Improving Weight Loss Outcomes for Binge Eating Disorder.
Phase: NA
Conditions: Eating Disorder, Binge-Eating Disorder, Weight Loss, Binge Eating
Sponsor: Drexel University

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improving Weight Loss Outcomes for Binge Eating Disorder 
Study Protocol 
NCT03712462 
October 26, 2017 
 

RESEARCH STRATEGY 
A. Significance 
A1. Binge eating disorder (BED) is the most prevalent eating disorder and is associated with 
substantial psychiatric and medical comorbidity. BED affects more than six million Americans, with 
lifetime prevalence at 3% for women and 2% for men.1 BED is characterized by frequent episodes of overeating 
accompanied by feelings of loss of control (i.e., binge eating episodes) without the use of compensatory 
behaviors (e.g., purging, excessive exercise).2 Although obesity is not part of the diagnostic criteria for BED, 
more than 65% of individuals with BED are obese3, 4, and more than a quarter of patients seeking treatment for 
obesity have BED.5 Obese individuals with BED, versus those without, experience more severe obesity, greater 
eating disorder psychopathology (e.g., greater weight and shape concerns, higher body dissatisfaction), and 
lower self-esteem.5-7 Obese individuals with BED are significantly more likely to suffer from health conditions 
such as dyslipidemia and impaired glucose levels compared to obese peers without BED4, in addition to being 
at increased risk for health problems associated with obesity generally.8, 9 Health complications due to obesity 
comprise a high proportion of the nation’s healthcare budget8,  and the healthcare costs of individuals with 
BED are $18,152 higher than in obese peers without BED.1 The prevalence of BED and the substantial burden 
of healthcare costs highlight the need for treatments that eliminate binge eating and produce weight loss.    
A2.  Obese patients with BED desire and would benefit from interventions that can improve 
binge eating and weight. Patients with BED frequently present to treatment seeking to both reduce binge 
eating and lose weight10, 11 and there is growing consensus among practitioners that there is harm in failing to 
address obesity co-morbid with eating pathology.12, 13 Although patients and practitioners recognize the value in 
treating both binge eating and obesity, there remains a lack of effective specialized interventions for obese 
individuals with BED. 14 Understanding why existing treatments for BED fail to adequately improve both binge 
eating and weight can inform the development of more effective treatments for obese patients with BED.  
A3. Shared mechanisms contribute to binge eating episodes and overeating without loss of 
control for patients with BED.  Individuals with BED show elevated risk for two types of eating behaviors 
that lead to weight gain: binge eating episodes and overeating episodes without loss of control. While calories 
consumed from binge eating episodes play a large role in the weight control difficulties observed in BED, 
individuals with BED also consume more calories than obese peers without BED outside of binge episodes.15 
When compared to obese individuals without BED, individuals with BED eat more when verbally instructed 
either to binge eat16-20or to eat normally18, 20 and consume more calories over the course of a day.21 These 
broader patterns of overeating appear to reflect a tendency for many internal factors (e.g., emotional states, 
cravings) and external factors (e.g., presence of palatable food) to trigger overeating episodes (with or without 
the loss of control that is the signature characteristic of binge eating) in patients with BED. Patients with BED 
appear to be particularly vulnerable to frequent episodes of disinhibited eating (i.e., the tendency, in those 
attempting to regulate their dietary intake, to overeat in response to internal and external cues).22 Disinhibition 
is one of the few psychological variables known to predict poor weight outcomes23, 24, suggesting that the 
greater vulnerability towards disinhibited eating in BED is an important target for treatment. 
One factor that drives disinhibited eating in BED is high food reward sensitivity (i.e., a hyper-
responsiveness of reward circuitry to food cues or intake).15. Patients with BED demonstrate increased food 
reward sensitivity compared to obese peers without BED and have greater difficulty inhibiting intake of 
palatable foods.15, 25-27 Patients with BED are often distressed by this elevated food reward sensitivity because of 
an overvaluation of weight and shape (e.g., a clinically elevated degree to which body weight or shape 
influences an individual’s self-evaluation) and subsequent fears of weight gain.28, 29 This fear of weight gain can 
encourage repeated attempts to control dietary 
intake. While efforts to restrain intake are not 
universally detrimental for patients with BED (as 
reviewed in greater detail below), rigid dietary 
restraint (e.g. strict adherence to dietary rules, 
avoidance of specific food groups) can increase 
vulnerability to both binge eating and overeating 
episodes.30 Overvaluation of weight and shape 
and rigid dietary restraint consistently predict the 
onset and maintenance of binge eating 
behaviors.31-37 A final factor that contributes to 
the development and maintenance of binge eating 

and overeating episodes without loss of control in BED is elevated negative affect and distress intolerance (i.e., 
the perceived inability to tolerate negative emotional states).38-42 For example, one recent study found that 
among patients with BED, days characterized by high or increasing negative affect were associated with a 
greater likelihood of either a binge episode or an overeating episode without loss of control occurring on that 
day.43 Although binge eating often begins as an impulsive attempt to regulate negative emotion39, 44-48, 
persistent binge eating can lead to a compulsive use of eating as a way to regulate emotions45, 49 and reduce 
access to more adaptive coping strategies.45, 50 Ultimately, eating becomes one of very few “tools in the tool-kit” 
for reducing distress.50 As seen in the figure above, elevated food reward sensitivity, overvaluation of shape and 
weight, and negative affect and distress intolerance directly and indirectly (e.g., by increasing rigid dietary 
restraint) contribute to binge eating, overeating episodes without loss of control, and an elevated BMI in 
patients with BED. These widely accepted maintenance factors for BED reflect areas where treatments can 
intervene to reduce overeating episodes with and without loss of control. However, existing behavioral 
treatments for BED fail to adequately address these shared maintenance factors.   
A4. Cognitive behavioral therapy effectively reduces binge eating, but fails to improve weight. 
The current gold-standard treatment for reducing binge eating in BED is Cognitive Behavioral Therapy (CBT)51, 
which uses cognitive and behavioral techniques to regularize eating, reduce dietary restraint, and alter the 
cognitive manifestations of BED.29 CBT for BED is superior to other treatments in eliminating binge eating, 
with up to 60% of patients achieving full remission from binge eating.51 However, despite success in reducing 
binge eating, CBT fails to produce clinically significant weight loss in BED.51-53  
CBT does not alter the calorie balance. Given that abstinence from binge eating is generally associated with 
modest weight loss14, 41, 54, 55 the large reductions in binge episodes produced by CBT should presumably lead to 
weight loss, despite the fact that weight reduction is not an explicit goal. Weight loss in CBT, however, is 
typically minimal or non-existent51-53 as calories previously consumed during binge episodes appear to be 
distributed over non-binge meals.56, 57 The inability of CBT to reduce weight is likely due to CBT’s emphasis on 
broadly reducing dietary restraint and a lack of attention to overeating episodes without loss of control.29 
CBT incompletely addresses elevated food reward sensitivity, negative affect, distress intolerance, and 
overvaluation of weight and shape. CBT addresses elevated food reward sensitivity by encouraging patients to 
reduce access to “binge trigger” foods early in treatment and schedule alternative activities in between planned 
eating times to reduce urges to binge.29 There are relatively few psychological skills provided for developing the 
ability to resist urges to eat palatable foods, which may explain why elevated food reward sensitivity predicts 
poor outcome in CBT.58 Newer cognitive behavioral models of eating pathology posit that negative affect and 
mood intolerance can maintain eating pathology, and mood intolerance is targeted by a more complex version 
of CBT, Enhanced CBT (CBT-E).29 However, mood intolerance is not a primary focus of standard CBT and even 
within CBT-E, mood intolerance is not addressed until later stages of treatment and is a relatively small 
treatment component. Negative affect and elevated emotional eating predict worse outcomes in CBT, further 
suggesting that CBT is not adequately addressing negative affect and distress intolerance.59, 60 CBT targets 
overvaluation of shape and weight by addressing its “expressions,” which are defined as behaviors that result 
from and maintain overvaluation of shape and weight.17, 18 CBT also notes that increasing the importance of 
other life domains should indirectly reduce weight and shape concerns, but minimal session time is devoted to 
this objective. Existing data suggests that CBT produces only modest improvements in overvaluation of weight 
and shape61 and baseline overvaluation of weight and shape continues to predict poorer treatment outcomes.62 
A5. Behavioral weight loss interventions for BED are less effective than CBT at reducing binge 
eating and produce only modest weight loss. Behavioral weight loss (BWL; which uses behavioral 
techniques to reduce caloric intake and increase physical activity63) is the most effective behavioral treatment 
at producing weight loss in BED.51 BWL also improves binge eating, although not as well or consistently as the 
improvements observed in CBT.51 Although BWL is the most effective behavioral weight loss treatment to date 
for BED, weight loss remains, on average, modest. For example, Dr. Grilo found that BED patients in a BWL 
program showed only a 2.1 mean percent BMI loss at 12-month follow-up.64 Most trials to date have found that 
patients with BED experience poorer weight outcomes than obese peers without BED, although a number of 
studies have not demonstrated this relation, particularly when using samples of self-assessed binge eaters or 
sub-threshold BED cases.65, 66  These mixed findings may be related to methodological shortcomings (e.g., 
reliance on self-report questionnaires, inclusion of heterogeneous patients with sub-threshold levels of BED), 
and a lack of long-term follow-up data.51, 64, 66 Despite the inconsistencies observed in individual trials, a recent 
meta-analysis conducted by our team comparing BED patients with matched obese peers without BED 
demonstrated a clear impact of BED on weight loss in BWL, with obese BED samples losing significantly less 
weight (M=6.95kg) compared to obese peers without BED (M=13.51). The long-term outcomes for BWL 

treatments in BED are especially poor, as patients with BED tend to re-gain lost weight more quickly than 
obese peers without BED67-69 and are more likely to drop out of treatment programs compared to obese peers 
without BED.67-70 Weight gain is often exacerbated by continued, or re-emergent, binge eating.64  
Most BWL programs have not tailored strategies to reduce caloric intake for BED patients.  Though there 
exists considerable variability across BWL interventions, most BWL programs instruct patients to set low to 
moderate calorie goals and restrict intake of palatable high-calorie foods. 71, 72 While strict diets often improve 
binge eating in the short term (even among patients who are in the normative weight range73, 74) long-term 
adherence over time is 1) difficult to maintain and 2) could promote the reoccurrence of binge eating if dietary 
restraint is rigidly applied.  A recent systematic review assessing the impact of very low calorie diets on binge 
eating65 found that most interventions reduced binge eating during active treatment75-83, but a re-occurrence in 
binge eating after treatment occurred in many (but not all) studies.76, 77, 79, 84 BWL, if not tailored for BED, may 
encourage the use of unsustainable restrictive eating behaviors, reducing the efficacy of this approach.  
BWL typically emphasizes reduced caloric intake as the primary method for altering the caloric balance, 
despite evidence that physical activity can reduce binge eating and encourage weight loss in BED.  Because 
most weight loss in BWL is attributed to reductions in calorie intake rather than increases in physical activity85, 
86 BWL typically devotes more intervention time to maintaining changes in eating behavior rather than 
physical activity. However, the few available studies that have specifically evaluated physical activity 
interventions in BED have found that increases in physical activity can reduce binge eating87, 88 and encourage 
weight loss54, 55, 87-89, suggesting that a stronger emphasis on physical activity for BED may be warranted.90-94 
 Strategies to facilitate adherence to dietary and physical activity goals are limited. Facilitating long-term 
adherence to the prescribed dietary and physical activity goals remains a challenge for nearly all patients in 
BWL programs. BWL patients, on average, fall far short of maintaining prescribed calorie levels and physical 
activity goals, and lose far less weight than would be expected given these prescriptions.91, 95  As noted above, 
patients with BED are prone to disinhibited eating, a strong predictor of poor adherence in BWL10, 96.  For 
example, in a recent trial completed by our team, patients who reported one or more binge eating episodes in 
the three months prior to starting BWL experienced more dietary lapses during the first two weeks of 
treatment than obese peers without a binge eating history (B=.39, SE = .19, Wald χ2 =4.39, p = .04).  This 
result adds to a growing body of literature suggesting that patients with BED are especially vulnerable to lapses 
from treatment prescriptions in BWL and may benefit from novel treatment strategies to increase adherence. 
BWL fails to adequately address elevated food reward sensitivity, negative affect, distress intolerance, 
and overvaluation of weight and shape. Most BWL programs encourage participants to use stimulus control 
techniques (e.g., strategies designed to reduce exposure to food cues) to limit access to high-calorie foods.71, 72, 97 
However, studies testing the use of stimulus control have found that commitment to maintaining these changes 
wanes over time.98 Additionally, while it may be possible to change the home food environment, it is not 
possible for participants to completely remove themselves from the larger obesogenic environment, and 
therefore urges and cravings for highly palatable foods will still arise.20-22 BWL devotes relatively little session 
time to urge management and elevated food reward sensitivity predicts poor outcome in BWL.98-100 While BWL 
often includes a session or two on stress management or emotional eating, the amount of time devoted to 
negative affect is limited and distress intolerance is not addressed in standard BWL.71, 72. These absences reflect 
a significant limitation when treating those with BED, as negative affect and distress intolerance are strongly 
associated with both binge episodes38-42 and overeating episodes without loss of control101 in BED. Lastly, 
overvaluation of shape and weight is not addressed in BWL. Continued overvaluation of weight and shape may 
maintain a problematic emphasis on obtaining a weight or shape that is unlikely to be achieved in BWL. 
Patients with BED have reported that reaching their desired BMI would require a 36% reduction in weight, an 
expectation that far exceeds weight losses in BWL.102 Even the BMI reduction patients with BED report as 
“disappointing” were 1.5 to 3 times greater than what could be expected in BWL. Although most obese patients 
want larger weight losses than are likely in BWL, the combined desire for substantial weight loss and 
overvaluation of weight and shape may reflect a particularly problematic combination. Once patients realize 
they are unlikely to achieve their desired weight, motivation to adhere to treatment prescriptions might 
decrease103, 104, which may explain, in part, why patients with BED are vulnerable to dropping out of BWL.67-70 
A6. Integrating CBT and BWL does not improve outcomes in BED. Several researchers have 
attempted to improve weight loss outcomes for BED by integrating CBT and BWL or using a sequential 
treatment design (e.g., CBT followed by BWL or vice versa).64, 82, 105, 106 While the appeal of this approach is 
clear, the results to date have consistently failed to show evidence of superior treatment outcomes. For 
example, a recent study by Dr. Grilo assessed whether sequential CBT and BWL treatment could produce 
greater weight loss than BWL alone and found no support for the sequential ordering of treatment.64 These 

results support the notion that the current iterations of both CBT and BWL (either alone or in conjunction) are 
unlikely to produce clinically meaningful weight outcomes for patients with BED.  
A7. Tailored dietary and physical activity recommendations for patients with BED may improve 
weight loss outcomes.  One of the key challenges for improving treatment outcomes in BED is the need to 
achieve a calorie deficit sufficient to produce meaningful weight loss without substantially increasing hunger, 
cravings, and perceived deprivation, all of which could increase urges to binge or overeat. Compared to obese 
peers without BED, individuals with BED are more likely to report hunger and cravings when dieting, and 
demonstrate greater food intake in response to hunger and cravings in laboratory tests.41, 107-109  Similarly, 
patients with BED experience greater hedonic hunger (i.e., hunger that occurs in the absence of an energy 
deficit and is largely driven by the palatability of food) than obese peers without BED110, 111 and greater feelings 
of deprivation when restricting intake of highly palatable foods, even in the absence of caloric restriction.112, 113 
This predisposition to hunger, cravings, and perceived deprivation in patients with BED suggests a need to 
tailor dietary prescriptions. A small body of evidence suggests that modified dietary recommendations can 
improve weight outcomes in BED compared to the traditional recommendations of BWL.105, 114, 115 For example, 
a reduced energy density diet lowers caloric intake among BED patients in laboratory studies without 
increasing self-reported hunger115 and changes in the energy density of food intake have been related to weight 
loss in previous trials.105, 114 To date, direct investigation of tailored strategies to reduce hunger, cravings, and 
perceived deprivation in patients with BED remains limited but worthy of study.      
As described above, incorporating physical activity into treatment for BED both reduces binge episodes87, 88 
and encourages weight loss.54, 55, 87-89 For example, one study found that for patients with BED, CBT plus 
nutritional counseling alone was less effective at producing weight loss than CBT plus nutritional counseling 
and physical activity.88 Only participants in the physical activity condition experienced reductions in drive for 
thinness, suggesting that physical activity may also target overvaluation of weight and shape. Physical activity 
is known to reduce depressive symptoms in patients with BED, and reduces the impact of anxiety sensitivity 
(e.g., fear of anxiety and related sensations, conceptually related to distress intolerance) on binge eating 
pathology, perhaps because physical activity functions as a coping strategy and reduces reliance on binge eating 
as a way to reduce emotional distress.116 A recent systematic review of physical activity for BED concludes that 
adding exercise to behavioral treatments for BED can facilitate reduced binge eating and weight loss both 
directly (e.g., by burning calories) and indirectly (e.g., by improving depression, reducing reliance on binge 
eating to reduce emotional distress).117 Despite the many known benefits of physical activity, existing 
treatments either do not include any physical activity (CBT) or target physical activity as only a secondary goal 
of treatment given evidence that reducing caloric intake is more important for producing initial weight loss 
(BWL).72, 118 Greater session time devoted to physical activity and a focus on physical activity as a primary 
method for directly and indirectly reducing binge eating and facilitating weight loss appears warranted.  
A8. Acceptance-based psychological strategies may be able to improve negative affect, distress 
intolerance, and overvaluation of weight and shape and support long-term adherence to BWL 
prescriptions despite elevated food reward sensitivity. Acceptance-Based Behavioral Treatments 
(ABBTs, a group of novel “third-generation” behavior therapies including Dialectical Behavior Therapy119 and 
Acceptance and Commitment Therapy (ACT)120) teach patients a set of psychological strategies that we believe 
can reduce binge eating and overeating without loss of control in patients with BED. The goal of ABBT is not to 
reduce the frequency of aversive experiences (e.g., hunger, cravings, fatigue); rather, the aim is to foster 
willingness to experience aversive internal experiences while simultaneously engaging in behaviors consistent 
with long-term goals and values (e.g., choosing to exercise even while feeling fatigued, adhering to a meal plan 
while having urges to eat more palatable foods). Patients are taught a number of psychological strategies 
(reviewed in detail in the ABBT Condition section below) designed to disrupt key maintenance factors in BED 
(e.g. experiential acceptance as an alternative to distress intolerance, values clarification to identify alternative 
valued life domains and reduce overvaluation of weight and shape). The conceptual fit between ABBTs and 
binge eating is well noted in existing literature and has led to the development of a number of acceptance-based 
treatment approaches designed to reduce binge eating including but not limited to Mindfulness-based Eating 
Awareness Training121, 122, Mindfulness-based Stress Reduction123, 124, DBT125-127, and ACT.128, 129 Recent 
systematic reviews and meta-analyses indicate that ABBTs can produce medium to large reductions in binge 
episodes123, 130 and support the promise of these interventions for reducing binge eating behavior in BED. 
While this early work is promising, no ABBT developed to date has focused on using acceptance-based 
strategies to increase adherence to BWL prescriptions in BED. A small number of the ABBT for BED trials 
described above examined weight loss as a secondary outcome (n=7), but results were typically subpar, likely 
because adherence to a prescribed weight loss diet was not a key goal of treatment.125, 127, 131-135 We believe that 

ABBTs focus on learning to tolerate uncomfortable internal states in the service of goal-directed behaviors is 
uniquely well-suited to improving adherence to BWL prescriptions. Recent work by our study team (reviewed 
in detail below) provides early support for the ability of ABBT to increase adherence to BWL prescriptions in 
obese individuals without BED.136, 137 As described above, patients with BED are especially vulnerable to lapses 
from treatment prescriptions in BWL, suggesting that psychological strategies designed to increase adherence 
may be particularly beneficial. Although ABBTs have shown promise at reducing binge eating symptoms in 
BED and facilitating weight loss in obese adults without BED, an ABBT designed to directly target both binge 
eating and weight loss in patients with BED has yet to be evaluted. 
A7. Current study. We propose to (a) compare the efficacy of an ABBT that targets both binge eating and 
weight loss in patients with BED to a Standard Behavioral Weight Loss Treatment (SBT), (b) evaluate the 
extent to which ABBT and SBT target shared maintenance factors for binge eating and overeating episodes, and 
(c) assess whether treatment efficacy is moderated by baseline values of constructs targeted in ABBT.   
B. Innovation 
B1. Our study will be the first to evaluate an ABBT for BED designed to 1) address maintenance 
factors that give rise to both binge eating episodes and overeating episodes without loss of 
control and 2) increase adherence to BWL prescriptions. Existing ABBTs for BED have focused 
almost exclusively on reducing binge eating episodes.  Our team conducted a review of treatment protocols of 
ABBTs for BED and found that session content dedicated to the use of acceptance-based strategies to augment 
adherence to BWL prescriptions or reduce overeating episodes without loss of control is minimal or non-
existent in treatments that have been evaluated to date. For example, in a recent trial of Mindfulness-Based 
Eating Awareness Training131, weight loss was evaluated as a secondary outcome and recommended calorie 
goals were provided. However, the authors state that “calorie levels specifically encouraged participants not to 
target weight loss, but rather to maintain current weight while addressing eating difficulties” and weight 
management was only briefly mentioned in two out of twelve sessions. Unsurprisingly, only 28% experienced 
>5 lb weight loss over approximately five months of treatment, a percentage that was nearly identical to the 
control condition.  Similar patterns were observed for all existing ABBT for BED protocols published to date, 
indicating that the ability of ABBT to improve weight loss outcomes in BED has not been adequately tested.  
ABBT for weight loss, developed by Dr. Forman and colleagues, has been called an advancement in 
behavioral treatment by experts in the field after a recent RCT of this approach produced one of the largest 
initial weight losses in the behavioral treatment literature absent the use of an aggressive diet or weight loss 
medication.138 At present, five large clinical trials have compared a treatment program that uses acceptance-
based techniques to facilitate weight loss, with three of the five trials showing superior results for the 
acceptance-based condition compared to SBT.136, 137, 139-141 Post-hoc analyses have indicated that patients with 
features often elevated in BED (e.g. high disinhibition, elevated food reward sensitivity, food-specific 
impulsivity; see Preliminary Studies section below for more details) experience the most added benefit from 
ABBT. However, all of these trials have excluded patients with full-threshold BED.  Our study will be the first to 
test an ABBT with an explicit focus on 1) altering shared mechanisms that give rise to both binge eating and 
overeating without loss of control and 2) increasing adherence to BWL prescriptions in patients with BED.  
B2. Very few studies to date have altered standard behavioral treatment prescriptions to 
address the unique needs of patients with BED. Our treatment will modify standard behavioral 
treatment recommendations to achieve a calorie deficit while minimizing hunger, cravings, and perceived 
deprivation that could increase urges to binge or overeat. These methods (described in greater detail in the 
ABBT Condition section) include providing guidance on the types of foods patients can eat to enhance satiety, 
eliminating rigid dietary rules (e.g., avoiding specific food groups, not eating after set times), incorporating 
portion-controlled, palatable foods (e.g., desserts, salty snack foods) to avoid feelings of deprivation, and 
promoting high levels of moderate-to-vigorous physical activity as a primary method for altering the calorie 
balance. While other studies have attempted to modify BWL for patients with BED, existing work has focused 
largely on the incorporation of CBT strategies into BWL treatments.64, 82, 105, 106 Our study will be one of the first 
to alter standard behavioral treatment prescriptions to increase suitability for a BED population.  
B3. Assessing mechanisms of action is treatment outcome studies for BED remains rare. To 
date, very few treatment outcome trials for eating disorders assess mechanisms of action.142 Recent NIH 
initiatives call for an increased emphasis on evaluating the impact of treatment on identified clinical targets to 
better inform treatment development.143, 144 The proposed study will test whether ABBT works through the 
hypothesized pathways and alters shared maintenance factors for binge eating and overeating in patients with 
BED. A primary goal is to assess whether patients who receive ABBT demonstrate (a) larger increases in 

flexible (but not rigid) dietary restraint, (b) greater adherence to caloric and physical activity goals, (c) larger 
improvements in negative affect and distress intolerance, and (d) greater reductions in overvaluation of weight 
and shape compared to patients in SBT, and whether changes in these targets are associated with outcomes. 
B4. Few studies of BED have assessed baseline moderators of weight loss. Although a growing 
number of studies have assessed baseline predictors of treatment outcome for binge eating, data on predictors 
of weight loss in BED is limited.145 If we can a priori identify specific individuals who may need a specialized 
intervention such as ABBT, we can appropriately refer patients to the correct type of care. Alternatively, if we 
identify individuals who can achieve clinically significant weight loss in SBT, an easily disseminable and 
relatively low-cost treatment, we can reduce the need for specialty treatments. Food reward sensitivity, 
overvaluation of weight and shape, negative affect, and distress intolerance have all been proposed as markers 
of a more severe subset of BED patients who may not respond as well to current interventions.146-148 Assessing 
baseline moderators of treatment outcome will provide meaningful data to personalize treatment selection.  
C. Approach 
C1. Preliminary studies. Promising results from several of our team’s studies demonstrate that 1) this team 
has the expertise and resources necessary to conduct the proposed research (e.g., recruit and retain BED 
participants, deliver SBT and ABBT), and 2) the hypotheses to be tested in this study are likely to be supported.    
CARE Project I. Drs. Juarascio and Forman recently completed an open-trial 
pilot study of ABBT for BED.128 Weight loss was not an aim of this ABBT and 
the trial included patients who were normal weight in addition to patients who 
were overweight or obese. Participants (n=19) reported high acceptability of the 
treatment and retention rates were high at 89.4%. Generalized linear multilevel 
modeling revealed large and significant improvements in global eating 
pathology and binge frequency. Increases in distress tolerance predicted 
decreases in binge eating across several measures (rs = .35-.54).  
CARE Project II. Dr. Juarascio recently completed a ten-session ABBT weight loss program with a small 
number of overweight and obese BED patients (n=5) who previously completed CARE Project I. Patients 
reported high acceptability of the program and lost 2.7% body weight by week 10. Although results are 
preliminary, past research has demonstrated that early weight loss predicts subsequent success in BWL.149-151  
REACT Project. Drs. Juarascio and Forman previously assessed ABBT in a sub-sample of obese patients (n= 
20, Mean BMI: 39.44) with eating pathology in a larger treatment study.152 The full study examined whether 
the addition of ABBT groups to treatment as usual in a residential treatment facility for eating disorders would 
improve treatment outcomes.153 Results revealed that obese patients in the ABBT condition trended towards 
larger reductions in shape/weight concern and global eating pathology by discharge, with effect sizes in the 
moderate range (partial eta squared of .29 to .38). Patients in the ABBT condition also lost more weight (ABBT: 
2.31 kg, TAU: 1.30 kg), despite the fact that weight loss was not explicitly a goal of this version of ABBT.  
Mind Your Health I. A previous NIH-funded project (Dr. Forman, PI) assigned participants (n=128) to 30 
sessions of ABBT or SBT for weight loss.154 Attendance at ABBT groups was excellent (M = 81.7% of 30 
sessions) and higher than in SBT (M=73.9%) indicating that the acceptability of ABBT is high. When 
administered by clinicians with obesity treatment experience, percent weight loss was significantly higher in 
ABBT than SBT at post-treatment (13.2% vs. 7.5%; p = .01) and 6-month follow-up (11.0% vs. 4.8%; p = .01). 
Although BED patients were excluded, higher levels of depression, disinhibition and responsivity to food 
(characteristics typically elevated in BED) moderated the main effect of treatment. For example, among 
individuals with depression at baseline, 40-week weight losses were 18.2% for ABBT and 5.5% for SBT.  
Mind Your Health II. A nearly completed NIH-funded project (Dr. Forman, PI) assessed the long-term efficacy 
of ABBT versus SBT for overweight and obese adults. Participants (n=190) were randomly assigned to 25 
sessions of ABBT or SBT. At post-treatment, ABBT yielded statistically and clinically significant greater percent 
weight loss (M= 13.3%) compared to SBT (M= 9.8%) and the superiority of ABBT was maintained at one-year 
follow-up.137 Post-treatment retention rates (82.6% at 12 months) exceeded our target. Similar to Mind Your 
Health I, patients with BED were excluded from the study; however, patients with high food-specific 
impulsivity (which is elevated in BED155) performed better in ABBT.156  
Project ENACT. Another NIH-funded project from our team (Dr. Forman, Co-I) randomized 283 overweight 
and obese participants to receive 26 sessions of group-based SBT (with or without a focus on changing the 
home environment) or ABBT. As in the previous trials, patients with full-threshold BED were excluded from 
0
5
10
15
20
Pre-Tx
Mid-Tx Post-Tx 3m F/U
Binge Frequency

treatment. However, patients with sub-clinical binge eating (defined as no more than three binge episodes in 
the three months before treatment) were included and preliminary results indicate greater weight loss in the 
ABBT condition (M=11.58%) than the SBT (M=9.71%) conditions for this subgroup. 
C2. Study design. Participants will be randomly assigned to SBT or ABBT. Treatment will be delivered in 75-
minute, small (12-15 participants), closed-group sessions. Groups will be held weekly in months 1-3, biweekly 
in months 4-6, and monthly in months 7-12, for a total of 25 sessions. Assessments will occur at months 0 
(baseline), 1 (midpoint 1), 3 (midpoint 2) 6 (midpoint 3), 12 (post-treatment), and 24 (1-year follow-up).  
C3. Alternative designs considered. While we considered a shorter treatment duration (to reduce burden 
and increase disseminability), we ultimately chose a 25-session treatment for three reasons. First, 25 sessions 
over 1 year is about the modal length and the recommended intensity for gold standard weight loss treatment.  
Second, this length is consistent with the increasingly-supported chronic care model of obesity.157 Third, 
clinical trial experts have recommended that, for initial tests of efficacy, treatments should be evaluated at full 
potency to reduce the likelihood that failure occurs because of sub-optimal dosage.158 If ABBT improves weight 
loss outcomes for BED, methods for reducing the intensity (e.g. optimization and refinement of session 
content) and increasing the scalability (e.g. use of alternative delivery methods and/or non-experts clinicians, 
both of which have been successfully completed with ABBTs for other disorders159) can be explored in future 
studies. We also considered including a second follow-up assessment, but determined that given the time 
needed to recruit and treat 130 participants with BED, a longer follow-up period would not be feasible.  
TIMELINE 
Year 1 
Year 2 
Year 3 
Year 4 
Year 5 
R= 
recruitment 
A = 
assessment 
(A1, A2, A3, 
A4, A5 = 
months 0, 3, 
6, 12, 24, 
respectively). 
Intervention 
period shaded. 
Manual refinement  
X X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Therapist training 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wave 1 
 
R A1 A2 
A3 
 
A4 
 
 
 
A5 
 
 
 
 
  
 
 
 
Wave 2  
 
 
R 
A1 
A2 
A3 
 
A4 
 
 
 
A5 
 
 
 
 
 
 
 
 
Wave 3 
 
 
 
 
R 
A1 
A2 
A3 
 
A4 
 
 
 
A5 
 
 
 
 
 
 
Wave 4 
 
 
 
 
 
R 
A1 
A2 
A3 
 
A4 
 
 
 
A5  
 
 
 
 
Wave 5 
 
 
 
 
 
 
 
R 
A1 
A2 
A3 
 
A4 
 
 
 A5  
 
 
Wave 6 
 
 
 
 
 
 
 
 
R 
A1 
A2 A3 
 
A4 
 
 
 A5  
 
Data analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X X 
Manuscript preparation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X X 
Planning future studies, e.g, optimization  
 
 
 
 
 
 
 
 
 
 
 
 
 
X X 
 C4. Participants. 130 participants will be recruited who meet the following inclusion criteria: DSM-5 
diagnosis of BED, BMI 27-45 kg/m2; age 18-70 years; and ability to engage in PA (i.e., can walk 2 blocks 
without rest). Exclusion criteria are as follows: medical condition (e.g., acute coronary syndrome, type I 
diabetes) or psychiatric condition (e.g., active substance abuse, severe depression) that may pose a risk to the 
participant during intervention, cause a change in weight, or limit ability to comply with the recommendations 
of the program; pregnant or planning to become pregnant in the next 2 years; planned move out of the 
Philadelphia area in the next 2 years; recently began a course of or changed the dosage of medication that can 
cause significant change in weight; history of bariatric surgery; and weight loss of > 5% in the past 6 months.  
C5. Recruitment, enrollment, and randomization. Recruitment will be conducted in six waves. Drs. 
Juarascio, Forman, and Grilo have established a variety of referral sources (including college counseling 
centers, private practitioners, and medical practices) for their ongoing grants recruiting patients with BED, 
bulimia nervosa, and obesity. We will also advertise in newspapers and radio stations. We will specially design 
advertisements (e.g., featuring images of men/ethnic minorities) and select media (e.g., that have high 
male/ethnic minority readership/listenership) to maximize participation of men and ethnic minorities. In Dr. 
Grilo’s most recent RCT (DK49587), similar recruitment methods yielded N=191 randomized BED patients 
(which exceeded target of N=175) and yielded 35% men and 24% minority enrollment. We considered making 
special effort to recruit participants high in proposed moderators to ensure adequate power for Secondary Aim 
2, but based on available literature112, 127, 160, 161 and our own pilot data162 we believe we will recruit a sample with 
sufficient variability in proposed moderators using existing methods. Drs. Juarascio, Forman, and Grilo will 
have monthly videoconference meetings to discuss any concerns related to recruitment, enrollment, or 
retention and will meet in-person during twice yearly during national conferences to review study progress.   
Participants will be screened by phone to assess preliminary eligibility.  Phone screens will use questions 
from the Mini International Neuropsychiatric Interview (MINI)163 to assess psychiatric comorbidity and will be 
conducted by trained graduate students, similar to procedures used successfully in our other NIH-funded 
trials.  Those who appear eligible will attend an orientation session where they will receive detailed information 
about the study. At a subsequent clinic visit, eligibility will be verified, informed consent obtained, and the 
baseline assessment completed. The enrollment process will provide participants with an adequate opportunity 

to determine whether the assessment burden and demands of the program are acceptable; this is expected to 
reduce attrition. After the baseline assessment, participants will be randomized to condition in blocks of 6, 
stratifying by BMI category (<30, 30-40, and >40), sex, race/ethnicity, and frequency of binge episodes. 
C6. Therapy conditions. We decided to use SBT as our control condition given that weight loss is our 
primary outcome. We considered including CBT as an alternative control condition, but ultimately decided that 
CBT would be a sub-par control because this treatment does not directly encourage weight loss and 
consistently produces minimal to no weight loss for patients with BED. 
C6a. Standard Behavior Therapy (SBT) condition. SBT will be adapted from state-of-the art SBT 
manuals our team has used for previous weight loss studies, which were themselves adapted from Look 
AHEAD and the Diabetes Prevention Program protocols.71, 72 Components of SBT include nutrition and 
physical activity education, self-monitoring of calorie intake, physical activity, and weight; stimulus control 
techniques; identifying triggers for overeating; setting individualized realistic goals for calorie intake, physical 
activity, and associated behaviors; using problem solving skills as a way of overcoming obstacles to behavior 
change; developing social support; and relapse prevention techniques. Patients will be given calorie goals based 
on weight, in accordance with standard balanced deficit diet guidelines164 (e.g., patients weighing 250-299 lbs. 
will be prescribed 1500 kcal/day). Patients will be instructed to gradually increase their physical activity until 
they reach at least 250 minutes per week of moderate activity, as consistent with American College of Sports 
Medicine165 and American Journal of Clinical Nutrition recommendations, and emerging data suggesting this 
higher level of PA is most associated with successful weight loss maintenance.166-168  
 C6b. Acceptance-Based Behavioral Treatment (ABBT) Condition. The ABBT manuals will be based 
on the manuals developed by Dr. Juarascio for the CARE I and CARE II Projects and the manuals developed by 
Dr. Forman for MYH1 and MYH2. ABBT is a behavioral treatment approach, and as such, uses some of the 
same behavioral techniques used in CBT and SBT, particularly during Phase 1. As described in greater detail 
below, many of the standard behavioral techniques and recommendations were modified to better suit the 
unique needs of patients with BED or facilitate weight loss.  Because acceptance-based techniques are designed 
to work in conjunction with behavioral treatment recommendations, we first introduce patients to modified 
behavioral strategies drawn from CBT and SBT during Phase 1 and subsequently introduce acceptance-based 
techniques to improve adherence and address key maintenance factors for BED during Phase 2.  
 Phase 1 (Sessions 1-8): The first eight sessions of ABBT will use behavioral strategies from both CBT and 
SBT to 1) reduce binge eating episodes and 2) alter the calorie balance.  
CBT techniques. We chose to focus on reducing binge episodes during Phase 1 based on data suggesting 
that early reductions in binge eating impact weight loss outcomes.14, 169-171 Sessions 1-3 will provide 
psychoeducation on the maintenance factors for binge eating episodes, introduce patients to self-monitoring, 
and start the regular eating interventions, which is a key driver of early reductions in binge eating in CBT.142, 172  
Patients with BED who consume more frequent meals weigh less, suggesting regular eating might indirectly 
assist in weight loss.173, 174  Regular eating produces a rapid reduction in binge eating episodes and rapid 
response to treatment is highly predictive of successful treatment outcomes, further supporting a strong focus 
on reducing binge eating episodes early in treatment.175-178 Unlike the regular eating interventions typically 
implemented in CBT, our regular eating intervention will incorporate personalized caloric goal ranges for each 
meal and snack designed to reduce caloric intake.  As described above, regular eating interventions are 
typically weight neutral, likely because calories previously consumed during binge episodes are distributed over 
non-binge meals.56, 57 We believe that providing explicit calorie goals for each eating episode during the 
implementation of regular eating can help prevent re-distribution. 
SBT techniques. During Phase 1, patients will be taught many of the same behavioral strategies described in 
the SBT section above to assist in meeting their calorie goals (e.g., self-monitoring of calorie intake; stimulus 
control techniques; problem solving skills).  While many techniques will be similar to SBT, some modifications 
will be made to address the unique needs of patients with BED.  For example, patients will receive education 
about the ways rigid dietary restraint can trigger binge episodes (e.g., severe caloric restriction, hedonic 
restriction, avoiding specific food groups, going long periods of time without eating), and will learn how to 
reduce caloric intake in ways that will minimize hunger and cravings. The table to the right provides examples 
of these strategies.  One core difference will be that patients in ABBT will be encouraged to incorporate portion 
controlled palatable foods regularly to avoid feelings of deprivation that could trigger binge eating. While 
avoiding highly palatable foods can be a successful strategy for many obese patients, hedonic deprivation may 
be less sustainable for patients with BED and could encourage future binge eating or overeating episodes.   
The exercise progression in ABBT will be the same as in SBT, with specific session content dedicated to 
psychoeducation about the benefits of physical activity for BED in Session 8. The ABBT treatment will also 

provide psychoeducation relevant to patients with BED (e.g., session content on avoiding compensatory and 
compulsive exercise). We chose to begin the exercise progression in Phase 1 because 1) this will allow patients 
who are currently sedentary time to safely build up to the recommended exercise progression, and 2) research 
indicates that exercise can indirectly reduce binge eating episodes by improving depression, self-efficacy, and 
body image as well as reducing the degree to which binge eating episodes are used to regulate emotions.117 We 
considered using a more intensive exercise progression for ABBT, but decided that given the low long-term 
adherence rates observed in SBT90-94, ,the feasibility of meeting even higher activity goals would be limited. 
Phase 2 (sessions 9-19): Phase 2 will focus on the use of acceptance-based strategies to improve adherence 
to dietary and physical activity goals and address shared maintenance factors for binge eating and overeating 
episodes. Below we will review how acceptance-based techniques will be incorporated in Phase 2.   
Values clarity/commitment enhancement. Consistent with principles of ACT120 and intrinsic motivation 
theory179, ABBT will emphasize that participants must choose goals that emanate from freely-chosen, personal 
life values (e.g., living a long and healthy life; being a present, active mother). A structured process for the 
identification of such life values will be followed and the connections between these values and eating and 
physical activity behaviors will be emphasized. Participants will be taught that commitment to difficult 
behavioral goals is only likely to be maintained when one connects psychologically with life values important 
enough and meaningful enough to make such effort and sacrifice worthwhile. Commitment will be presented as 
a critical component of maintaining changes to the personal food and physical activity environment. Values 
clarity interventions will also be used to alter overvaluation of weight and shape. An underlying assumption 
about values is that they are finite; that is, there is a limit to what can be encapsulated in an individual’s value 
base. Thus, the overvaluation of weight and shape that occurs in BED necessitates that there is less “room” for 
other valued domains.128 By helping patients pursue committed actions towards personal values, ABBT may be 
able to foster awareness of the values-inconsistent nature of binge eating and overeating episodes, reduce 
overvaluation of weight and shape, and improve motivation for adherence to program goals.  
Distress tolerance. ABBT will help participants recognize that, 1) eating-related distress (e.g. urges to 
binge, hunger, cravings) is bound to occur in today’s obesogenic environment, particularly given the elevated 
food reward sensitivity common in BED and 2) attempts to avoid these internal experiences are often 
ineffectual or even counterproductive. Participants will learn to tolerate aversive states related to eating (e.g., 
cravings) and physical activity (e.g., boredom, discomfort) while continuing to engage in the desired behaviors 
through in-session experiential activities and at-home practice. For example, in one session, participants will 
hold themselves in the “plank” (an unsupported sitting) position and practice tolerating the bodily discomfort 
that is generated by this exercise. Willingness (simultaneously engaging in a valued action while accepting the 
discomfort it generates) will be framed as more adaptive than distress intolerance (i.e., eating foods or 
ceasing/avoiding activity to avoid being uncomfortable). Experiential exercises will allow participants to 
practice distancing themselves from thoughts and feelings in a way that enhances willingness to experience 
them, thereby reducing the necessity of acting (e.g., ending a walk early, eating a chocolate bar) to alter the 
experience. Unlike SBT, ABBT assumes that attempts to distract from or modify thoughts and feelings are 
rarely productive; rather, long-term adherence to health behaviors depends on the ability to tolerate 
unpleasant internal experiences. Distress tolerance will also be used to address elevated negative affect that 
contributes to binge eating and overeating episodes. Reductions in binge eating have been mediated by changes 
in distress tolerance, supporting its importance as a treatment target in BED.180 Patients will be taught how to 
tolerate negative affect without using food as a way to distract from or numb out uncomfortable experiences.  
Phase 3 (sessions 20-25): The final phase will have a strong focus on achieving weight loss maintenance by 
enhancing long-term adherence to dietary and physical activity recommendations. Acceptance-based strategies 
such as values clarity and committed action will be used to address reductions in motivation. Patients will also 
be taught how to address a reoccurrence of binge eating if this behavior emerges at any point during their 
weight loss efforts (e.g., re-establish self-monitoring, reduce dietary restriction, reincorporate regular eating).  
C7. Intervention cultural sensitivity. The research team will recruit participants from the Philadelphia 
metropolitan area, which is 38% non-white based on the most recent census data.181 All interventions will be 
culturally sensitive by, for example, discussing barriers to behavior change unique to each participant’s social 
context (e.g., neighborhood safety as a barrier to exercise), and emphasizing health benefits and general 
wellbeing as the motivation for weight loss and exercise.182-184 
C8. Clinician training, supervision, competence and fidelity. Group leaders will be clinicians with a 
graduate degree in psychology or a related field and previous experience conducting both BWL and CBT. 
Research indicates that previous experience with an acceptance-based approach is not necessary for effective 
treatment delivery and that brief training is sufficient.153, 185-193 Clinicians will complete a 10-hour initial 

training and attend weekly supervision provided by Dr. Manasse. Consistent with our previous clinical trials of 
ABBT for obesity, clinicians will be balanced across conditions. Data from our MYH II and ENACT trials have 
demonstrated that contamination across conditions is extremely low based on codings of audio-recorded 
sessions (MYH II: 0.12/10, ENACT: 0.23/10; 0= perfectly avoided contamination and 10= substantial 
contamination occurred). All treatment sessions will be audio-recorded, and 25% will be rated for competence 
and fidelity. Feedback on competence and fidelity will be shared after each rated session and shortcomings will 
be addressed immediately. An intervention allegiance survey also will be administered to all clinicians.    
C9. Assessments and Measures.  Assessments will occur at the start of treatment (baseline), 1 month 
(midpoint 1), 3 months (midpoint 2), 6 months (midpoint 3), 12 months (post-treatment), and 24 months (1-
year follow up). All outcome and process measures described below will be completed at each assessment. 
Acceptability will be assessed at post-treatment.  All assessments will be completed onsite in Drexel 
University’s Department of Psychology. Efforts will be made to schedule midpoint assessments directly after or 
directly before a treatment session to reduce participant travel burden (e.g. month 3 assessment will occur 
between sessions 12 and 13, with effort made to schedule participants right after session 12 or right before 
session 13 if possible).  All assessments will be conducted by blind raters (graduate students who will be highly 
trained and closely supervised by Dr. Manasse). Blind raters will receive training on standard procedures for 
collecting anthropometric data and administering all process measures described below. Raters will be 
required to pass a “mock” assessment with Dr. Manasse and reach 100% agreement on eating disorder 
diagnosis and acceptable reliability (>.80) on EDE scoring before they will be cleared to conduct assessments.  
 Feasibility and Acceptability. Assessment of feasibility will include number of patients screened per 
month, % of eligible patients enrolled, treatment attrition (% of patients that prematurely terminate 
treatment), study retention (% of patients that complete all assessments), treatment adherence, and treatment 
fidelity. Acceptability will be assessed using the Feedback Questionnaire and Credibility/Expectancy 
Questionnaire194 to gauge participant’s attitudes and feelings toward the treatment.  
Outcomes. The primary outcome measure for the study will be change in weight. Weight will be measured 
in street clothes without shoes using a standardized Secca scale accurate to 0.1 kg. Eating pathology will be 
a secondary outcome measure and will be measured by The Eating Disorder Examination (EDE), a widely 
utilized, semi-structured interview for eating disorder symptoms.195 Participant’s EDE global scores and 
objective binge frequency will be the primary outcome measures for eating disorder pathology.  
Process Measures. The study will assess whether patients who receive ABBT show greater improvements in 
1) flexible restraint (and less rigid dieting behaviors), 2) adherence to caloric and physical activity goals, 3) 
negative affect, 4) distress tolerance, and 5) overvaluation of weight and shape compared to patients who 
receive SBT. Measurement tools were selected on the basis of assessing clinical targets using multiple 
assessment approaches. We will assess flexible restraint and disinhibited eating with the Eating 
Inventory (Three Factor Eating Questionnaire)196, a commonly used measure of dietary restraint. Three specific 
subscales within this measure will be of particular focus: Rigid Control of Eating Behaviors, Flexible Control of 
Eating Behaviors, and Disinhibition.197 Dietary intake will be measured by 72 hours of recalled intake using 
the Automated Self-administered 24-hour Dietary Recall (ASA24), a National Cancer Institute-designed free 
software tool that enables self-administered, but interactive, 24-hour dietary recalls.198 ASA24 is based on the 
well-validated Automated Multiple Pass Method which is as or more accurate than nutritionist-administered 
24-hour food recall when using doubly-labeled water as the criterion.199   
We will define physical activity (PA) in kcal/wk of energy expended through MVPA200 with ActiGraph 
GT3X tri-axial, solid state accelerometers. Accelerometers, particularly models made by Actigraph, have been 
found to be valid and reliable means of measuring PA.201, 202 The tri-axial models can measure movements in 
multiple planes and assess activity intensity providing more accurate estimates of energy expenditure than do 
less sophisticated methods such as pedometers or self-report questionnaires.203-205 The data collection interval 
will be set at one minute with a minimum of 12 hours constituting a valid day. We will also use a 7-day Physical 
Activity Recall200 measure to gather further information about duration and intensity of bouts of swimming, 
biking, and strength training. Estimates of PA will be calculated with and without imputation from these self-
report data. For assessment purposes, accelerometers will be distributed just prior to each assessment point, 
either through mail or at group meetings, and returned at each assessment visit. For 7 consecutive days at each 
assessment point, participants will wear accelerometers for all waking hours.  
A Negative Mood Induction (NMI) task will be used to assess negative affect and distress intolerance 
during and after an acute stressor. Following completion of all study measures participants will undergo an 
autobiographical recall task, a commonly used negative mood induction.206-208 Mood will be assessed using the 
Short Positive and Negative Affect Scale (PANAS)209 before and after the mood induction and after a ten-
minute waiting period following the mood induction. Heart rate (a physiological measure of emotional state) 

will be monitored throughout the induction and post-induction period using the Polar E600 heart rate 
monitor. Several prior studies have utilized mood inductions to assess ability to regulate and tolerate negative 
emotions in response to a stressor.210-213 Distress intolerance will also be measured using the Difficulties in 
Emotion Regulation Scale (DERS).214 The DERS assesses awareness and understanding of emotions, ability to 
tolerate emotional arousal, and effective action in the presence of intense emotions. We will also use two 
behavioral measures of distress intolerance. The computerized Mirror-Tracing Persistence Task215, 216 measures 
the amount of time a participant is willing to engage in a frustrating task (tracing a dot on a computer screen 
that moves in the opposite direction as one moves the computer mouse). The cold pressor test measures the 
length of time a participant is willing to leave her hand in water kept at 3° C through the use of a circulating 
water bath system (Lauda RM6) For safety reasons, participants are not allowed to exceed 300 sec of exposure 
to the cold water.217 Both of the aforementioned behavioral tasks have proven valid measures of distress 
tolerance in health behavior areas, particularly smoking cessation.216, 218-223 Lastly, depressive symptoms will be 
assessed using the Beck Depression Inventory-II, a 21-item measure assessing levels of depressive 
symptomology.224 This self-report scale is widely used and has proven reliable across a variety of demographic 
groups and in both clinical and nonclinical populations.  
Overvaluation of shape and weight will be assessed using the following two questions pulled from 
the Eating Disorder Examination: “Over the past four weeks, has your shape influenced how you feel about 
(judge, think, evaluate) yourself as a person?” and “Over the past 4 weeks has your weight influenced how you 
feel about (judge, think, evaluate) yourself as a person?”. This method of defining and assessing overvaluation 
of weight/shape has been used in several past studies with BED patients.32, 225 Measures used to assess values 
clarity will be the Valued Living Questionnaire II226, a commonly used quantitative measure of values, and the 
Values Clarity Measure, which is an open-ended, qualitative assessment where responses are recorded and 
coded. The Values Clarity Measure has been proven reliable and valid as a mediator of outcome in a lifestyle 
modification pilot study conducted by this research team.227 Reward sensitivity will be assessed with the 
Power of Food Scale, a self-report questionnaire that has been shown to reliably and validly measure thoughts 
and feelings about highly palatable foods when not physically hungry.27, 228, 229 
C10. Statistical Analyses 
Descriptive statistics will be generated for all variables. Data summaries will be produced for the combined 
sample and separately by treatment arm. Continuous variables will be summarized using mean/median as 
measures of location and SD/inter-quartile range as measures of dispersion; normalizing transformations will 
be used if there is evidence of skewness/kurtosis. Categorical variables will be presented as proportions.  
Primary Aim (Efficacy of ABBT). Analyses will be conducted via linear mixed effects models for 
longitudinal data, which increase power by fully exploiting the strong correlation in treatment outcomes of 
interests (i.e., primarily, percent weight loss and secondarily, percent binge frequency reduction) across time. 
Patterned covariance matrices as implemented in SAS/STAT PROC MIXED V9.2 will be used to evaluate 
between group differences for percent weight loss and percent binge reduction across the study as a whole, and 
at each assessment post-baseline.225 Separate variance components will be used to capture therapist and 
participant-within-therapist variation. The within-subject covariance matrix will be assumed common across 
study arms, with an exponential variance function to deal with heteroscedasticity and a continuous-time AR(1) 
correlation matrix to accommodate residual autocorrelation over the unequal–size time intervals between 
follow-ups. Outcomes at all six time points will be estimated jointly for maximum statistical efficiency in the 
presence of intermittent missingness and loss to follow-up. The model will include random effects for subject 
and time (with higher-order effects if needed to capture nonlinear change), and fixed effects for treatment arm, 
time by treatment interaction, demographic information, and baseline values of weight, dietary intake and 
physical activity. Time-specific covariate-adjusted contrasts will be used to compare outcome between groups.   
Secondary Aim 1 (Between-Subjects Mediation). We will examine the extent to which variables of interest 
(i.e., dietary restraint, adherence to caloric and physical activity goals, negative affect and distress tolerance, 
overvaluation of shape/weight, and values clarity) will mediate differences in weight loss and reduction in 
binge eating between treatments. Specifically, we will determine whether temporally-precedent changes in 
each mediator from baseline to 1 month and baseline to 3 months mediate subsequent differences in weight 
loss at 6, 12 and 24 months respectively. We will use the mediation model outlined by Preacher and Hayes and 
Mplus version 6.12 to estimate the total and specific indirect effects of each hypothesized mediator 
individually.230, 231 This approach expands on Baron and Kenny’s methods by providing additional guidelines 
and techniques that allow for the most robust and accurate interpretation of these mediating effects.232, 233 
Confidence intervals for the indirect effects will be generated using the bias-corrected (BC) bootstrapping 
approach.234 

Secondary Aim 2 (Between-Subjects Moderation). Reward sensitivity, overvaluation of shape/weight, 
negative affect, and distress tolerance will be added to the model described in Aim 1, and allowed to interact 
with time and treatment arm, to determine whether these variables moderate the effect of treatment. 
Statistically significant interactions will be interpreted by plotting simple regression lines for each variable.235  
Missing data. Our likelihood-based estimation methods remain unbiased when missingness is related to 
previously-observed outcomes as well as model covariates.236 If loss to follow-up is related to the missing 
outcome itself (an assumption that by its very nature cannot be tested empirically), we will use sensitivity 
analyses based on multiple imputation models237 to explore how robust our findings are with respect to a range 
of assumptions regarding missing data. We feel that these approaches are superior to alternatives (such as 
including only subjects with complete data or assigning a pre-specified score to the missing data) because these 
methods typically generate tests that are less powerful than the tests used assuming random censoring. We 
have experience with each of these approaches for handling non-ignorable non-response, and will analyze the 
data using several of these methods, which incorporate varying assumptions about the missing observations. 
To determine the extent to which the pattern of missing data might influence our findings, two approaches will 
be used. Compliance rates will be calculated for each participant. Participants with markedly low compliance 
rates (e.g., attendance at fewer than 3 assessments) will be considered for exclusion from analyses. Secondly, 
pattern mixture models169, 172, 174, 175 based on a random regression model (RRM)238, 239 will be used to examine 
the impact of missing data patterns on all variables. Subjects will be divided into groups based on their missing 
data pattern following the guidelines provided by Hedeker & Gibbons.240 The influence of missing data patterns 
on key variables will then be evaluated using RRM by comparing groups. If missing data patterns are found to 
be associated with key variables, this variable will be used as a covariate in subsequent analyses.   
C11. Power Analyses 
Primary Aim (Efficacy of ABBT). The study’s data will consist of repeated assessments over time within 
randomized individuals within each treatment condition. Therefore, power calculations are dependent on both 
an expected difference between treatment arms as well as the clustering of the data (repeated observations 
within an individual with up to six repeated measures per participant within one of the two treatment 
conditions), resulting in a multilevel model structure. Using the method described by Raudenbush252-254 and 
implemented with the software Optimal Design, power calculations were made for this multilevel model 
structure. No results are available which directly compare the effect of ABBT and SBT on weight loss in BED 
patients. However, effect size can be predicted by deriving effect sizes from trials with elements similar to the 
proposed study, e.g., percent weight loss comparison between ABBT and SBT from the Mind Your Health II 
study (effect size at 12 months d=0.39) and percent weight loss and binge reduction comparison of CBT vs. SBT 
(d=0.625; 30% difference in binge reduction rates).64 Based on previous studies, we aim to detect a clinically 
meaningful difference for both weight and binge eating frequency (3.5% weight loss between groups (d=0.46) 
and a difference in 4 binge eating episodes over the 4-week time period). Baseline covariates that can account 
for variability in the trial outcomes were taken into consideration in the power analysis. Given these 
assumptions, a sample size of 104 (52 for each group) is required for 80% power with the significant level of 
0.05 and five assessment points, assuming the ratio of the variability of level-1 coefficient to the variability of 
level-1 residual is one. While allowing for up to 20% attrition, the proposed sample size of 130 is adequately 
powered to examine a clinically meaningful difference between treatment conditions for both percent weight 
loss and frequency of binge episodes. We believe this power estimate to be conservative given: 1) attrition 
estimates are greater than the team has achieved in similar weight control studies; and 2) missing values will 
be imputed using multiple imputation to maximize the number of the observations used to estimate models. 
Secondary Aim 1 (Between-Subjects Mediation). Tests of mediation will utilize bias-corrected 
bootstrapping which demonstrates the best balance of statistical power and type I error.255-257 Fritz and 
MacKinnon255 documented sample size requirements to guarantee 80% power at a significance level of 0.05 for 
regression-based mediation models. Under the assumption of small to medium effect sizes for intervention 
with the mediator and for the mediator on outcome controlled for intervention, a sample size of 130 (58 per 
group) is required to achieve 80% power.241, 244, 255 Given a sample size of 130 and the pattern of weight loss and 
attrition described above, we will be sufficiently powered to evaluate our hypothesized effects. 
Secondary Aim 2 (Between-Subjects Moderation). In the linear mixed models used for the primary 
hypotheses, we will add as covariates both the main effects of our proposed moderators and their interactions 
with intervention assignment. Given N=130 and the pattern of weight loss, binge reduction, and attrition 
described above, we will have 80% power to detect moderation if the standardized coefficient for the treatment 
x moderator interaction is ≥ 0.3 (accounts for at least 8% of the variance) in a model in which the total variance 
accounted for is ≥ 20%. 
 
 

REFERENCES 
 
1. 
Bellows, B.K., S.L. DuVall, A.W. Kamauu, D. Supina, T. Babcock, and J. LaFleur, Healthcare costs and 
resource utilization of patients with binge‐eating disorder and eating disorder not otherwise specified 
in the Department of Veterans Affairs. International Journal of Eating Disorders, 2015 
2. 
Association, A.P., Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). 2013: American 
Psychiatric Pub. 
3. 
Hudson, J.I., E. Hiripi, H.G. Pope, and R.C. Kessler, The prevalence and correlates of eating disorders 
in the National Comorbidity Survey Replication. Biological Psychiatry, 2007. 61(3): p. 348-358 
4. 
Mitchell, J.E., Medical comorbidity and medical complications associated with binge‐eating disorder. 
International Journal of Eating Disorders, 2015 
5. 
Fandiño, J., R.O. Moreira, C. Preissler, C.W. Gaya, M. Papelbaum, W.F. Coutinho, and J.C. Appolinario, 
Impact of binge eating disorder in the psychopathological profile of obese women. Comprehensive 
Psychiatry, 2010. 51(2): p. 110-114 
6. 
Mitchell, J.E. and M.P. Mussell, Comorbidity and binge eating disorder. Addictive Behaviors, 1995. 
20(6): p. 725-732 
7. 
Wilfley, D.E., M.E. Bishop, G.T. Wilson, and W.S. Agras, Classification of eating disorders: Toward 
DSM‐V. International Journal of Eating Disorders, 2007. 40(S3): p. S123-S129 
8. 
Manson, J.E., P.L. Skerrett, and W.C. Willett, Epidemiology of helath risks associated with obesity, in 
Eating disorders and obesity, C.G. Fairburn and K.D. Brownell, Editors. 2001, Guilford Publications: 
New York. 
9. 
Mustelin, L., A. Raevuori, H.W. Hoek, J. Kaprio, and A. Keski‐Rahkonen, Incidence and weight 
trajectories of binge eating disorder among young women in the community. International Journal of 
Eating Disorders, 2015 
10. 
Villarejo, C., et al., Lifetime obesity in patients with eating disorders: increasing prevalence, clinical 
and personality correlates. European Eating Disorders Review, 2012. 20(3): p. 250-254 
11. 
Brody, M.L., R.M. Masheb, and C.M. Grilo, Treatment preferences of patients with binge eating 
disorder. International Journal of Eating Disorders, 2005. 37(4): p. 352-356 
12. 
Hart, L.M., M.T. Granillo, A.F. Jorm, and S.J. Paxton, Unmet need for treatment in the eating 
disorders: a systematic review of eating disorder specific treatment seeking among community cases. 
Clinical psychology review, 2011. 31(5): p. 727-735 
13. 
Bulik, C.M., M.D. Marcus, S. Zerwas, M.D. Levine, and M. La Via, The changing “weightscape” of 
bulimia nervosa. American Journal of Psychiatry, 2012. 169(10): p. 1031-1036 
14. 
Wilson, G.T., D.E. Wilfley, W.S. Agras, and S.W. Bryson, Psychological treatments of binge eating 
disorder. Archives of General Psychiatry, 2010. 67(1): p. 94-101 
15. 
Schag, K., J. Schönleber, M. Teufel, S. Zipfel, and K. Giel, Food‐related impulsivity in obesity and 
Binge Eating Disorder–a systematic review. Obesity Reviews, 2013. 14(6): p. 477-495 
16. 
Galanti, K., M.E. Gluck, and A. Geliebter, Test meal intake in obese binge eaters in relation to 
impulsivity and compulsivity. International Journal of Eating Disorders, 2007. 40(8): p. 727-732 
17. 
Guss, J.L., H.R. Kissilejf, B.T. Walsh, and M.J. Devlin, Binge eating behavior in patients with eating 
disorders. Obesity Research, 1994. 2(4): p. 355-363 
18. 
Guss, J.L., H.R. Kissileff, M.J. Devlin, E. Zimmerli, and B.T. Walsh, Binge Size Increases with Body 
Mass Index in Women with Binge‐Eating Disorder. Obesity Research, 2002. 10(10): p. 1021-1029 
19. 
Goldfein, J.A., B.T. Walsh, M.J. Devlin, J.L. Lachaussée, and H.R. Kissileff, Eating behavior in binge 
eating disorder. International Journal of Eating Disorders, 1993. 14(4): p. 427-431 
20. 
Yanovski, S.Z., M. Leet, J.A. Yanovski, M.n. Flood, P.W. Gold, H.R. Kissileff, and B.T. Walsh, Food 
selection and intake of obese women with binge-eating disorder. The American Journal of Clinical 
Nutrition, 1992. 56(6): p. 975-980 
21. 
Hsu, L., et al., Binge eating disorder in extreme obesity. International Journal of Obesity and Related 
Metabolic Disorders: Journal of the International Association for the Study of Obesity, 2002. 26(10): p. 
1398-1403 
22. 
Bond, M., A. McDowell, and J. Wilkinson, The measurement of dietary restraint, disinhibition and 
hunger: an examination of the factor structure of the Three Factor Eating Questionnaire (TFEQ). 
International Journal of Obesity and Related Metabolic Disorders: Journal of the International 
Association for the Study of Obesity, 2001. 25(6): p. 900-906 

23. 
Dishman, R.K., Increasing and maintaining exercise and physical activity. Behavior Therapy, 1991. 
22(3): p. 345-378 
24. 
McGuire, M.T., R.R. Wing, M.L. Klem, W. Lang, and J.O. Hill, What predicts weight regain in a group 
of successful weight losers? Journal of Consulting and Clinical Psychology, 1999. 67: p. 177-185 
25. 
Schienle, A., A. Schäfer, A. Hermann, and D. Vaitl, Binge-eating disorder: reward sensitivity and 
brain activation to images of food. Biological Psychiatry, 2009. 65(8): p. 654-661 
26. 
Manwaring, J.L., L. Green, J. Myerson, M.J. Strube, and D.E. Wilfley, Discounting of various types of 
rewards by women with and without binge eating disorder: Evidence for general rather than specific 
differences. The Psychological Record, 2011. 61(4): p. 561 
27. 
Appelhans, B.M., K. Woolf, S.L. Pagoto, K.L. Schneider, M.C. Whited, and R. Liebman, Inhibiting food 
reward: delay discounting, food reward sensitivity, and palatable food intake in overweight and 
obese women. Obesity, 2011. 19(11): p. 2175-2182 
28. 
Fairburn, C.G., Z. Cooper, and R. Shafran, Cognitive behaviour therapy for eating disorders: A 
“transdiagnostic” theory and treatment. Behaviour Research and Therapy, 2003. 41(5): p. 509-528 
29. 
Fairburn, C.G., Cognitive behavior therapy and eating disorders. 2008: Guilford Press. 
30. 
Schaumberg, K., D. Anderson, L. Anderson, E. Reilly, and S. Gorrell, Dietary restraint: what's the 
harm? A review of the relationship between dietary restraint, weight trajectory and the development 
of eating pathology. Clinical obesity, 2016 
31. 
Stice, E. and H.E. Shaw, Role of body dissatisfaction in the onset and maintenance of eating 
pathology: A synthesis of research findings. Journal of Psychosomatic Research, 2002. 53(5): p. 985-
993 
32. 
Hrabosky, J.I., R.M. Masheb, M.A. White, and C.M. Grilo, Overvaluation of shape and weight in binge 
eating disorder. Journal of Consulting and Clinical Psychology, 2007. 75(1): p. 175 
33. 
Goldschmidt, A.B., A. Hilbert, J.L. Manwaring, D.E. Wilfley, K.M. Pike, C.G. Fairburn, and R.H. 
Striegel-Moore, The significance of overvaluation of shape and weight in binge eating disorder. 
Behaviour Research and Therapy, 2010. 48(3): p. 187-193 
34. 
Grilo, C.M., et al., Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and 
sub-threshold bulimia nervosa. Behaviour Research and Therapy, 2009. 47(8): p. 692-696 
35. 
Stice, E., Risk and maintenance factors for eating pathology: a meta-analytic review. Psychological 
Bulletin, 2002. 128(5): p. 825 
36. 
Marcus, M.D., R.R. Wing, and D.M. Lamparski, Binge eating and dietary restraint in obese patients. 
Addictive Behaviors, 1985. 10(2): p. 163-168 
37. 
Polivy, J. and C.P. Herman, Dieting and binging: A causal analysis. American Psychologist, 1985. 
40(2): p. 193 
38. 
Agras, W.S. and C.F. Telch, The effects of caloric deprivation and negative affect on binge eating in 
obese binge-eating disordered women. Behavior Therapy, 1998. 29(3): p. 491-503 
39. 
Berg, K.C., R.D. Crosby, L. Cao, C.B. Peterson, S.G. Engel, J.E. Mitchell, and S.A. Wonderlich, Facets of 
negative affect prior to and following binge-only, purge-only, and binge/purge events in women with 
bulimia nervosa. Journal of Abnormal Psychology, 2013. 122(1): p. 111 
40. 
Deaver, C.M., R.G. Miltenberger, J. Smyth, A. Meidinger, and R. Crosby, An evaluation of affect and 
binge eating. Behavior Modification, 2003. 27(4): p. 578-599 
41. 
Greeno, C.G., R.R. Wing, and S. Shiffman, Binge antecedents in obese women with and without binge 
eating disorder. Journal of Consulting and Clinical Psychology, 2000. 68(1): p. 95 
42. 
Hilbert, A. and B. Tuschen‐Caffier, Maintenance of binge eating through negative mood: A 
naturalistic comparison of binge eating disorder and bulimia nervosa. International Journal of Eating 
Disorders, 2007. 40(6): p. 521-530 
43. 
Berg, K.C., C.B. Peterson, R.D. Crosby, L. Cao, S.J. Crow, S.G. Engel, and S.A. Wonderlich, Relationship 
between daily affect and overeating-only, loss of control eating-only, and binge eating episodes in 
obese adults. Psychiatry Research, 2014. 215(1): p. 185-191 
44. 
Stice, E. and W.S. Agras, Subtyping bulimic women along dietary restraint and negative affect 
dimensions. Journal of Consulting and Clinical Psychology, 1999. 67(4): p. 460.10450616 
45. 
Pearson, C., From impulsivity to compulsivity, in Eating Disorders Research Society2013: Bethesda, 
MD. 
46. 
Smyth, J.M., S.A. Wonderlich, K.E. Heron, M.J. Sliwinski, R.D. Crosby, J.E. Mitchell, and S.G. Engel, 
Daily and momentary mood and stress are associated with binge eating and vomiting in bulimia 
nervosa patients in the natural environment. Journal of Consulting and Clinical Psychology, 2007. 
75(4): p. 629 

47. 
Munsch, S., A.H. Meyer, V. Quartier, and F.H. Wilhelm, Binge eating in binge eating disorder: A 
breakdown of emotion regulatory process? Psychiatry Research, 2012. 195(3): p. 118-124.21849214 
48. 
Haedt-Matt, A.A. and P.K. Keel, Revisiting the affect regulation model of binge eating: a meta-
analysis of studies using ecological momentary assessment. Psychological bulletin, 2011. 137(4): p. 
660 
49. 
Robbins, T.W., C.M. Gillan, D.G. Smith, S. de Wit, and K.D. Ersche, Neurocognitive endophenotypes of 
impulsivity and compulsivity: towards dimensional psychiatry. Trends in Cognitive Sciences, 2012. 
16(1): p. 81-91 
50. 
Whiteside, U., E. Chen, C. Neighbors, D. Hunter, T. Lo, and M. Larimer, Difficulties regulating 
emotions: Do binge eaters have fewer strategies to modulate and tolerate negative affect? Eating 
Behaviors, 2007. 8(2): p. 162-169 
51. 
Wilson, G.T., C.M. Grilo, and K.M. Vitousek, Psychological treatment of eating disorders. American 
Psychologist, 2007. 62(3): p. 199 
52. 
McElroy, S.L., A.I. Guerdjikova, N. Mori, M.R. Munoz, and P.E. Keck, Overview of the treatment of 
binge eating disorder. CNS Spectrums, 2015. 20(06): p. 546-556 
53. 
Dingemans, A.E., P. Spinhoven, and E.F. van Furth, Predictors and mediators of treatment outcome in 
patients with binge eating disorder. Behaviour Research and Therapy, 2007. 45(11): p. 2551-2562 
54. 
Vanderlinden, J., A. Adriaensen, D. Vancampfort, G. Pieters, M. Probst, and K. Vansteelandt, A 
cognitive-behavioral therapeutic program for patients with obesity and binge eating disorder: short-
and long-term follow-up data of a prospective study. Behavior Modification, 2012: p. 
0145445512439313 
55. 
Fossati, M., F. Amati, D. Painot, M. Reiner, C. Haenni, and A. Golay, Cognitive-behavioral therapy 
with simultaneous nutritional and physical activity education in obese patients with binge eating 
disorder. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 2004. 9(2): p. 134-
138 
56. 
Peat, C.M., K.A. Brownley, N.D. Berkman, and C. Bulik, Binge eating disorder: Evidence-based 
treatments. Current Psychiatry, 2012. 11(5): p. 33-39 
57. 
Walsh, B.T., The importance of eating behavior in eating disorders. Physiology & Behavior, 2011. 
104(4): p. 525-529 
58. 
Balodis, I.M., et al., A pilot study linking reduced fronto–Striatal recruitment during reward 
processing to persistent bingeing following treatment for binge‐eating disorder. International Journal 
of Eating Disorders, 2014. 47(4): p. 376-384 
59. 
Masheb, R. and C. Grilo, Prognostic significance of two sub-categorization methods for the treatment 
of binge eating disorder: negative affect and overvaluation predict, but do not moderate, specific 
outcomes. Behaviour Research and Therapy, 2008. 46(4): p. 428-437 
60. 
Ricca, V., G. Castellini, E. Mannucci, C.L. Sauro, C. Ravaldi, C.M. Rotella, and C. Faravelli, Comparison 
of individual and group cognitive behavioral therapy for binge eating disorder. A randomized, three-
year follow-up study. Appetite, 2010. 55(3): p. 656-665 
61. 
Munsch, S., A.H. Meyer, and E. Biedert, Efficacy and predictors of long-term treatment success for 
Cognitive-Behavioral Treatment and Behavioral Weight-Loss-Treatment in overweight individuals 
with binge eating disorder. Behaviour Research and Therapy, 2012. 50(12): p. 775-785 
62. 
Grilo, C., M. White, R. Gueorguieva, G. Wilson, and R. Masheb, Predictive significance of the 
overvaluation of shape/weight in obese patients with binge eating disorder: findings from a 
randomized controlled trial with 12-month follow-up. Psychological Medicine, 2013. 43(06): p. 1335-
1344 
63. 
Wadden, T.A. and M.L. Butryn, Behavioral treatment of obesity Endocrinology and Metabolism Clincis 
of North America, 2003. 32(4): p. 981-1003 
64. 
Grilo, C.M., R.M. Masheb, G.T. Wilson, R. Gueorguieva, and M.A. White, Cognitive–behavioral 
therapy, behavioral weight loss, and sequential treatment for obese patients with binge-eating 
disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 2011. 79(5): p. 
675 
65. 
Luz, F., P. Hay, A. Gibson, S. Touyz, J. Swinbourne, J. Roekenes, and A. Sainsbury, Does severe dietary 
energy restriction increase binge eating in overweight or obese individuals? A systematic review. 
Obesity Reviews, 2015. 16(8): p. 652-665 
66. 
Wonderlich, S.A., K.H. Gordon, J.E. Mitchell, R.D. Crosby, and S.G. Engel, The validity and clinical 
utility of binge eating disorder. International Journal of Eating Disorders, 2009. 42(8): p. 687-705 

67. 
Marcus, M.D., R.R. Wing, and J. Hopkins, Obese binge eaters: Affect, cognitions, and response to 
behavioral weight control. Journal of Consulting and Clinical Psychology, 1988. 56(3): p. 433 
68. 
de Zwaan, M., D.O. Nutzinger, and G. Schoenbeck, Binge eating in overweight women. Comprehensive 
Psychiatry, 1992. 33(4): p. 256-261 
69. 
Yanovski, S.Z., J.F. Gormally, M.S. Leser, H.E. Gwirtsman, and J.A. Yanovski, Binge eating disorder 
affects outcome of comprehensive very‐low‐calorie diet treatment. Obesity Research, 1994. 2(3): p. 
205-212 
70. 
Sherwood, N., R. Jeffery, and R. Wing, Binge status as a predictor of weight loss treatment outcome. 
International Journal of Obesity, 1999. 23(5): p. 485-493 
71. 
Brownell, K.D., The LEARN program for weight management. 2000, Dallas, TX: American Health. 
72. 
Diabetes Prevention Program, University of Pittsburgh. 
73. 
Presnell, K. and E. Stice, An experimental test of the effect of weight-loss dieting on bulimic pathology: 
Tipping the scales in a different direction. Journal of Abnormal Psychology, 2003. 112(1): p. 166 
74. 
Stice, E., K. Presnell, L. Groesz, and H. Shaw, Effects of a weight maintenance diet on bulimic 
symptoms in adolescent girls: an experimental test of the dietary restraint theory. Health Psychology, 
2005. 24(4): p. 402 
75. 
Wadden, T.A., G.D. Foster, and K.A. Letizia, One-year behavioral treatment of obesity: comparison of 
moderate and severe caloric restriction and the effects of weight maintenance therapy. Journal of 
Consulting and Clinical Psychology, 1994. 62(1): p. 165 
76. 
Telch, C.F. and W.S. Agras, The effects of a very low calorie diet on binge eating. Behavior Therapy, 
1993. 24(2): p. 177-193 
77. 
Pekkarinen, T., I. Takala, and P. Mustajoki, Two year maintenance of weight loss after a VLCD and 
behavioural therapy for obesity: correlation to the scores of questionnaires measuring eating 
behaviour. International Journal of Obesity, 1996. 20: p. 332-337 
78. 
Williamson, D.A., C.K. Martin, S.D. Anton, E. York-Crowe, H. Han, L. Redman, and E. Ravussin, Is 
caloric restriction associated with development of eating-disorder symptoms? Results from the 
CALERIE trial. Health Psychology, 2008. 27(1S): p. S32 
79. 
Annunziato, R.A., et al., A randomized trial examining differential meal replacement adherence in a 
weight loss maintenance program after one-year follow-up. Eating Behaviors, 2009. 10(3): p. 176-183 
80. 
Fogelholm, M., K. Kukkonen-Harjula, and P. Oja, Eating control and physical activity as determinants 
of short-term weight maintenance after a very-low-calorie diet among obese women. International 
Journal of Obesity and Related Metabolic Disorders: Journal of the International Association for the 
Study of Obesity, 1999. 23(2): p. 203-210 
81. 
Raymond, N.C., M. de Zwaan, J.E. Mitchell, D. Ackard, and P. Thuras, Effect of a very low calorie diet 
on the diagnostic category of individuals with binge eating disorder. International Journal of Eating 
Disorders, 2002. 31(1): p. 49-56 
82. 
de Zwaan, M., J.E. Mitchell, R.D. Crosby, M.P. Mussell, N.C. Raymond, S.M. Specker, and H.C. Seim, 
Short-term cognitive behavioral treatment does not improve outcome of a comprehensive very-low-
calorie diet program in obese women with binge eating disorder. Behavior Therapy, 2006. 36(1): p. 
89-99 
83. 
Yanovski, S.Z. and N.G. Sebring, Recorded food intake of obese women with binge eating disorder 
before and after weight loss. International Journal of Eating Disorders, 1994. 15(2): p. 135-150 
84. 
LaPorte, D.J., Treatment response in obese binge eaters: preliminary results using a very low calorie 
diet (VLCD) and behavior therapy. Addictive Behaviors, 1992. 17(3): p. 247-257 
85. 
Catenacci, V.A. and H.R. Wyatt, The role of physical activity in producing and maintaining weight 
loss. Nature Clinical Practice Endocrinology & Metabolism, 2007. 3(7): p. 518-529 
86. 
Peirson, L., J. Douketis, D. Ciliska, D. Fitzpatrick-Lewis, M.U. Ali, and P. Raina, Treatment for 
overweight and obesity in adult populations: a systematic review and meta-analysis. CMAJ open, 
2014. 2(4): p. E306-E317 
87. 
Moulton, P., Exercise in the treatment of binge eating disorder. International Journal of Eating 
Disorders, 1996. 19(2): p. 171-177 
88. 
Pendleton, V.R., G.K. Goodrick, W.S.C. Poston, R.S. Reeves, and J.P. Foreyt, Exercise augments the 
effects of cognitive‐behavioral therapy in the treatment of binge eating. International Journal of 
Eating Disorders, 2002. 31(2): p. 172-184 
89. 
McIver, S., P. O’Halloran, and M. McGartland, Yoga as a treatment for binge eating disorder: a 
preliminary study. Complementary Therapies in Medicine, 2009. 17(4): p. 196-202 

90. 
Dunn, A.L., B.H. Marcus, J.B. Kampert, M.E. Garcia, H.W. Kohl, and S.N. Blair, Comparison of lifestyle 
and structured interventions to increase physical activity and cardiorespiratory fitness. Journal of the 
American Medical Association, 1999. 281(4): p. 327-334 
91. 
Wilson, G., Behavioral treatment of obesity: Thirty years and counting. Advances in Behaviour 
Research & Therapy, 1994. 16(1): p. 31-75 
92. 
Jakicic Jm, M.B.H.L.W.J.C., EFfect of exercise on 24-month weight loss maintenance in overweight 
women. Archives of Internal Medicine, 2008. 168(14): p. 1550-1559 
93. 
Perri, M.G. and J.A. Corsica, Improving the maintenance of weight lost in behavioral treatment of 
obesity, in Handbook of Obesity Treatment, T.A. Wadden and A.J. Stunkard, Editors. 2002, Guilford: 
New York. p. 357-379. 
94. 
Tate, D.F., R.W. Jeffery, N.E. Sherwood, and R.R. Wing, Long-term weight losses associated with 
prescription of higher physical activity goals. Are higher levels of physical activity protective against 
weight regain? The American Journal of Clinical Nutrition, 2007. 85(4): p. 954-9 
95. 
Brownell, K.D. and R.W. Jeffery, Improving long-term weight loss: Pushing the limits of treatment. 
Behavior Therapy, 1987. 18(4): p. 353-374 
96. 
Niemeier, H.M., S. Phelan, J.L. Fava, and R.R. Wing, Internal disinhibition predicts weight regain 
following weight loss and weight loss maintenance. Obesity, 2007. 15(10): p. 2485-2494 
97. 
Wing, R.R., G. Bray, and C. Bouchard, Behavioral approaches to the treatment of obesity. Handbook of 
Obesity: Clinical Applications, 2004. 2: p. 147-167 
98. 
Murdaugh, D.L., J.E. Cox, E.W. Cook, and R.E. Weller, fMRI reactivity to high-calorie food pictures 
predicts short-and long-term outcome in a weight-loss program. Neuroimage, 2012. 59(3): p. 2709-
2721 
99. 
Cornier, M.-A., Is your brain to blame for weight regain? Physiology & Behavior, 2011. 104(4): p. 608-
612 
100. 
Jeffery, R.W., L.H. Epstein, G.T. Wilson, A. Drewnowski, A.J. Stunkard, and R.R. Wing, Long-term 
maintenance of weight loss: current status. Health psychology, 2000. 19(1S): p. 5 
101. 
Faith, M., D. Allison, A. Geliebter, and S. Dalton, Emotional eating and obesity: theoretical 
considerations and practical recommendations. Overweight and Weight Management: the Health 
Professional's Guide to Understanding and Practice., 1997: p. 439-465 
102. 
Masheb, R.M. and C.M. Grilo, Weight Loss Expectations in Patients with Binge‐Eating Disorder. 
Obesity Research, 2002. 10(5): p. 309-314 
103. 
Foster, G.D., T.A. Wadden, R.A. Vogt, and G. Brewer, What is a reasonable weight loss? Patients' 
expectations and evaluations of obesity treatment outcomes. Journal of Consulting and Clinical 
Psychology, 1997. 65(1): p. 79 
104. 
Grave, R., S. Calugi, E. Molinari, M.L. Petroni, M. Bondi, A. Compare, and G. Marchesini, Weight loss 
expectations in obese patients and treatment attrition: an observational multicenter study. Obesity 
Research, 2005. 13(11): p. 1961-1969 
105. 
Masheb, R.M., C.M. Grilo, and B.J. Rolls, A randomized controlled trial for obesity and binge eating 
disorder: low-energy-density dietary counseling and cognitive-behavioral therapy. Behaviour 
Research and Therapy, 2011. 49(12): p. 821-829 
106. 
Nauta, H., H. Hospers, G. Kok, and A. Jansen, A comparison between a cognitive and a behavioral 
treatment for obese binge eaters and obese non-binge eaters. Behavior Therapy, 2000. 31(3): p. 441-
461 
107. 
Sobik, L., K. Hutchison, and L. Craighead, Cue-elicited craving for food: a fresh approach to the study 
of binge eating. Appetite, 2005. 44(3): p. 253-261 
108. 
Staiger, P., S. Dawe, and R. McCarthy, Responsivity to food cues in bulimic women and controls. 
Appetite, 2000. 35(1): p. 27-33 
109. 
Jarosz, P.A., M.T. Dobal, F.L. Wilson, and C.A. Schram, Disordered eating and food cravings among 
urban obese African American women. Eating Behaviors, 2007. 8(3): p. 374-381 
110. 
Davis, C.A., et al., Dopamine for “wanting” and opioids for “liking”: a comparison of obese adults with 
and without binge eating. Obesity, 2009. 17(6): p. 1220-1225 
111. 
Lowe, M.R. and M.L. Butryn, Hedonic hunger: a new dimension of appetite? Physiology & behavior, 
2007. 91(4): p. 432-439 
112. 
Witt, A.A. and M.R. Lowe, Hedonic hunger and binge eating among women with eating disorders. 
International Journal of Eating Disorders, 2014. 47(3): p. 273-280 
113. 
Timmerman, G.M. and E.K. Gregg, Dieting, perceived deprivation, and preoccupation with food. 
Western Journal of Nursing Research, 2003. 25(4): p. 405-418 

114. 
Compare, A., S. Calugi, G. Marchesini, E. Shonin, E. Grossi, E. Molinari, and R. Dalle Grave, 
Emotionally focused group therapy and dietary counseling in binge eating disorder. Effect on eating 
disorder psychopathology and quality of life. Appetite, 2013. 71: p. 361-368 
115. 
Latner, J.D., J.K. Rosewall, and A.M. Chisholm, Energy density effects on food intake, appetite ratings, 
and loss of control in women with binge eating disorder and weight-matched controls. Eating 
Behaviors, 2008. 9(3): p. 257-266 
116. 
DeBoer, L.B., C.D. Tart, K.E. Presnell, M.B. Powers, A.S. Baldwin, and J.A. Smits, Physical activity as a 
moderator of the association between anxiety sensitivity and binge eating. Eating Behaviors, 2012. 
13(3): p. 194-201 
117. 
Vancampfort, D., et al., A systematic review on physical therapy interventions for patients with binge 
eating disorder. Disability and Rehabilitation, 2013. 35(26): p. 2191-2196 
118. 
Pi-Sunyer, X., et al., Reduction in weight and cardiovascular disease risk factors in individuals with 
type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care, 2007. 30(6): p. 1374-
83.2665929 
119. 
Linehan, M.M., Cognitive-behavioral treatment of borderline personality disorder. Diagnosis and 
Treatment of Mental Disorders. 1993, New York, NY: Guilford Press. xvii, 558. 
120. 
Hayes, S.C., K.D. Strosahl, and K.G. Wilson, Acceptance and commitment therapy: An experiential 
approach to behavior change. 1999, New York, NY: Guilford Press. xvi, 304. 
121. 
Kristeller, J.L., R.A. Baer, and R. Quillian-Wolever, Mindfulness-based approaches to eating disorders. 
Mindfulness-Based Treatment Approaches: Clinician’s Guide to Evidence Base and Applications, 2006: 
p. 75-91 
122. 
Kristeller, J.L. and R.Q. Wolever, Mindfulness-based eating awareness training for treating binge 
eating disorder: the conceptual foundation. Eating Disorders, 2010. 19(1): p. 49-61 
123. 
Katterman, S.N., B.M. Kleinman, M.M. Hood, L.M. Nackers, and J.A. Corsica, Mindfulness meditation 
as an intervention for binge eating, emotional eating, and weight loss: a systematic review. Eating 
behaviors, 2014. 15(2): p. 197-204 
124. 
Baer, R.A., S. Fischer, and D.B. Huss, Mindfulness and acceptance in the treatment of disordered 
eating. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 2005. 23(4): p. 281-300 
125. 
Chen, E.Y., L. Matthews, C. Allen, J.R. Kuo, and M.M. Linehan, Dialectical behavior therapy for clients 
with binge‐eating disorder or bulimia nervosa and borderline personality disorder. International 
Journal of Eating Disorders, 2008. 41(6): p. 505-512 
126. 
Telch, C.F., W.S. Agras, and M.M. Linehan, Dialectical behavior therapy for binge eating disorder. 
Journal of Consulting and Clinical Psychology, 2001. 69(6): p. 1061 
127. 
Safer, D.L. and B. Jo, Outcome from a randomized controlled trial of group therapy for binge eating 
disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison 
group therapy. Behavior Therapy, 2010. 41(1): p. 106-120 
128. 
Juarascio, A.S., S.M. Manasse, L. Schumacher, H. Espel, and E. Forman, Developing an Acceptance-
Based Behavioral Treatment for Binge Eating Disorder: Rationale and Challenges. Cognitive and 
Behavioral Practice, in press 
129. 
Hill, M.L., A. Masuda, H. Melcher, J.R. Morgan, and M.P. Twohig, Acceptance and commitment 
therapy for women diagnosed with binge eating disorder: a case-series study. Cognitive and 
Behavioral Practice, 2014 
130. 
Godfrey, K.M., L.C. Gallo, and N. Afari, Mindfulness-based interventions for binge eating: a 
systematic review and meta-analysis. Journal of Behavioral Medicine, 2015. 38(2): p. 348-362 
131. 
Kristeller, J., R.Q. Wolever, and V. Sheets, Mindfulness-based eating awareness training (MB-EAT) 
for binge eating: A randomized clinical trial. Mindfulness, 2014. 5(3): p. 282-297 
132. 
Telch, C.F., W.S. Agras, and M.M. Linehan, Group dialectical behavior therapy for binge-eating 
disorder: A preliminary, uncontrolled trial. Behavior Therapy, 2000. 31(3): p. 569-582 
133. 
Pinto-Gouveia, J., et al., Incorporating psychoeducation, mindfulness and self-compassion in a new 
programme for binge eating (BEfree): Exploring processes of change. Journal of health psychology, 
2016: p. 1359105316676628 
134. 
Chen, E., J. Cacioppo, K. Fettich, R. Gallop, M. McCloskey, T. Olino, and T. Zeffiro, An adaptive 
randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating. 
Psychological medicine, 2017. 47(4): p. 703-717 
135. 
Kristeller, J.L., The struggle continues: Addressing concerns about eating and weight for older 
women’s well-being. Women & Therapy, 2016. 39(1-2): p. 202-212 

136. 
Forman, E., M. Butryn, A. Juarascio, L. Bradley, M. Lowe, J. Herbert, and J. Shaw, The mind your 
health project: a randomized controlled trial of an innovative behavioral treatment for obesity. 
Obesity, 2013. 21(6): p. 1119-1126 
137. 
Forman, E.M., M.L. Butryn, S.M. Manasse, R.D. Crosby, S.P. Goldstein, E.P. Wyckoff, and J.G. Thomas, 
Acceptance‐based versus standard behavioral treatment for obesity: Results from the mind your 
health randomized controlled trial. Obesity, 2016. 24(10): p. 2050-2056 
138. 
Wadden, T.A. and R.I. Berkowitz, Advancing the revolution in the behavioral treatment of obesity. 
Obesity, 2016. 24(10): p. 2029-2030 
139. 
Lillis, J., et al., A randomized trial of an acceptance‐based behavioral intervention for weight loss in 
people with high internal disinhibition. Obesity, 2016. 24(12): p. 2509-2514 
140. 
Butryn, M.B., Forman, E.M., Lowe, M.R., Gorin, A. A., Zhang, F., & Schaumberg, K., An Innovative 
Behavioral Treatment Improves Weight Losses for African-American Participants. Obesity, in press 
141. 
Daubenmier, J., et al., Effects of a mindfulness‐based weight loss intervention in adults with obesity: A 
randomized clinical trial. Obesity, 2016. 24(4): p. 794-804 
142. 
Wilson, G.T., C.C. Fairburn, W.S. Agras, B.T. Walsh, and H. Kraemer, Cognitive-behavioral therapy for 
bulimia nervosa: Time course and mechanisms of change. Journal of Consulting and Clinical 
Psychology, 2002. 70(2): p. 267 
143. 
Insel, T. Director’s Blog: Experimental Medicine. 2014; Available from: 
http://www.nimh.nih.gov/about/director/2012/experimental-medicine.shtml. 
144. 
NIMH, Exploratory Clinical Trials of Novel Interventions for Mental Disorders (R21/R33). 2014 
145. 
Vall, E. and T.D. Wade, Predictors of treatment outcome in individuals with eating disorders: A 
systematic review and meta‐analysis. International Journal of Eating Disorders, 2015. 48(7): p. 946-
971 
146. 
Grilo, C.M., Why no cognitive body image feature such as overvaluation of shape/weight in the binge 
eating disorder diagnosis? International Journal of Eating Disorders, 2013. 46(3): p. 208-211 
147. 
Grilo, C.M., R.M. Masheb, and G.T. Wilson, Subtyping binge eating disorder. Journal of Consulting 
and Clinical Psychology, 2001. 69(6): p. 1066 
148. 
Stice, E., D. Akutagawa, A. Gaggar, and W.S. Agras, Negative affect moderates the relation between 
dieting and binge eating. International Journal of Eating Disorders, 2000. 27(2): p. 218-229 
149. 
Elfhag, K. and S. Rössner, Initial weight loss is the best predictor for success in obesity treatment and 
sociodemographic liabilities increase risk for drop-out. Patient Education and Counseling, 2010. 
79(3): p. 361-366 
150. 
Nackers, L.M., K.M. Ross, and M.G. Perri, The association between rate of initial weight loss and long-
term success in obesity treatment: does slow and steady win the race? International Journal of 
Behavioral Medicine, 2010. 17(3): p. 161-167 
151. 
Unick, J., T. Leahey, K. Kent, and R. Wing, Examination of whether early weight loss predicts 1-year 
weight loss among those enrolled in an Internet-based weight loss program. International Journal of 
Obesity (2005), 2015 
152. 
Juarascio, A.S., J.A. Shaw, and E. Forman, A pilot study of acceptance and commitment therapy as a 
group treatment for overweight individuals with eating pathology., in The Obesity Society2012: San 
Antonio, TX. 
153. 
Juarascio, A., et al., Acceptance and Commitment Therapy as a Novel Treatment for Eating Disorders 
An Initial Test of Efficacy and Mediation. Behavior Modification, 2013. 37(4): p. 459-489 
154. 
Forman, E.M., M.L. Butryn, A.S. Juarascio, L.E. Bradley, M.R. Lowe, J.D. Herbert, and J.A. Shaw, The 
Mind Your Health Project: Evaluating an innovative behavioral treatment for obesity. Obesity, in 
press 
 
155. 
Schag, K., M. Teufel, F. Junne, H. Preissl, M. Hautzinger, S. Zipfel, and K.E. Giel, Impulsivity in binge 
eating disorder: food cues elicit increased reward responses and disinhibition. PloS One, 2013. 8(10): 
p. e76542 
156. 
Manasse, S.M., D. Flack, C. Dochat, F. Zhang, M.L. Butryn, and E.M. Forman, Not so fast: The impact 
of impulsivity on weight loss varies by treatment type. Appetite, 2017. 113: p. 193-199 
157. 
Rippe, J.M., S. Crossley, and R. Ringer, Obesity as a chronic disease: modern medical and lifestyle 
management. Journal of the American Dietetic Association, 1998. 98(10 Suppl 2): p. S9-15 
158. 
Singal, A.G., P.D. Higgins, and A.K. Waljee, A primer on effectiveness and efficacy trials. Clinical and 
translational gastroenterology, 2014. 5(1): p. e45 

159. 
Hayes, S.C., M.E. Levin, J. Plumb-Vilardaga, J.L. Villatte, and J. Pistorello, Acceptance and 
commitment therapy and contextual behavioral science: Examining the progress of a distinctive 
model of behavioral and cognitive therapy. Behavior therapy, 2013. 44(2): p. 180-198 
160. 
Grilo, C.M., M.A. White, and R.M. Masheb, Significance of overvaluation of shape and weight in an 
ethnically diverse sample of obese patients with binge-eating disorder in primary care settings. 
Behaviour research and therapy, 2012. 50(5): p. 298-303 
161. 
Stice, E., W.S. Agras, C.F. Telch, K.A. Halmi, J.E. Mitchell, and T. Wilson, Subtyping binge eating‐
disordered women along dieting and negative affect dimensions. International Journal of Eating 
Disorders, 2001. 30(1): p. 11-27 
162. 
Juarascio, A.S., S.M. Manasse, L. Schumacher, H. Espel, and E.M. Forman, Developing an Acceptance-
Based Behavioral Treatment for Binge Eating Disorder: Rationale and Challenges. Cognitive and 
Behavioral Practice, 2016 
163. 
Sheehan, D., J. Janavs, R. Baker, K. Sheehan, E. Knapp, and M. Sheehan, Mini international 
neuropsychiatric interview–version 7.0. 0 DSM-5. 2014, 2015. 
164. 
American Gastroenterological Association medical position statement on Obesity. Gastroenterology, 
2002. 123(3): p. 879-81 
165. 
Haskell, W.L., et al., Physical activity and public health: updated recommendation for adults from the 
American College of Sports Medicine and the American Heart Association. Circulation, 2007. 116(9): 
p. 1081-93 
166. 
Catenacci, V.A., L.G. Ogden, J. Stuht, S. Phelan, R.R. Wing, J.O. Hill, and H.R. Wyatt, Physical activity 
patterns in the National Weight Control Registry. Obesity, 2008. 16(1): p. 153-61 
167. 
Jakicic, J.M., B.H. Marcus, K.I. Gallagher, M. Napolitano, and W. Lang, Effect of exercise duration and 
intensity on weight loss in overweight, sedentary women: a randomized trial. JAMA : the Journal of 
the American Medical Association, 2003. 290(10): p. 1323-30 
168. 
Jeffery, R.W., R.R. Wing, N.E. Sherwood, and D.F. Tate, Physical activity and weight loss: does 
prescribing higher physical activity goals improve outcome? The American Journal of Clinical 
Nutrition, 2003. 78(4): p. 684-9 
169. 
Devlin, M.J., et al., Cognitive behavioral therapy and fluoxetine as adjuncts to group behavioral 
therapy for binge eating disorder. Obesity Research, 2005. 13(6): p. 1077-1088 
170. 
Grilo, C.M. and R.M. Masheb, A randomized controlled comparison of guided self-help cognitive 
behavioral therapy and behavioral weight loss for binge eating disorder. Behaviour Research and 
Therapy, 2005. 43(11): p. 1509-1525 
171. 
Wilfley, D.E., et al., 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, 2002. 59(8): p. 713-721 
172. 
Zendegui, E.A., J.A. West, and L.J. Zandberg, Binge eating frequency and regular eating adherence: 
The role of eating pattern in cognitive behavioral guided self-help. Eating Behaviors, 2014. 15(2): p. 
241-243 
173. 
Masheb, R.M. and C.M. Grilo, Eating patterns and breakfast consumption in obese patients with binge 
eating disorder. Behaviour Research and Therapy, 2006. 44(11): p. 1545-1553 
174. 
Masheb, R.M., C.M. Grilo, and M.A. White, An examination of eating patterns in community women 
with bulimia nervosa and binge eating disorder. International Journal of Eating Disorders, 2011. 
44(7): p. 618-624 
175. 
Grilo, C.M., R.M. Masheb, and G.T. Wilson, Rapid response to treatment for binge eating disorder. 
Journal of Consulting and Clinical Psychology, 2006. 74(3): p. 602 
176. 
Masheb, R.M. and C.M. Grilo, Rapid response predicts treatment outcomes in binge eating disorder: 
implications for stepped care. Journal of Consulting and Clinical Psychology, 2007. 75(4): p. 639 
177. 
Grilo, C.M. and R.M. Masheb, Rapid response predicts binge eating and weight loss in binge eating 
disorder: Findings from a controlled trial of orlistat with guided self-help cognitive behavioral 
therapy. Behaviour Research and Therapy, 2007. 45(11): p. 2537-2550 
178. 
Turner, H., R. Bryant-Waugh, and E. Marshall, The impact of early symptom change and therapeutic 
alliance on treatment outcome in cognitive-behavioural therapy for eating disorders. Behaviour 
Research and Therapy, 2015. 73: p. 165-169 
179. 
Deci, E. and R.M. Ryan, Intrinsic motivation and self-determination in human behavior. 1985, New 
York: Plenum. 
180. 
Lillis, J., S.C. Hayes, and M.E. Levin, Binge eating and weight control: The role of experiential 
avoidance. Behavior Modification, 2011: p. 0145445510397178 

181. 
Philadelphia Metropolitan Area Demographics. 2011; Available from: 
https://datausa.io/profile/geo/philadelphia-camden-wilmington-pa-nj-de-md-metro-area/. 
182. 
Agurs-Collins, T.D., S.K. Kumanyika, T.R. Ten Have, and L.L. Adams-Campbell, A randomized 
controlled trial of weight reduction and exercise for diabetes management in older African-American 
subjects. Diabetes Care, 1997. 20(10): p. 1503-11 
183. 
McNabb, W., M. Quinn, J. Kerver, S. Cook, and T. Karrison, The PATHWAYS church-based weight loss 
program for urban African-American women at risk for diabetes. Diabetes Care, 1997. 20(10): p. 
1518-23 
184. 
Foreyt, J.P., Weight loss programs for minority populations, in Eating Disorders and Obesity: A 
Comprehensive Handbook, C.G.F.K.D. Brownell, Editor. 2002, Guilford: New York. p. 583-587. 
185. 
Woods, D.W., C.T. Wetterneck, and C.A. Flessner, A controlled evaluation of acceptance and 
commitment therapy plus habit reversal for trichotillomania. Behav Res Ther, 2006. 44(5): p. 639-56 
186. 
Dalrymple, K.L. and J.D. Herbert, Acceptance and Commitment Therapy for Generalized Social 
Anxiety Disorder: A Pilot Study. Behavior Modification, 2007. 31(5): p. 543-568 
187. 
Forman, E.M., J.D. Hebert, E. Moitra, P.D. Yeomans, and P.A. Geller, A randomized controlled 
effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and 
depression. Behavior Modification, 2007. 31(6): p. 772-799 
188. 
Juarascio, A.S., E.M. Forman, and J.D. Herbert, Acceptance and commitment therapy versus cognitive 
therapy for the treatment of comorbid eating pathology. Behavior Modification, 2010. 34(2): p. 175-
90 
189. 
Buhrman, M., et al., Guided internet-delivered acceptance and commitment therapy for chronic pain 
patients: A randomized controlled trial. Behaviour Research and Therapy, 2013 
190. 
Lappalainen, R., T. Lehtonen, E. Skarp, E. Taubert, M. Ojanen, and S.C. Hayes, The impact of CBT and 
ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial. 
Behavior Modification, 2007. 31(4): p. 488-511 
191. 
Hesser, H., et al., A randomized controlled trial of internet-delivered cognitive behavior therapy and 
acceptance and commitment therapy in the treatment of tinnitus. Journal of Consulting and Clinical 
Psychology, 2012. 80(4): p. 649 
192. 
Gregg, J.A., G.M. Callaghan, S.C. Hayes, and J.L. Glenn-Lawson, Improving Diabetes Self-
Management Through Acceptance, Mindfulness, and Values: A Randomized Controlled Trial. Journal 
of Consulting and Clinical Psychology, 2007. 75(2): p. 336-343 
193. 
Hayes, S.C., et al., A preliminary trial of Twelve-Step Facilitation and Acceptance and Commitment 
Therapy with poly substance-abusing methadone-maintained opiate addicts. Behavior Therapy, 
2004(35): p. 667-688 
194. 
Devilly, G.J. and T.D. Borkovec, Psychometric properties of the credibility/expectancy questionnaire. 
Journal of Behavior Therapy and Experimental Psychiatry, 2000. 31(2): p. 73-86 
195. 
Fairburn, C., Z. Cooper, and M. O’Connor, Eating Disorder Examination, Edition 17.0 D. The Center 
for Research on Dissemination at Oxford, 2014 
196. 
Stunkard, A.J. and S. Messick, The three-factor eating questionnaire to measure dietary restraint, 
disinhibition and hunger. Journal of Psychosomatic Research, 1985. 29(1): p. 71-83 
197. 
Westenhoefer, J., A.J. Stunkard, and V. Pudel, Validation of the flexible and rigid control dimensions 
of dietary restraint. International Journal of Eating Disorders, 1999. 26(1): p. 53-64 
198. 
National Cancer Institute (NCI). Automated self-administred 24-hour recall (ASA24). Applied 
Research Program, Risk Factor Monitoring and Methods Branch. Accessed 2/6/2010. 
http://riskfactor.cancer.gov/tools/instruments/asa24/. 2008. 
199. 
Moshfegh, A.J., et al., The US Department of Agriculture Automated Multiple-Pass Method reduces 
bias in the collection of energy intakes. The American Journal of Clinical Nutrition, 2008. 88(2): p. 
324-32 
200. 
Matthew, C.E., Calibration of accelerometer output for adults. Medicine and Science in Sports and 
Exercise, 2005. 37(11 Suppl): p. S512-22 
201. 
Plasqui, G. and K.R. Westerterp, Physical activity assessment with accelerometers: an evaluation 
against doubly labeled water. Obesity, 2007. 15(10): p. 2371-2379 
202. 
Slootmaker, S.M., A.J. Schuit, M.J. Chinapaw, J.C. Seidell, and W. Van Mechelen, International 
Journal of Behavioral Nutrition and Physical Activity. International Journal of Behavioral Nutrition 
and Physical Activity, 2009. 6: p. 17 
203. 
Bouten, C.V., K.R. Westerterp, M. Verduin, and J. JANSSEN, Assessment of energy expenditure for 
physical activity using a triaX| aI. Age (yr), 1994. 23(1.8): p. 21-27 

204. 
Hashii, Y., Y. Yamada, S. Ando, and M. Kimura, Validity Of Triaxial Accelerometer For Estimating 
Energy Expenditure In Non-athletes And Athletes: 1524: Board# 126 May 27 9: 30 AM-11: 00 AM. 
Medicine & Science in Sports & Exercise, 2009. 41(5): p. 41-42 
205. 
Westerterp, K.R., Assessment of physical activity: a critical appraisal. European Journal of Applied 
Physiology, 2009. 105(6): p. 823-828 
206. 
Jallais, C. and A.-L. Gilet, Inducing changes in arousal and valence: Comparison of two mood 
induction procedures. Behavior Research Methods, 2010. 42(1): p. 318-325 
207. 
Krauth-Gruber, S. and F. Ric, Affect and stereotypic thinking: A test of the mood-and-general-
knowledge model. Personality and Social Psychology Bulletin, 2000. 26(12): p. 1587-1597 
208. 
Corson, Y. and N. Verrier, Emotions and False Memories Valence or Arousal? Psychological Science, 
2007. 18(3): p. 208-211.17444912 
209. 
Mackinnon, A., A.F. Jorm, H. Christensen, A.E. Korten, P.A. Jacomb, and B. Rodgers, A short form of 
the Positive and Negative Affect Schedule: Evaluation of factorial validity and invariance across 
demographic variables in a community sample. Personality and Individual Differences, 1999. 27(3): p. 
405-416 
210. 
Arch, J.J. and M.G. Craske, Mechanisms of mindfulness: Emotion regulation following a focused 
breathing induction. Behaviour Research and Therapy, 2006. 44(12): p. 1849-1858 
211. 
Petrides, K. and A. Furnham, Trait emotional intelligence: Behavioural validation in two studies of 
emotion recognition and reactivity to mood induction. European Journal of Personality, 2003. 17(1): 
p. 39-57 
212. 
Josephson, B.R., Mood regulation and memory: Repairing sad moods with happy memories. 
Cognition & Emotion, 1996. 10(4): p. 437-444 
213. 
Kliegel, M., T. Jäger, and L.H. Phillips, Emotional development across adulthood: Differential age-
related emotional reactivity and emotion regulation in a negative mood induction procedure. The 
International Journal of Aging and Human Development, 2007. 64(3): p. 217-244 
214. 
Gratz, K.L. and L. Roemer, Multidimensional assessment of emotion regulation and dysregulation: 
Development, factor structure, and initial validation of the difficulties in emotion regulation scale. 
Journal of Psychopathology and Behavioral Assessment, 2004. 26(1): p. 41-54 
215. 
Strong, D.R., Lejuez, C. W., Daughters, S., Marinello, M., Kahler, C.W., & Brown., The Computerized 
Mirror Tracing Task Version 1. Unpublished Manual, 2003 
216. 
Quinn, E.P., T.H. Brandon, and A.L. Copeland, Is task persistence related to smoking and substance 
abuse? Applying learned industriousness theory to addictive behaviors. Experimental and Clinical 
Psychopharmacology, 1996. 4: p. 186-190 
217. 
Mitchell, L.A., R.A.R. MacDonald, and E.E. Brodie, Temperature and the cold pressor test. The Journal 
of Pain, 2004. 5(4): p. 233-238 
218. 
Leyro, T.M., M.J. Zvolensky, and A. Bernstein, Distress tolerance and psychopathological symptoms 
and disorders: a review of the empirical literature among adults. Psychological bulletin, 2010. 136(4): 
p. 576-600.2891552 
219. 
Abrantes, A.M., et al., The role of negative affect in risk for early lapse among low distress tolerance 
smokers. Addictive behaviors, 2008. 33(11): p. 1394-401.2570958 
220. 
MacPherson, L., B.A. Stipelman, M. Duplinsky, R.A. Brown, and C.W. Lejuez, Distress tolerance and 
pre-smoking treatment attrition: examination of moderating relationships. Addictive behaviors, 
2008. 33(11): p. 1385-93.2561069 
221. 
Brandon, T.H., T.A. Herzog, L.M. Juliano, J.E. Irvin, A.B. Lazev, and V.N. Simmons, Pretreatment task 
persistence predicts smoking cessation outcome. Journal of Abnormal Psychology, 2003. 112(3): p. 
448-56 
222. 
Matthews, K.A. and C.M. Stoney, Influences of sex and age on cardiovascular responses during stress. 
Psychosom Med, 1988. 50(1): p. 46-56 
223. 
Tutoo, D.N., Psychodiagnostic applications of the mirror tracing test. Indian Educational Review, 
1971. 6: p. 293-303 
224. 
Beck, A.T., R.A. Steer, and G.K. Brown, Beck depression inventory-II. San Antonio, 1996. 78(2): p. 
490-8 
225. 
Grilo, C.M., J.I. Hrabosky, M.A. White, K.C. Allison, A.J. Stunkard, and R.M. Masheb, Overvaluation of 
shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic 
construct. Journal of Abnormal Psychology, 2008. 117(2): p. 414 

226. 
Wilson, K.G., E.K. Sandoz, J. Kitchens, and M. Roberts, The Valued Living Questionnaire: Defining 
and measuring valued action within a behavioral framework. The Psychological Record, 2011. 60(2): 
p. 4 
227. 
Goodwin, C.L., Forman, E.M., Butryn, M.L., Herbert, J.D., Ledley, G.S., Park, J.A., Yuen, E.K., Ambani, 
R., Project ABLE: An Acceptance-based Behavioral Lifestyle Modification Program for Cardiac 
Patients. A Preliminary Investigation. Poster to be presented at the 44th annual convention of the 
Association for Behavioral and Cognitive Therapies, 2010, November: San Francisco, CA. 
228. 
Lowe, M.R., et al., The Power of Food Scale. A new measure of the psychological influence of the food 
environment. Appetite, 2009. 53(1): p. 114-118 
229. 
Forman, E.M., K.L. Hoffman, K.B. McGrath, J.D. Herbert, L.L. Brandsma, and M.R. Lowe, A 
comparison of acceptance-and control-based strategies for coping with food cravings: An analog 
study. Behaviour research and therapy, 2007. 45(10): p. 2372-2386 
230. 
Preacher, K.J. and A.F. Hayes, SPSS and SAS procedures for estimating indirect effects in simple 
mediation models. Behavior Research Methods, Instruments, & Computers, 2004. 36(4): p. 717-731 
231. 
Hayes, A.F. and K.J. Preacher, Statistical mediation analysis with a multicategorical independent 
variable. British Journal of Mathematical and Statistical Psychology, 2014. 67(3): p. 451-470 
232. 
Baron, R.M. and D.A. Kenny, The moderator–mediator variable distinction in social psychological 
research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social 
Psychology, 1986. 51(6): p. 1173 
233. 
Hayes, A.F., Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. 
Communication Monographs, 2009. 76(4): p. 408-420 
234. 
Efron, B., Better bootstrap confidence intervals. Journal of the American Statistical Association, 1987. 
82: p. 171-185 
235. 
Hayes, A.F., Introduction to mediation, moderation, and conditional process analysis: A regression-
based approach. 2013: Guilford Press. 
236. 
Little, R. and D. Rubin, Statistical Analysis of Missing Data. 2nd ed. 2002, New York: Wiley. 
237. 
Rubin, D.B., Multiple Imputation for Nonresponse in Surveys. 1987, New York: John Wiley & Sons, 
Inc. 
238. 
Gibbons, R.D., et al., Some conceptual and statistical issues in analysis of longitudinal psychiatric 
data. Application to the NIMH treatment of Depression Collaborative Research Program dataset. 
Archives of General Psychiatry, 1993. 50(9): p. 739-50 
239. 
Gibbons, R.D., D. Hedeker, C. Waternaux, and J.M. Davis, Random regression models: a 
comprehensive approach to the analysis of longitudinal psychiatric data. Psychopharmacology 
bulletin, 1988. 24(3): p. 438-43 
240. 
Hedeker, D. and R.D. Gibbons, Application of random-effects pattern-mixture models for missing 
data in longitudinal studies. Psychol Methods, 1997. 2: p. 64-78 
241. 
Hudson, J.I., E. Hiripi, H.G. Pope, and R.C. Kessler, The prevalence and correlates of eating disorders 
in the National Comorbidity Survey Replication. Biological psychiatry, 2007. 61(3): p. 348-358 
242. 
Marques, L., M. Alegria, A.E. Becker, C.n. Chen, A. Fang, A. Chosak, and J.B. Diniz, Comparative 
prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic 
groups: Implications for reducing ethnic disparities in health care access for eating disorders. 
International Journal of Eating Disorders, 2011. 44(5): p. 412-420 
243. 
Franko, D.L., et al., Racial/ethnic differences in adults in randomized clinical trials of binge eating 
disorder. Journal of consulting and clinical psychology, 2012. 80(2): p. 186 
244. 
Butryn, M.L., E.M. Forman, M.R. Lowe, A.A. Gorin, F. Zhang, and K. Schaumberg, Efficacy of 
environmental and acceptance‐based enhancements to behavioral weight loss treatment: The ENACT 
trial. Obesity, 2017. 25(5): p. 866-872