The use of a manual-driven group cognitive behavior therapy in a Brazilian sample of obese individuals with binge-eating disorder

Utilização de terapia cognitivo-comportamental em grupo baseada em manual em uma amostra brasileira de indivíduos obesos com transtorno da compulsão alimentar periódica

ORIGINAL ARTICLE

The use of a manual-driven group cognitive behavior therapy in a Brazilian sample of obese individuals with binge-eating disorder

Utilização de terapia cognitivo-comportamental em grupo baseada em manual em uma amostra brasileira de indivíduos obesos com transtorno da compulsão alimentar periódica

Mônica Duchesne^{I, II}; José Carlos Appolinario^{I, II}; Bernard Pimentel Rangé^III; Julia Fandiño^{I, II}; Tatiana Moya^II; Silvia R Freitas^II

^IInstitute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro (RJ), Brazil

^IIObesity and Eating Disorders Group (Grupo de Obesidade e Transtornos Alimentares - GOTA), State Institute of Diabetes and Endocrinology of Rio de Janeiro, Rio de Janeiro (RJ), Brazil

^IIIGraduate Program in Psychology, Institute of Psychology, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro (RJ), Brazil

^{Correspondence}

ABSTRACT

OBJECTIVE: To assess the effectiveness of a manual-based cognitive behavior therapy adapted to a group format in a sample of Brazilian obese subjects with binge-eating disorder.

METHOD: In an open trial, 21 obese subjects with binge-eating disorder received a group cognitive-behavioral therapy program. Changes in binge-eating frequency, weight, body shape concerns, and depressive symptoms were compared between baseline and the end of the study.

RESULTS: The mean frequency of binge-eating episodes significantly decreased from baseline to post-treatment (p < 0.001), with a binge eating remission rate of 76.1% at the end of the trial. Depressive symptoms and body shape concern also improved (p < 0.001). In addition, weight loss was statistically and clinically significant.

CONCLUSION: The use of this adapted manual-based cognitive behavior therapy in this sample resulted in a marked improvement in binge-eating, weight, body shape concern, and depressive symptoms related to binge-eating disorder.

Descriptors: Eating disorders; Binge-eating; Obesity; Cognitive-behavior therapy; Behavior therapy

RESUMO

OBJETIVO: Avaliar a efetividade da terapia cognitivo-comportamental baseada em um manual adaptado para o formato de grupo em uma amostra brasileira de obesos com transtorno da compulsão alimentar periódica.

MÉTODO: Em um estudo aberto, 21 pacientes obesos com transtorno da compulsão alimentar periódica participaram de um programa da terapia cognitivo-comportamental em grupo. A freqüência da compulsão alimentar, o peso corporal, o grau de satisfação com a forma corporal e os sintomas depressivos foram avaliados no início do tratamento e no final do estudo.

RESULTADOS: Houve uma redução estatisticamente significativa da freqüência média de episódios de compulsão alimentar entre a linha de base e o final do tratamento (p < 0,001), com uma taxa de remissão de episódios no final do estudo de 76,1%. Foi observada, também, uma redução significativa dos sintomas depressivos e da insatisfação com a forma corporal (p < 0,001). Adicionalmente, a perda de peso foi clínica e estatisticamente significativa.

CONCLUSÃO: A utilização de terapia cognitivo-comportamental baseada em um manual adaptado para o transtorno da compulsão alimentar periódica resultou em melhora significativa da compulsão alimentar, do peso corporal, da preocupação com a forma corporal e dos sintomas depressivos associados ao transtorno da compulsão alimentar periódica nessa amostra.

Descritores: Transtornos alimentares; Compulsão alimentar; Obesidade; Terapia cognitivo-comportamental; Terapia comportamental

INTRODUCTION

Binge-eating disorder (BED) is characterized by recurrent binge-eating episodes, without the inappropriate compensatory weight control methods found in bulimia nervosa.^1-2 Although obesity is not a criterion for BED, it is a condition frequently associated with this diagnosis.³ Compared to matched obese subjects who do not binge, obese binge-eaters experience higher levels of general and eating-related psychopathology.⁴ For example, they show more concerns with body shape, and some authors found that binge-eating is significantly correlated with the perception that body weight is above the ideal.^4-5

Cognitive behavior therapy (CBT) is a semi-structured focal therapy, especially focused on the present and the future of the patient. It can be delivered by a therapist or in a self-help format.⁶ In the treatment of obese subjects with BED, the main aims of CBT are to increase the patient's control over eating and to improve the associated psychopathological symptoms.⁷ CBT is regarded as the best-established intervention for BED and has been increasingly used in the usual clinical practice.⁸ The present open study aims to investigate the effectiveness of a manual-based CBT adapted to a group format in reducing binge-eating and weight in a sample of Brazilian obese subjects with BED.

Method

This study was carried out in the eating disorders' outpatient clinic at the State Institute of Endocrinology and Diabetes of Rio de Janeiro, Brazil. The protocol was approved by the institutional review board of the hospital and a written informed consent was obtained from patients prior to the accomplishment of any study procedure.

All subjects who spontaneously sought treatment at the clinic were evaluated. Subjects were eligible for the study if they met the following inclusion criteria: 1) diagnosis of BED according to DSM-IV criteria,¹ 2) age between 18-60 years, 3) a minimum of 6 years of schooling, 4) body mass index [BMI: weight (kg)/height² (m²)] between 30-45 kg/m², and 5) score in the Binge-Eating Scale (BES)⁹ > 17, suggesting at least a moderate severity level of binge-eating. Of the 60 obese patients initially interviewed, 21 subjects met all eligible criteria and were included in the study. Of note, seven patients (33% of 21) had a current major depressive disorder and were treated with fluoxetine 20 mg/day during the course of the study.

The Structured Clinical Interview for DSM-IV Axis I Disorders, Patient Version (SCID I/P)¹⁰ was used for BED diagnosis. Eligible subjects were asked to complete a self-monitoring register of their daily food intake (highlighting the occurrence of binge-eating episodes). They also fulfilled the BES,⁹ the Beck Depression Inventory (BDI)¹¹ and the Body Shape Questionnaire (BSQ).^12-13 The BES was chosen because it is a self-reported questionnaire, specifically designed to measure, in a dimensional way, behaviors, feelings and cognitions associated with binge eating.

The study was a single center open trial. Subjects were assigned to one of three groups of seven patients each, and received 19 sessions of group CBT for 22 weeks. They were assessed at baseline and immediately following completion of treatment. CBT groups were conducted by a therapist and a co-therapist experienced in the treatment of eating disorders. They underwent a previous extensive training in the manual-based treatment used in this study.

All CBT sessions were videotaped and therapists received ongoing supervision to ensure adherence to the CBT manual and standardized administration of the treatment.

The primary outcome measure was frequency of binge-eating assessed as the number of days per week in which patients had at least one binge-eating episode according to DSM-IV criteria, considering the seven days prior to the beginning of CBT and the seven days following completion of treatment. Secondary outcome measures included the scores of BES,⁹ BDI¹¹ and BSQ,¹² besides changes in weight and BMI.

The CBT used in this study was based on the manual for binge-eating and bulimia nervosa of Fairburn et al.⁷ After the author's written approval, this manual was independently translated by two CBT professionals and one eating disorders specialist. Afterwards, these three translators adapted the manual to a group format, including some weight loss strategies. Cognitive-behavioral therapy groups were composed by nineteen 90-minute sessions. It was a three-stage intervention weekly conducted over the two first stages and biweekly in the third stage.

Demographic and clinical data variables were described as means and standard deviations. Wilcoxon¹⁴ and Mann-Whitney Tests¹⁴ were applied to assess the treatment effect. Mann-Whitney Tests¹⁴ were performed comparing subjects taking fluoxetine to those without fluoxetine, and no significant differences were found. Thus, they were included in the final analysis. Treatment outcomes were analyzed using the last observation carried forward as the end-point (intention-to-treat analysis). All statistical tests were interpreted at the 5% significance level.

RESULTS

Most participants were women (85.7%), married (52.4%), and had at least 11 years of schooling (61.9%). On average, subjects were 37.2 (SD = 10.8) years old, and had a mean weight and BMI of 103.0 kg (SD = 13.3) and 39.4 kg/m² (SD = 3.8), respectively. Eighteen patients completed the trial (85.8%). Subjects were considered completers if they attended at least 15 group meetings and completed end-of-treatment assessments.

Intention-to-treat analysis showed that the mean frequency of binge-eating significantly decreased from baseline to post-treatment (p < 0.001). The number of binge-eating days showed a mean reduction of 86% following treatment. For completers, end-of-treatment rate of remission was 76.1% (16 subjects), whereas 9.5% (2 subjects) presented one binge-day during the post-treatment assessment week. Dimensional evaluation of binge-eating behavior showed a marked reduction in binge severity. In addition, depressive symptoms and body shape concerns were also significantly reduced, in the end of CBT. Moreover, over the course of treatment weight loss was significant (p < 0.001), with a mean weight loss of 6.1 kg. Among completers, 7 subjects (33.3%) have attained a weight loss of at least 5% of their initial weight, and 4 subjects (19.0%) have reduced at least 10%. Detailed information of changes in all outcomes measures is available in Table 1.

DISCUSSION

The trial has revealed that this manual-based group CBT produced significant improvements in binge-eating, body shape concerns and depressive symptoms, along with a marked decrease in body weight. Quite similar to other studies that found remission rates ranging from 47%¹⁵ to 82%,¹⁶ in this study it was observed a binge eating remission rate of 76.1%. Additionally, our treatment completion rates (85.8%) were comparable to those reported in other trials involving obese individuals with BED treated with group CBT.^16-17

Of note, contrasting to previous findings,¹⁶ this study revealed clinically and statistically significant reduction in body weight. Completer analyses showed that 52.3% of the sample lost at least 5% of their initial body weight. Although Ricca et al.¹⁷ also reported significant weight loss with CBT in obese patients with BED, most of the studies with this intervention reported no clinically significant weight loss.^4,16

To better understand this lack of effect observed on body weight it is important to consider some of the theoretical basis of CBT. The initial CBT model for BED assumed that because ongoing binge-eating could interfere with weight loss treatment, patients should first learn to control binge-eating in order to adhere to a weight loss regimen. In this model it was also assumed that the focus on weight loss would increase dietary restriction and that, in turn, would trigger binge-eating. Considering these assumptions, weight loss strategies were not included in the initial CBT protocols for BED patients.

Conversely, in our study, some weight loss strategies were added to the treatment. The inclusion of these techniques may have played an important role in the weight loss observed in this trial, and apparently have not necessarily undermined binge-eating control, as expected by those initial CBT assumptions. Other studies support this finding, once traditional behavioral weight control programs have reported success in treating obesity without increasing binge-eating in obese patients with BED in the short-term.⁴

A different aspect of this study is that, as mood disorders are a prevalent comorbidity in BED patients,⁴ we decided to include patients with major depression in order to have a sample that is not much different from the general population of BED patients. However, there are several limitations in this study. The sample size was small and most participants were women with at least 6 years of schooling. Therefore, generalization of findings is limited. Another limitation is that binge/days have been assessed for one week, and a longer period of assessment could provide a more consistent measure. Additionally, there was no control treatment condition able to differentiate the effect of non-specific influences, such as intensity of therapeutic contact. Given the high placebo response observed in studies with BED,⁴ for a better assessment of the manual's efficacy, a randomized controlled trial comparing TCC with another intervention is advisable.

Conclusions

This study suggests that the Fairburn's CBT manual adapted to a group format may be an effective treatment in Brazilian obese patients with BED. The treatment produced significant improvement in binge-eating, body shape concern and depressive symptoms, along with a relevant weight loss.

Acknowledgments

The authors gratefully acknowledge Christopher G. Fairburn for authorizing the use of his manual.

Submitted: July 10, 2006

Accepted: October 23, 2006

Financing: This research was supported by grants of Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Conflict of interests: None

• 1. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Press; 2000.
• 2. Borges MB, Morgan CM, Claudino AM, da Silveira DX. Validation of the Portuguese version of the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) for the screening of binge eating disorder. Rev Bras Psiquiatr 2005;27(4):319-22.
• 3. Appolinario JC, Coutinho W, Povoa LC. O transtorno do comer compulsivo no consultório endocrinológico: comunicação preliminar. J Bras Psiquiatr 1995;44(Supl 1):S46-9.
• ⁴
  American Psychiatric Association (APA). Practice guideline for the treatment of patients with eating disorders. 3rd ed. 2006. [cited 2006 Apr 25] Available at: http://www.psych.org
• 5. Siqueira KS, Appolinario JC, Sichieri R. Relationship between binge-eating episodes and self-perception of body weight in a nonclinical sample of five Brazilian cities. Rev Bras Psiquiatr 2005;27(4):290-4.
• 6. Stefano SC, Bacaltchuk J, Blay SL, Hay P. Self-help treatments for disorders of recurrent binge eating: a systematic review. Acta Psychiatr Scand 2006;113(6):452-9.
• 7. Fairburn CG, Marcus MD, Wilson GT. Cognitive-behavioral therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment and treatment. New York: Guilford Press; 1993. p. 361-404.
• ⁸
  National Health Service (NHS). National Institute for Clinical Excellence (NICE). Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Clinical Guideline CG009. London, UK. [cited 2006 Aug 25] Available at: www.nice.org.uk/guidance/CG9
• 9. Freitas S, Lopes CS, Coutinho W, Appolinario JC. Translation and adaptation into Portuguese of the Binge-Eating Scale. Rev Bras Psiquiatr 2001;23(4):215-20.
• 10. First MB, Spitzer RL, Gibbon M, Williams JB. Structured clinical interview for DSM-IV Axis I disorders Patient Edition (SCID-I/P) version 2.0. New York, NY: New York State Psychiatric Institute, Biometrics Research; 1996.
• 11. Gorestein C, Andrade L. Inventário de Depressão Beck: propriedades psicométricas da versão em português. In: Gorestein C, Andrade LH, Zuardi AW, editores. Escalas de avaliação clínica em psiquiatria e psicofarmacologia. São Paulo: Lemos; 2000. p. 89-95.
• 12. Freitas SR. Instrumentos para a avaliação dos transtornos alimentares. In: Nunes MA, Appolinario JC, Galvao AL, Coutinho W, editores. Transtornos alimentares e obesidade Porto Alegre: Artmed; 2006. p. 241-96.
• 13. Cooper PJ, Taylor MJ, Cooper Z, Fairburn CG. The development and of the Body Shape Questionnaire. Int J Eat Dis 1987;6:485-94.
• 14. Siegel S, Castellan NJ Jr. Nonparametric statistics for the behavioral sciences international edition. 2nd ed. New York, NY: McGraw-Hill; 1988. p. 284-91.
• 15. Kenardy J, Mensch M, Bowen K, Green B, Walton J. Group therapy for binge eating in type 2 diabetes: a randomized trial. Diabet Med 2002;19(3):234-9.
• 16. Wilfley DE, Welch RR, Stein RI, Spurrell EB, Cohen LR, Saelens BE, Dounchis JZ, Frank MA, Wiseman CV, Matt GE. A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Arch Gen Psychiatry 2002;59(8):713-21.
• 17. Ricca V, Mannucci E, Mezzani B, Moretti S, Di Bernardo M, Bertelli M, Rotella CM, Faravelli C. Fluoxetine and fluvoxamine combined with individual cognitive-behaviour therapy in binge-eating disorder: a one-year follow-up study. Psychother Psychosom 2001;70(6):298-306.

Publication Dates

• Publication in this collection
  22 Feb 2007
• Date of issue
  Mar 2007

History

• Accepted
  23 Oct 2006
• Received
  10 July 2006