Problematic and adaptive eating in people with obesity after a DBT-based skills training intervention: 3- and 8-month follow-up and mediation analysis

Souza, Lucas André Schuster de; Cancian, Ana Carolina Maciel; Castro, Thiago Gomes de; Oliveira, Margareth da Silva

doi:10.1186/s41155-019-0116-5

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Health Psychology, RESEARCH • Psicol. Reflex. Crit. 32 • 2019 • https://doi.org/10.1186/s41155-019-0116-5 copy

Problematic and adaptive eating in people with obesity after a DBT-based skills training intervention: 3- and 8-month follow-up and mediation analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Dialectical behavior therapy conceptualizes problematic behaviors as attempts to regulate emotions that occur when the individual lacks effective skills with which to manage his or her emotions and cope with distress. Problematic eating behaviors, e.g., binge and emotional eating, may serve to alleviate aversive emotional states, being highly associated with overweight and obesity. Dialectical behavior therapy skills training has been proven effective in reducing binge eating in several clinical studies. However, few studies reveal the effects of DBT on adaptive eating behaviors or the stability of outcomes.

Objectives:

This study aimed to test the effect of a brief DBT-based skills training intervention, and the stability of outcomes at 3- and 8-month follow-ups.

Methods:

Self-report measures of binge eating, emotional eating, intuitive eating, and mindful eating were taken on 5 timepoints before and after a 10-session DBT skills training intervention (2 baseline measures, 1 post-test, and 2 follow-ups). Data were analyzed using a mixed-model intention-to-treat approach and mediation analysis was conducted with path analysis.

Results:

After the intervention, intuitive eating and mindful eating scores were significantly higher than before the intervention, while emotional eating and binge eating scores were lower. The results remained stable during the follow-up period, with minor fluctuations and small trends towards returning to baseline values for binge eating and emotional eating. Mindful eating partially mediated the improvements in all outcomes.

Limitations:

Given that results are entirely based on self-report measures and that some instruments showed poor reliability, in addition to the high attrition rates, the results should be interpreted as preliminary.

Conclusions:

The results provide evidence that a brief DBT intervention is effective not only in reducing problematic eating but also in increasing adaptive eating, achieving reasonably stable results. Also, the mediation analysis results support the hypothesis that mindful eating partially explains the effects of the intervention on binge and emotional eating. Future research should address the limitations of this study by investigating a more diverse sample, triangulating different measurement strategies, and including other putative mediators.

Keywords:
Dialectical behavior therapy; Emotional eating; Mindful eating; Intuitive eating; Binge eating; Obesity

Item number	Item
Brief name
1	Dialectical behavior therapy-based skills training group intervention for Brazilian individuals with obesity.
Why
2	The rationale of DBT is that problematic behaviors are attempts to regulate intense emotional states and that these behaviors are harmful in the long term. The skills training aims to teach new behavioral skills that can replace dysfunctional behaviors. The main goal of the present intervention was to teach emotion regulation skills and thus help individuals manage their problematic eating behaviors and increase adaptive eating behaviors.
What
3	The trainers utilized standardized audiovisual material to conduct the intervention and a structured theme agenda, both of which were developed to increase professional adherence to the protocol, regardless of the group. In each session, participants received printed material to follow during the skills class and printed material that served as homework. The printed materials utilized in the intervention by the leaders to conduct the sessions and given to the participants are both available in the online appendix.
4	Group sessions began with mindfulness practice (10 min) and then moved to a homework review from the previous session (30 min), continued with a brief break (5 min), and ended with teaching new material (1 h and 15 min) according to the standard DBT group format.
Who provided
5	Two psychologists lead the intervention, one who attended a 10-day intensive DBT workshop conducted by a certified senior DBT trainer (author 2), and one who received a 200-h DBT training conducted by two experienced DBT trainers (author 1). The researchers trained three groups each, and for each group, a different co-leader was chosen from the consultation team. The coleaders were trained by the researchers, participated in a reading group 6 months prior to the intervention, and went through the intervention themselves (conducted by the researchers).
How
6	Face-to-face adapted DBT skills training was conducted by two trainers in groups, and each group included a maximum of nine participants.
Where
7	The participants were recruited at the university, and the sessions were carried out in the same location. The infrastructure included a classroom, chairs, a projector, a computer (for slides presentation), and air conditioning.
When and how much
8	The intervention was composed of 2-h sessions conducted twice a week. The sessions were scheduled according to participants’ preferences (in the morning, in the afternoon, or at night). Once a participant chose a group, he or she could not change to another time or group. In total, six groups received the intervention. Two groups were trained in the morning, from 10 am to 12 am; two groups were trained in the afternoon, from 15 pm to 17 pm; and two groups were trained at night from 19 pm to 21 pm
Tailoring
9	The intervention was adapted to Brazilian Portuguese and to the population with obesity.
Modifications
10	The intervention was not modified during the study.
How well 11	A consultation team was formed to increase adherence to the model. Intervention fidelity was discussed weekly in the consultation team meetings. The consultation team was formed by seven professionals who participated as leaders or co-leaders of the intervention. The weekly consultation meeting aimed to coach team members who fell outside of the DBT model used for the intervention reduce burnout by offering support and validation to the trainers, and provide feedback on the conducting of the intervention.
12	The intervention was generally delivered as planned. However, some leaders had difficulties regarding time management. In addition, participants tended to provide life examples unrelated to eating contexts, so trainers had to provide additional examples to explain the use of skills related to eating behaviors.

Session	Module	Selected handouts and worksheets	Mindfulness exercise and skills taught
1	Orientation and mindfulness	General handout 1 Mindfulness handout 1A, 3 e 4 mindfulness worksheet 4A	Mindfulness: breath Goals of skills training Mindfulness definitions Wise mind—states of mind Taking hold of your mind—“what” skills
2	Mindfulness	Mindfulness handout 5 Mindfulness worksheet 2 e 5A	Mindfulness: find your lemon Taking hold of your mind—“how” skills
3	Emotion regulation	Emotion regulation handout 1, 3, 4, 5 e 6 Emotion regulation worksheet 2	Mindfulness: wise mind—stone flake on a lake Goals of emotion regulation What emotions do for you What makes it hard to regulate your emotions Model for describing emotions Ways to describe emotions
4	Emotion regulation	Emotion regulation handout 8, 8A Emotion regulation worksheet 5	Mindfulness: mindful participation—improvisation Check the facts Examples of emotions that fit the facts
5	Emotion regulation	Emotion regulation handout 9, 10, 12 e 13 Emotion regulation worksheet 7 e 8	Mindfulness: noticing urges Opposite action and problem solving—deciding which to use Opposite action Problem solving Reviewing opposite action and problem solving
6	Emotion regulation	Emotion regulation handout 15, 16, 17 e 18 Emotion regulation worksheet 9	Mindfulness: noticing sensations Accumulating positive emotions—short term and long term Pleasant events list Values and priorities list
7	Emotion regulation	Emotion regulation handout 19 e 20 Distress tolerance handout 8 Emotion regulation worksheet 9 e 16	Mindfulness: raisin Build mastery and cope ahead Taking care of your mind by taking care of your body Self-soothing
8	Distress tolerance	Distress tolerance handout 7 e 9	Mindfulness: noticing sounds Distracting Improving the moment
9	Distress tolerance	Distress tolerance handout 5, 11 e 11B Distress tolerance worksheet 3 e 9	Mindfulness: body scan Pros and cons Radical acceptance Practicing radical acceptance step by step
10	Review		Mindfulness: wise mind—focus on your breath

Variable	Extended baseline	n	Pre-test	N	Post-test	n	3-month follow-up	n	8-month follow-up	n
Emotional eating—EES total	2.24 (2-2.48)	50	2.16 (1.96-2.36)	71	1.47 (1.1-1.84)	25	1.56 (1.21-1.91)	19	1.73 (1.36-2.1)	12
Intuitive eating—IES-2 total	2.77 (2.67-2.87)	51	2.74 (2.66-2.82)	67	3.13 (2.97-2.79)	26	3.15 (2.97-3.33)	19	3.21 (3.01-3.41)	14
Mindful eating—MEQ total	2.43 (2.35-2.51)	51	2.41 (2.33-2.49)	67	2.63 (2.47-2.79)	26	2.68 (2.54-2.82)	19	2.7 (2.54-2.86)	14
Binge eating—BES total	24 (21.41-26.59)	48	24.33 (21.94-26.52)	61	16.44 (12.85-20.03)	25	16.06 (11.96-20.16)	18	18.62 (13.33-23.91)	13

		EES—emotional eating			BES—binge eating			MEQ—Mindful eating			B	IES-2—intuitive eating
		B	CI	P	B	CI	P	B	CI	p	B	CI	p
Fixed parts
	(Intercept)	2.19	2.03-2.35	<.001	24.39	22.57-26.21	<.001	2.42	2.36-2.49	<.001	2.74	2.67-2.81	<.001
	Int	– 0.54	– 0.75 to – 0.33	<.001	– 8.28	– 10.58 to −5.98	<.001	0.25	0.16-0.33	<.001	0.37	0.26-0.47	<.001
Random parts
	σ²	0.289			32.824			0.050				0.085
	τ_{00, ID}	0.417			51.855			0.060				0.054
	N_ID	105			95			100				100
	ICC_ID	0.590			0.612			0.546				0.387
	Observations	177			165			177				177
	R²_m/R²_c	.083/.624			.154/.672			.111/.596				.176/.495

95% confidence interval
Effect		Label	Estimate	SE	Lower	Upper	Z	p	% mediation
Binge eating
	Indirect	a × b	– 4.22	1.08	– 6.43	– 2.13	– 3.89	< 0.001	58.03
	Direct	C	– 3.05	1.11	– 5.11	– 0.81	-2.75	0.006	41.97
	Total	c + a × b	– 7.27	1.46	– 10.19	– 4.38	– 4.99	< 0.001	100.00
Emotional eating
	Indirect	a × b	– 0.32	0.08	– 0.47	– 0.18	– 4.17	< 0.001	46.28
	Direct	C	– 0.37	0.13	– 0.64	– 0.12	-2.77	0.006	53.72
	Total	c + a × b	– 0.69	0.14	– 0.96	– 0.41	– 4.99	< 0.001	100.00
Intuitive eating
	Indirect	a × b	0.12	0.03	0.06	0.19	3.79	< 0.001	30.09
	Direct	C	0.28	0.05	0.18	0.38	5.32	< 0.001	69.91
	Total	c + a × b	0.40	0.06	0.28	0.52	6.74	< 0.001	100.00

Curso de Pós-Graduação em Psicologia da Universidade Federal do Rio Grande do Sul Rua Ramiro Barcelos, 2600 - sala 110, 90035-003 Porto Alegre RS - Brazil, Tel.: +55 51 3308-5691 - Porto Alegre - RS - Brazil
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[1] * Correspondence: lucas.schuster@gmail.com