count, with BMI, and BSI depression and BSI anxiety included as

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covariates. Binge frequency data were log-transformed to produce a normal distribution.

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3. Results

3.1. Participant Characteristics

Of 157 individuals who completed the study screening questionnaires, 71 participants

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met the eligibility criteria for the BED group and 79 met the eligibility criteria for the NED

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group. Baseline characteristics of the participants are presented in Table 1. The BED group had a

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mean BMI that was significantly higher than the NED group, t(112.61) = -8.45, p < .001,

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Cohen’s d = 1.16. Individuals with BED were also significantly older than the NED group,

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t(148) = -3.13, p = .002, Cohen’s d = 0.51. In addition, individuals with BED were more likely to

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report having a college diploma than those in the NED group, χ2(1, n = 150) = 23.65, p = .001,

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Cramer’s V = .28. There were no other significant differences in demographics between the two

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groups. Thus, age, BMI and education were included as covariates in subsequent comparisons

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between the BED and NED groups.

Group

BED (n=71) Mean (SD) or n (%)

26.6 (5.8) 33.9 (13.7)

37.7 (9.6) *** 40.4 (11.4) ***

4 5 6 7

37 (47%) 39 (49%)

25 (35%) 42 (59%)

2 (3%) 0 (0%) 1 (1%)

3 (4%) 0 (0%) 1 (2%)

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College Diploma Bachelor’s Degree Graduate Degree

5 (7%) 66 (93%)

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NED (n=79) Mean (SD) or n (%)

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BMI Age Biological Sex Male Female Marital Status Single Married/Common Law Divorced Widowed Separated Ethnicity Caucasian/White Hispanic Black Asian Other Highest level of Education High School Diploma or Equivalent

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74 (94%) 1 (1%) 1 (1%) 1 (1%) 2 (3%)

69 (97 %) 0 (0 %) 0 (0 %) 0 (0 %) 2 (3 %)

20 (25%)

6 (8%)

8 (10%) 31 (40%) 20 (25%)

28 (39%) *** 26 (37%) 11 (16%)

Table 1. Descriptive characteristics of the no history of an eating disorder (NED) and binge eating disorder (BED) groups. Note. BMI = Body Mass Index; SD = Standard Deviation Note. ** indicates p < .05 *** indicates p < .001.

ACCEPTED MANUSCRIPT 16 1

In terms of clinical characteristics, when controlling for BMI, age and education, an ANCOVA revealed that the BED group did not significantly differ from the NED group on the

3

EDE-Q Restraint subscale, F(1,146) = 3.47, p .065, η2p = 0.02. However, the BED group

4

reported significantly higher scores on the EDE-Q Overvaluation subscale, F(1,146) = 25.56, p <

5

.001, η2p= 0.15 and the EDE-Q Body Dissatisfaction subscale F(1,146) = 28.64 , p < .001, η2p=

6

0.16 than the NED group. Additionally, the BED group reported significantly higher scores on

7

the EDE-Q Global scale, F(1,146) = 24.51 , p < .001, η2p= 0.14. Of note, the BED group

8

reported a mean EDE-Q Restraint score below the recommended clinical cut-off of 4 (Fairburn

9

& Cooper, 1993), whereas they scored above this cut-off on the other EDE-Q subscales and the

10

Global EDE-Q score. After controlling for BMI, age and education, an ANCOVA revealed that

11

individuals with BED also reported significantly higher scores on the BSI Depression, F(1,146)

12

= 5.34, p =.022, η2p= 0.04, and the BSI Anxiety F(1,146) = 4.38, p = .040, η2p= 0.03, subscales.

13

Estimated Marginal Means and Standard Error values for the EDE-Q and BSI results are

14

presented in Table 2. Detailed ANCOVA statistics as well as raw means and standard deviations

15

for the study measures for BED and NED groups are presented in Tables S1 to S7.

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Group

NED (n=79) Estimated Marginal Mean (SE)

BED (n=71) Estimated Marginal Mean (SE)

F

Effect Size (η2p)

2.44 (0.26) 2.71 (0.22) 3.52 (0.17) 2.82 (0.16)

3.21 (0.28) 4.48 (0.23) 5.02 (0.19) 4.09 (0.17)

3.36 26.42*** 28.84*** 25.25***

0.02 0.15 0.17 0.15

0.92 (0.10)

1.29 (0.11)

5.23*

0.04

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ACCEPTED MANUSCRIPT 17 0.79 (0.10)

Anxiety

0.03

Table 2. Clinical characteristics of the NED and BED groups after controlling for BMI, age and education. Note. * indicates p < .05. ** indicates p < .01. *** indicates p < .001. Note. NED = no history of an eating disorder; BED = Binge Eating Disorder; EDE-Q = Eating Disorder Examination Questionnaire, BSI = Brief Symptom Inventory; SE = Standard Error of the Mean 3.2. Comparison of BED and NED on YFAS 2.0

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4.26*

To examine our first research question - whether a community sample of individuals

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1 2 3 4 5 6 7 8

1.12 (0.11)

diagnosed with BED reported significantly more symptoms of YFAS 2.0 ‘food addiction’ than

11

the NED group - an ANCOVA was conducted controlling for differences between the groups in

12

terms of BMI, age, education, depression, anxiety and EDE-Q Global scores. After controlling

13

for these covariates, it was found that the BED group (6.92 ± 0.32) reported significantly higher

14

‘food addiction’ scores compared to individuals in the NED group (1.74 ± 0.30), F(1, 142) =

15

110.04, p < .001, η2p = .44.

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Next, the percentage of individuals in each group who met the YFAS 2.0 criteria for the

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various categories of ‘food addiction’ were compared. Participants were categorized into one of

18

four categories as defined by Gearhardt and colleagues (2016), [i.e., no food addiction (1 or

19

fewer symptoms and no clinical significance), mild food addiction (2 or 3 symptoms and clinical

20

significance), moderate food addiction (4 or 5 symptoms and clinical significance), or severe

21

food addiction (6 or more symptoms and clinical significance)]. A chi square test of

22

independence revealed significant differences in the proportion of individuals in the four

23

categories of ‘food addiction’ across the BED and NED groups, χ2(3, n=151) =114.00, p < .001,

24

Cramer’s V=0.87 (see Table 3). A post hoc analysis indicated that 92% of individuals in the

25

BED group met YFAS 2.0 criteria for at least mild ‘food addiction’ compared to only 6% of

26

individuals in the NED group, χ2(1, n=151) =110.12, p < .001, Cramer’s V= 0.85. Therefore,

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participants with BED were significantly more likely to meet YFAS 2.0 criteria for ‘food

2

addiction’ than individuals in the NED group.

Group

74 (94%) 3 (4%) 1 (1%) 1 (1%)

BED (n=71) n (%)

6 (8%)*** 4 (6%)*** 8 (11%)*** 53 (75%)***

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No Mild Moderate Severe 4 5 6 7 8 9

NED (n=79) n (%)

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YFAS 2.0 ‘Food Addiction’ Category

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Table 3. Proportion of participants in the four categories of YFAS 2.0 ‘food addiction’ across the BED and NED groups. Note. YFAS 2.0 = Yale Food Addiction Scale 2.0; NED = no history of an eating disorder; BED = Binge Eating Disorder Note. *** indicates p ≤ .001. 3.3. Comparison of BED participants who met the YFAS 2.0 criteria for No/Mild versus

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Moderate/Severe ‘food addiction’

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To address our second aim – to compare BED participants who did and did not meet YFAS 2.0 criteria for ‘food addiction’ – BED participants who met YFAS 2.0 criteria for

14

No/Mild (n=10) and Moderate/Severe (n= 61) ‘food addiction’ were compared in terms of eating

15

disorder symptoms and general psychopathology. First, to identify any covariates that should be

16

controlled in these analyses, all demographic variables and BMI were compared between these

17

two groups using independent t-tests for continuous variables and chi squared tests of

18

independence for categorical variables. Results indicated that there were no significant

19

differences between these two groups on BMI or any demographic variable (see Table S8). Next,

20

the MANOVA indicated significant differences in eating disorder symptoms and general

21

psychopathology, as measured by the EDE-Q and BSI subscales, between the No/Mild and

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ACCEPTED MANUSCRIPT 19 Moderate/Severe ‘food addiction’ groups, Wilks’s λ = .79, F(1, 69) = 3.54, p = .007, η2p = .214.

2

Examination of the univariate effects indicated that the Moderate/Severe ‘food addiction’ BED

3

group reported significantly higher scores on the EDE-Q Body Dissatisfaction ( F(1, 69) = 10.40,

4

p = .002, η2p = .13) and Overvaluation (F(1, 69) = 7.56, p = .008, η2p = .10) subscales as well as

5

the EDE-Q Global scale (F(1, 69) = 6.46, p = .013, η2p = .09) compared to the No/Mild ‘food

6

addiction’ group. However, there was no difference in terms of the EDE-Q Restraint subscale

7

(F(1, 69) = .49, p = .486, η2p = .01). In addition, BED participants in the Moderate/Severe ‘food

8

addiction’ group reported significantly higher scores on the BSI Anxiety (F(1, 69) = 7.40, p =

9

.008, η2p = .10) and Depression (F(1, 69) = 10.15, p = .002, η2p= .13) subscales compared to the

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No/Mild ‘food addiction’ group. Means and standard deviations on the study measures for the

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No/Mild and Moderate/Severe ‘food addiction’ groups see Table 4.

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Group No/Mild Moderate/Severe ‘food addiction’ ‘food addiction’ (n=10) (n=61) Mean (SD) Mean (SD)

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EDE-Q Restraint Overvaluation Body Dissatisfaction Global BSI Depression Anxiety

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2.90 (1.71) 3.55 (0.83) 4.70 (0.79) 3.60 (0.80)

3.40 (2.14) 4.88 (1.48) 5.57 (0.79) 4.44 (1.00)

0.65 (0.40) 0.52 (0.41)

1.47 (0.79) 1.23 (0.81)

Table 4. Means and standard deviations on the study measures for BED participants who met the YFAS 2.0 criteria for No/Mild versus Moderate/Severe ‘food addiction’. Note. ** indicates p ≤ .01.

ACCEPTED MANUSCRIPT 20 Note. EDE-Q = Eating Disorder Examination Questionnaire; BSI = Brief Symptom Inventory; SE = Standard Error of the Mean

4

3.4 Association between ‘food addiction’ symptoms and eating disorder psychopathology in BED

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To address the third research aim – to examine whether YFAS 2.0 ‘food addiction’ scores

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predicted eating disorder psychopathology and binge eating frequency in the BED group - two

7

hierarchical regression analyses were conducted. First, we examined whether scores on the

8

YFAS 2.0 predicted EDE-Q Global scores among BED participants, while controlling for

9

relevant covariates. The first block of the model contained BMI, depression and anxiety, then

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YFAS 2.0 scores were entered into the second block of the model, with EDE-Q Global score as

11

the criterion. Results showed that the number of ‘food addiction’ symptoms did not predict

12

unique variance in EDE-Q Global scores above and beyond the other variables, F(4, 66) = 3.07,

13

p = .085. Next, a second hierarchical regression analysis demonstrated that YFAS 2.0 scores

14

explained unique variance in binge frequency above and beyond BMI, depression and anxiety,

15

F(1, 66) = 7.20, p = .009 , R2 change= .08, (see Table 5). Thus, severity of ‘food addiction’

16

symptoms predicted the frequency of binge eating in the BED group after controlling for relevant

17

covariates. The only other variable that explained unique variance in binge frequency in this

18

analysis was BSI Depression, b=0.30, t(66) = 2.05, p=.045. Together, these two variables

19

accounted for 30% of the variance in binge frequency.

20 21 22 23 24 25 26 27 28 29

______________________________________________________________________________

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Binge Frequency Model 1 BMI

R2

Unstandardized coefficients ___________________________ B

0.01

Standard Error

0.01

Standardized coefficients

β

0.14

t

1.26

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2.47* 0.49

0.003 0.30 0.01

0.01 0.15 0.14

0.04 0.31 0.01

0.32 2.05* 0.06

0.09

0.03

0.33

2.68**

.22

.30

Table 5. Results of hierarchical regression analysis of the association between ‘food addiction’ symptom count and binge frequency after controlling for BMI, depression and anxiety. Note. * indicates p < .05. ** indicates p < .01 Note. BMI = Body Mass Index

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0.15 0.15

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Model 2 BMI Depression Anxiety Food Addiction Symptoms Total Model

0.37 0.07

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Depression Anxiety Total Model

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4. Discussion

The primary aim of the present study was to compare a community sample of individuals diagnosed with BED and a community sample of individuals with no history of an eating

21

disorder (NED) in terms of ‘food addiction’ symptoms as measured by the YFAS 2.0 (Gearhardt

22

et al., 2016). To our knowledge, this was the first study to examine the YFAS 2.0 in a sample of

23

individuals who had been diagnosed with BED. Consistent with previous research, BED

24

participants reported significantly more symptoms of ‘food addiction’ than NED participants

25

after controlling for relevant covariates. In fact, in the current study, 91% of the BED group met

26

YFAS 2.0 criteria for at least mild ‘food addiction’. This is a substantially higher rate of ‘food

27

addiction’ classification than reported in previous studies of BED (i.e., 25-57%) using the

28

original version of the YFAS (Gearhardt et al., 2012; Gearhardt et al., 2013). This discrepancy is

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likely to be related to differences between the two versions of the YFAS as well as overlap

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between the symptoms of ‘food addiction’ measured by the revised scale and the clinical features

31

of BED.

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The original YFAS was based on the DSM-IV criteria for substance dependence. In the DSM-5, substance dependence and substance abuse were merged into a single category of

3

substance use disorders (SUD). As a result, there are more symptoms of SUD listed in the DSM-

4

5 and this therefore increases the likelihood that a person will meet criteria for at least mild SUD.

5

In addition, tolerance and withdrawal are no longer required criteria for a diagnosis. Thus, since

6

the YFAS 2.0 is based on the DSM-5 criteria for substance-related disorders, the likelihood of

7

meeting the criteria for ‘food addiction’ on the revised scale is also higher than on the original

8

version. Furthermore, overlap between the symptoms assessed by the YFAS 2.0 and the clinical

9

features of BED make it difficult to determine whether this scale is actually measuring ‘food

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addiction’ symptoms per se or whether it is measuring certain aspects of BED symptomatology.

11

For example, “When I started to eat certain foods, I ate much more than planned” or “I ate to the

12

point where I felt physically ill” are YFAS 2.0 items that are almost certain to be endorsed by

13

anyone with BED. The same is likely to be true of the YFAS 2.0 items intended to assess

14

distress or impairment related to eating behavior such as “My eating behavior caused me a lot of

15

distress”. This overlap inflates the likelihood that BED participants will endorse ‘food addiction’

16

symptoms on the YFAS 2.0, but brings into question the clinical meaningfulness of a ‘food

17

addiction’ classification in people with BED on this measure.

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The second main finding of the current study was that BED participants who were classified

19

with at least moderate ‘food addiction’ reported higher eating disorder psychopathology (except

20

dietary restraint) as well as higher levels of depression and anxiety than individuals classified

21

with no or mild ‘food addiction’. This is consistent with previous research that has similarly

22

reported significantly higher eating disorder and general psychopathology among BED cases

23

classified with YFAS ‘food addiction’ compared to controls (Gearhardt et al., 2012; Gearhardt et

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ACCEPTED MANUSCRIPT 23 al., 2013). In addition, consistent with the findings of Gearhardt and colleagues (2012, 2013), the

2

current results similarly showed that, in the BED group, YFAS 2.0 symptom count predicted the

3

frequency of binge eating after controlling for age, BMI, and negative affect. However, in

4

contrast to previous findings, YFAS 2.0 symptom count did not predict the severity of eating

5

disorder psychopathology as measured by the EDE-Q Global score in the BED group. It is

6

possible that this difference may be due to differences in study samples (i.e., community versus

7

clinic) or differences resulting from the use of different versions of the ‘food addiction’ measure.

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In terms of clinical implications, the pertinent question is whether a classification of YFAS

9

2.0 ‘food addiction’ provides additional meaningful clinical information above and beyond the

10

eating disorder diagnosis in BED. As predicted, our results suggested that the presence of 'food

11

addiction' symptoms may indicate a more severe presentation in BED both in terms of eating

12

disorder psychopathology (except dietary restraint) and psychological disturbances (i.e.,

13

depression). However, given that over 90% of BED participants in the current sample were

14

classified as meeting criteria for at least mild YFAS 2.0 ‘food addiction’, the clinical

15

meaningfulness of this classification is uncertain. Once again, this is likely to reflect overlap

16

between the ‘food addiction’ symptoms assessed by the YFAS 2.0 and the clinical features of

17

BED.

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This study had a number of strengths including the use of a community (rather than a clinic)

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sample and well-validated measures which increases the generalizability and interpretability of

20

the results. The study also had a number of limitations. Due to the cross-sectional and

21

correlational nature of this study, neither the direction nor the temporal course of the observed

22

relationships are known and causal conclusions are not possible. For example, it is not known

23

whether ‘food addiction’ symptoms contribute to the development of BED symptoms or vice

ACCEPTED MANUSCRIPT 24 versa. In addition, overlap between the symptoms measured by the YFAS 2.0 and those

2

measured by the EDE-Q makes it difficult to know whether these two measures are measuring

3

different or overlapping phenotypes. The degree of overlap between YFAS 2.0 ‘food addiction’

4

symptoms and the clinical features of BED is even higher than with the original YFAS. This is

5

likely related to changes in the second version to reflect the revised criteria for substance-related

6

disorders in the DSM-5. For example, both BED and ‘food addiction’ are characterized by loss

7

of control over eating, failed attempts to cut down on food consumption, and intense food

8

cravings. Another potential limitation is that our participants were recruited from only one region

9

which may limit the generalizability of our findings.

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In conclusion, we believe our findings provide evidence for the viewpoint expressed by Schulte and colleagues (2016) that researchers need to move beyond studying descriptive

12

similarities and differences between the symptoms of BED and ‘food addiction’, and instead

13

focus on identifying relevant overlapping and distinctive underlying mechanisms. Relevant

14

underlying mechanisms may include reward system dysfunction, difficulties in emotion

15

regulation, decision-making deficits, and impulsivity (Schulte et al., 2016). For example, as

16

noted by Meule and Gearhardt (2014), researchers have identified two subtypes of BED, with

17

one subtype characterized by high dietary restraint and the other typified by high negative affect

18

and impulsivity (Grilo, Masheb & Wilson, 200; Stice et al., 2001). It may be that these two

19

subtypes are related to different underlying mechanisms, with mechanisms shared with ‘food

20

addiction’ being more relevant to the second subtype (e.g., reward system dysfunction).

21

Identifying subgroups of individuals with BED who are characterized by different underlying

22

mechanisms may suggest different targets for intervention. In cases where binge eating appears

23

to be related to emotion dysregulation, for example, interventions focused on teaching emotion

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ACCEPTED MANUSCRIPT 25 regulations skills (e.g., dialectical behavior therapy) may be recommended while BED patients

2

who engage in high levels of dietary restraint may be best suited for cognitive behavior therapy.

3

Among individuals with BED who appear to fit an addiction model of binge eating,

4

incorporating an addiction perspective into current treatments for BED may prove helpful (Carter

5

et al., 2018). Signs of reward dysfunction related to food may include extreme food

6

preoccupation, strong physiological responses to anticipatory food cues, and intense food

7

cravings even though the person is not food deprived and not experiencing intense negative

8

affect. Integrating an addiction perspective may include helping the person to understand that

9

they may be fighting a strong neurobiological drive to overeat in an environment that exploits

10

these vulnerabilities and helping them to develop strategies to increase their ability to tolerate

11

food cravings and inhibit urges to overeat in response to triggers (Carter et al., 2018).

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In conclusion, this study reported very high rates of YFAS 2.0 ‘food addiction’ symptoms in

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5. Conclusion

a community sample of individuals diagnosed with BED in comparison with a control group.

15

Most BED participants in this sample were classified with at least moderate ‘food addiction’ and

16

these individuals reported more severe eating disorder-related and general psychopathology than

17

those with no or mild ‘food addiction’. Finally, ‘food addiction’ scores positively predicted binge

18

eating frequency in BED. It is possible that the presence of addictive-like eating behavior in

19

BED may signal that different risk factors and/or maintaining factors may be operating and this

20

may suggest different targets for intervention. Consistent with the view of Schulte and colleagues

21

(2016), a focus on identifying overlapping and distinctive underlying mechanisms rather than

22

similarities and differences in clinical features is recommended for future research on BED and

23

‘food addiction’.

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Competing Interests The authors have no competing interests to declare.

3

Acknowledgements This research was funded by a grant from the Newfoundland Center for Applied Health

5

Research to the first author (grant number 20160438). The sponsor had no involvement in the

6

study design; collection, analysis or interpretation of data; the writing of the report; or the

7

decision to submit this article for publication. The authors thank Christopher Singleton and

8

Therese Kenny for their help with data collection for this study.

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American Psychiatric Association (APA). (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. The American Psychiatric Association: Washington, D. C. American Psychiatric Association (APA). (2013). Feeding and eating disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

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Source

Sum of Squares

df

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Supplemental Materials

Mean Square

F

P

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1.20 1 1.20 0.28 0.60 BMI 4.04 1 4.04 0.94 0.33 Age 11.92 1 11.92 2.78 0.10 Education 14.36 1 14.36 3.36 0.07 Group 620.74 145 4.28 ----Error 1850.00 150 -------Total Table S1. Results of ANCOVA comparing BED and NED groups on EDE-Q Dietary Restraint, after controlling for BMI, age, and education. Note. BED = Binge Eating Disorder; NED = no history of an eating disorder; BMI = Body Mass Index; EDE-Q = Eating Disorder Examination Questionnaire Source

Sum of Squares

df

Mean Square

F

P

12.74 1 12.74 4.38 0.04 BMI 1.44 1 1.44 0.49 0.48 Age 31.65 1 31.65 10.89 .001 Education 76.78 1 76.78 26.42 <.001 Group 421.40 145 2.91 ----Error 2540.50 149 -------Total Table S2. Results of ANCOVA comparing BED and NED groups on EDE-Q Overvaluation, after controlling for BMI, age, and education.

ACCEPTED MANUSCRIPT 32 Note. BED = Binge Eating Disorder; NED = no history of an eating disorder; BMI = Body Mass Index; EDE-Q = Eating Disorder Examination Questionnaire Source

Sum of Squares

df

Mean Square

F

P

Source

Sum of Squares

df

M AN U

SC

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48.51 1 48.51 25.43 <.001 BMI 0.16 1 0.16 0.09 0.77 Age 10.12 1 10.12 5.30 0.02 Education 55.03 1 55.03 28.84 <.001 Group 276.65 145 1.91 ----Error 3223.00 149 -------Total Table S3. Results of ANCOVA comparing BED and NED groups on EDE-Q Body Dissatisfaction, after controlling for BMI, age, and education. Note. BED = Binge Eating Disorder; NED = no history of an eating disorder; BMI = Body Mass Index; EDE-Q = Eating Disorder Examination Questionnaire Mean Square

F

P

Sum of Squares

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Source

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12.11 1 12.11 7.83 .006 BMI 0.16 1 0.16 0.11 0.75 Age 15.97 1 15.97 10.33 .002 Education 39.03 1 39.03 25.25 <.001 Group 224.15 145 1.55 ----Error 2121.22 150 -------Total Table S4. Results of ANCOVA comparing BED and NED groups on EDE-Q Global after controlling for BMI, age, and education. Note. BED = Binge Eating Disorder; NED = no history of an eating disorder; BMI = Body Mass Index; EDE-Q = Eating Disorder Examination Questionnaire

df

Mean Square

F

P

1.21 1 1.21 1.89 0.17 BMI 0.33 1 0.33 0.51 0.48 Age 3.60 1 3.60 5.60 0.02 Education 3.36 1 3.36 5.23 0.02 Group 93.16 145 0.64 ----Error 288.81 150 -------Total Table S5. Results of ANCOVA comparing BED and NED groups on BSI Depression after controlling for BMI, age, and education. Note. BED = Binge Eating Disorder; NED = no history of an eating disorder; BMI = Body Mass Index; EDE-Q = Eating Disorder Examination Questionnaire; BSI = Brief Symptom Inventory

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Source

Sum of Squares

df

Mean Square

F

P

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SC

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0.17 1 0.17 0.28 0.60 BMI 0.45 1 0.45 0.74 0.39 Age 2.68 1 2.68 4.35 0.04 Education 2.63 1 2.63 4.26 0.04 Group 89.26 145 0.62 ----Error 232.17 150 -------Total Table S6. Results of ANCOVA comparing BED and NED groups on BSI Anxiety after controlling for BMI, age, and education. Note. BED = Binge Eating Disorder; NED = no history of an eating disorder; BMI = Body Mass Index; EDE-Q = Eating Disorder Examination Questionnaire; BSI = Brief Symptom Inventory

NED Raw Mean (SD)

BED Raw Mean (SD)

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EDE-Q 2.33 (2.07) 3.33 (2.08) Restraint 2.52 (2.04) 4.69 (1.48) Overvaluation 3.13 (1.93) 5.45 (0.85) Body Dissatisfaction 2.61 (1.54) 4.32 (1.01) Global BSI 0.87 (0.84) 1.35 (0.80) Depression 0.78 (0.79) 1.13 (0.81) Anxiety Table S7. Raw Means and Standard Deviations on the study measures for the BED and NED groups. Note. BED = Binge Eating Disorder; NED = no history of an eating disorder; BMI = Body Mass Index; EDE-Q = Eating Disorder Examination Questionnaire; BSI = Brief Symptom Inventory

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Group No/Mild Moderate/Severe ‘food addiction’ ‘food addiction’ (n=10) (n=61) Mean (SD) or Mean (SD) or n (%) n (%)

BMI Age Biological Sex Male

t or χ2

p

Cohen’s d or Cramer’s V

32.8 (7.8) 42.8 (10.8)

38.4 (9.7) 40.0 (11.5)

-1.742 0.730

.086 .468

.636 .251

2 (20%)

3 (5%)

2.985

.084

.205

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58 (95%) 8 (80%) Female Marital Status 0.977 .807 .117 3 (30%) Single 22 (36%) 7 (70%) Married/Common 35 (57%) Law 0 (0%) Divorced 3 (5%) 0 (0%) Separated 1 (2%) Ethnicity 2.194 .139 .176 9 (90%) Caucasian/White 60 (98%) 1 (10%) Other 1 (2%) Education .117 .288 0 (0%) 5.898 High School Diploma 6 (10%) or Equivalent 3 (30%) College Diploma 25 (40%) 3 (30%) Bachelor’s Degree 23 (38%) 4 (40%) Graduate Degree 7 (12%) Table S8. Results of comparisons between BED participants who met the YFAS 2.0 criteria for No/Mild versus Moderate/Severe ‘food addiction’ on BMI and demographic variables. Note. EDE-Q = Eating Disorder Examination Questionnaire; BSI = Brief Symptom Inventory; SE = Standard Error of the Mean