Emotion-Focused Therapy and Dietary Counseling for Obese Patients with Binge Eating Disorder: A Propensity Score-Adjusted Study
Authors: Angelo Compare, Simona Calugi, Giulio Marchesini, Enrico Molinari, Riccardo Dalle Grave
Journal: Psychotherapy and Psychosomatics (2013)

Controlled studies have shown that psychological treatments for binge eating disorder (BED) are effective on binging episodes and associated psychopathology in the short and long term [1], but have a limited effect on body weight reduction. The combination of psychotherapy with dietary counseling (DC) might be a potential useful strategy to improve both eating disorder psychopathology and body weight in patients with BED. Recent research [2,3] seems to support a model of binge eating that includes emotional vulnerability and a deficit of skills that functionally modulate negative emotions, a mechanism not directly addressed by both cognitive behavior and interpersonal psychotherapy.Moreover, differently from the dialectical behavior therapy approach adapted for BED [4] that encourages patients to observe and describe their emotions in a nonjudgmental way, emotion-focused therapy (EFT) is a psychological treatment designed to address the cognitive and interpersonal experiential perspective of emotions. With this treatment, once the contact with emotional experience is achieved, clients must cognitively orient to that experience as information and must explore, reflect on and make sense of it. This is achieved by exploring beliefs associated with the experienced emotion and by identifying the needs that can motivate change in personal meanings and beliefs. EFT trials showed promising results with respect to both acute response and subsequent prevention of depressive symptoms [5]. Despite these promising findings, no study is available so far on the utility of EFT in the treatment of BED associated with obesity. We report the results of a naturalistic study that evaluated the effect of EFT [6], DC to reduce the consumption of energy-dense food, and combined treatment (CT) in treatment-seeking patients with BED and obesity.We screened 245 consecutive adult patients referred to our outpatient department for the treatment of eating disorders by family doctors and other clinicians. Eligibility criteria required age between 35 and 60 years, BMI ≥30, and DSM-IV research criteria for BED [7]. Exclusion criteria included (1) concurrent treatment for eating and/or weight disorders or psychiatric illness, (2) medical conditions that might have influenced weight or eating, (3) severe current psychiatric conditions requiring different treatments (psychosis, bipolar disorder), and (4) pregnancy or lactation. 189 patients who met DSM-IV research criteria for BED were included in the study. Thirty-four cases were excluded because they did not fulfill the BED criteria, 13 were being treated with psychotropic drugs, 5 had medical conditions, and 4 failed to complete the screening protocol.After completing the screening procedures and giving informed consent, 126 participants received EFT administered via 20 group sessions (10-15 participants; weekly sessions of 60-90 min) over a 5-month treatment period. 63 participants received DC administered via 12 one-hour weekly individual sessions over the first 3-month treatment period, and 8 weekly group sessions (30 min) over the last 2-month treatment period. In half of the participants in the EFT program, sessions were combined with DC. For this purpose, individual sessions of DC were programmed over the first 3 months on the same day and 1 h before the EFT sessions. Participants were assigned to treatment (without any restriction) by a clinical psychologist; assignment was based on the results of psychometric tests, on clinical interview and partly on patients' preferences. No treatment was provided during the 6-month follow-up period after completing the 20-week treatment. The primary outcomes were: (a) percentage of participants achieving 5% weight loss or more, and (b) binge eating remission, defined as zero binges during the previous 28 days, based on the Binge Eating Bulimic Episodes and Other Episodes of Overeating section of the Eating Disorder Examination interview (EDE) [8]. The EDE section was administered at baseline, at the end of treatment, and at the 6-month follow-up and was the primary method for determining the outcome of binge eating (i.e. binge eating defined as eating unusually large quantities of food with a subjective sense of loss of control). Secondary outcomes were improvement in the score of Binge Eating Scale (BES), and the Obesity-Related Well-Being questionnaire (ORWELL-97).Analyses presented here refer only to primary outcomes and were carried out on completers and on an intent-to-treat basis, comparing the effects of treatments on primary outcomes. Comparisons were performed using a propensity score approach to adjust treatment for baseline values. The propensity score was calculated by logistic regression analysis as the probability to be assigned to a structured program (EFT with/without DC), based on differences in clinical variables at baseline, compared to subjects who entered the DC group. The variables included were age, sex, education, civil status, BMI (weight was obtained weighting, without shoes or coats, participants at each assessment point and treatment session) and the values of the BES at baseline. Propensity scores were then used to adjust for baseline values in logistic regression analysis in different models, having the treatment group results as independent variables. The first model had remission from binge eating as the outcome measure, and the second had weight loss ≥5% body weight. DC was considered the reference treatment. EFT results with/without DC were also compared with each other, with EFT as the reference.The 3 groups were fairly well balanced as to clinical and anthropometric data. The only differences were a moderately higher prevalence of female sex in the EFT versus the DC group (65.5 vs. 41.3%, p = 0.004) and higher baseline BMI in the CT versus the DC group (33.6 ± 2.6 vs. 32.3 ± 1.3), but no differences were found in age, BES and the presence of objective bulimic episodes.Almost 87% of participants (n = 164) completed treatment (continuers), whereas almost 13% (n = 25) left the program before its conclusion (dropouts). A higher dropout rate was reported in DC compared with both EFT and CT (27 vs. 12.7 vs. 0%, respectively, χ2[d.f. = 2] = 20.01, p < 0.001). A post hoc analysis showed that the group available at follow-up (164 of the 189 patients enrolled) was not different from the total entry population and was not different from dropouts on sex, age and baseline BMI values. No differences were observed across the treatment groups.By the end of treatment (table 1), no significant differences in the remission rate from binge eating were observed in the per-protocol analysis (between 36.4 and 49.2%). However, on an intention-to-treat basis, CT produced a significantly higher remission rate, more than doubling the effects of both EFT and DC. At the 6-month follow-up, both in the per-protocol and in the intention-to-treat analysis, EFT and CT produced significantly better results than DC, increasing the outcome rate by a factor of two or three. CT maintained a higher outcome rate compared with EFT.A proportion of cases between 44.4% and 74.6% achieved the 5% weight loss target by the end of treatment, depending on the type of treatment and the method of analysis (table 1). CT was superior to other treatments in the intention-to-treat analysis, not per-protocol. At the 6-month follow-up, EFT, either alone or in combination with DC, significantly increased the outcome rate.From a clinical point of view, our results, along with literature data [9], show that EFT, a psychotherapy focused on the cognitive and interpersonal experiential perspectives of emotions associated with DC, produces promising results on binge eating remission, weight loss, binge eating behavior and health-related quality of life in treatment-seeking BED patients with obesity. The data also suggest that the combination of EFT and DC might be a promising strategy to produce both an improvement of the eating disorder psychopathology and a healthy amount of weight loss. The main limitations of the study include the short-term follow-up, the different rates of dropout between groups and the nonrandom assignment to groups. Matching by propensity, the advantages and limits of which have been discussed elsewhere [10], may only partly overcome the allocation bias. Our data may be considered the basis for future confirmatory studies with long-term follow-up and a randomized controlled design.