Developing a new treatment approach to binge eating and weight management Clinical Psychology Forum, Number 244, April 2013 Dr Marie Prince 1
Contents Service information Binge Eating Disorder Binge Eating Disorder and Weight Loss DEG Model DEG Outcomes Summary www.nhsggc.org.uk/gcwms Health and Social Care Information Centre, The Times, 21 st February 2013
Glasgow Drivers 1 in 4 Obese Prevalence 2008, Route Map 175 mill (2%) 2007/2008 49.9 billion Healthcare costs 2050 Foresight, 2008 Clear Pathway Surgical waiting lists 3
GCWMS Aim To establish a weight management pathway of care, from prevention through to the management of morbid obesity, which is evidence based and equitable across NHS GGC Board. offer consistent treatment approaches optimise current resources provide a clear referral route ensure the appropriate use of drugs and surgical interventions A healthier weight through lasting lifestyle changes 4
SIGN: 08, 1996 SIGN: 115, 2010 Management of Obesity The Evidence Base NICE Clinical Guideline 43, 2006 The Scottish Government Review of Bariatric Surgical Services in Scotland 2005
GCWMS Whole System Approach
Psychological Service Provision Priority Referrals directly to this level Routine Referrals directly to this level 7
Aims of Integrated Psychology Service Improve treatment outcomes (adherence to diet & activity changes required for weight management) To alleviate psychological distress interfering with obesity treatment (e.g. disordered eating; low self esteem; body image distress) Improve delivery of healthcare (reduce inappropriate uptake of treatment e.g. re-route clients to appropriate services; consider readiness to change ) Lead, train & support other health professionals (in the use of psychological approaches) Glasgow & Clyde Weight Management Service 8
Developing a new treatment approach to binge eating and weight management
Binge Eating Disorder DSM-IV Recurrent episodes of binge eating Binge eating episode: Eating in a discrete period of time an amount of food that is definitely larger than most people would eat in a similar period of time in similar circumstances A sense of lack of control over eating during the episode The binge eating episodes are associated with at least three of the following: Eating more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not physically hungry Eating alone because of being embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or guilty after overeating. Marked distress regarding binge eating The binge eating occurs, on average at least 2 days a week for six months. The binge eating is not associated with regular use of inappropriate compensatory behaviours and does not occur exclusively during the course of anorexia nervosa or
Binge Eating Disorder Frequent weight fluctuations Childhood weight gain Higher levels of psychological co-morbidity compared to those without BED Female BMI>40 Kg/m 2 Yanovski, 1993, Friedman & Brownell, 2002 A healthier weight through lasting lifestyle changes
Prevalence of BED General population: 3% (Hudson et al 2007) Obese population: 10% Treatment seeking obese population: 30% (Blaine & Rodman, 2007) Half of outpatient diagnoses (Fairburn et al, 2009)
Clinical Experience Other individuals present with sub-clinical disordered eating requiring psychological intervention: compulsive eating using food as an emotional coping strategy dysfunctional eating patterns www.nhsggc.org.uk/gcwms
Weight Loss Interventions & BED Matched study meta-analysis, obese patients with BED lost 2% of body weight compared with 11% in non-bed participants (Blaine and Rodman, 2007) Presence of disordered eating may reduce motivation and adherence to treatment (Hainer et al., 2005) A healthier weight through lasting lifestyle changes
BED Interventions and Weight Loss Systematic review of 7 RCTs comparing individual and group interventions in patients with BED, found CBT was effective in reducing binge eating and improving abstinence, but does not lead to weight loss. (Brownley, 2007, Wilson, 2010) The effectiveness of CBT in reducing binge frequency but without influencing weight loss was also confirmed in an RCT with two years follow up. (Devlin et al., 2005) Glasgow & Clyde Weight Management Service
BED and Mood Increased levels of depression are seen in adults with severe obesity (BMI>40kg/m 2 ) and obese adults with BED. (Onyike et al, 2003) Increased rates of anxiety and lower levels of self esteem are also observed in obese adults with BED compared to non bingeing obese adults. (Jirik-Bibb and Geliebter, 2003) In addition to the above BED is also associated with guilt and shame. (APA, 2000) www.nhsggc.org.uk/gcwms
Predictors of Outcome Baseline high level of negative affect lead to less weight loss. Increased severity of disordered eating is observed in people with higher negative affect and increased psychiatric co morbidities. Lifetime history of depression predicted less remission from binge eating behaviours. (Wilson et al, 2010) Glasgow & Clyde Weight Management Service
Psychological Treatment Guided Self Help CBT-E Fairburn, 2008, 2009 Interpersonal Therapy Wilson et al, 2010 Mindfulness Compassion Focussed Therapy Glasgow & Clyde Weight Management Service
DEG Model Integrate CBT for BED within an evidence based, multi component lifestyle intervention program. Address disordered eating and encourage weight loss and weight maintenance. Beneficial & supportive for clients Research in this area limited A healthier weight through lasting lifestyle changes
DEG Structure 11 sessions 2 hours per session Fortnightly Delivered by a clinical psychologist and assistant Successful pilot study N=10 www.nhsggc.org.uk/gcwms
DEG Overview CBT Model Psychoeducation re dieting Taking control of eating Self Monitoring Motivation Goal setting Regular eating Cravings Changing habits Problem Solving Mindful Eating Emotional Eating Body Image Self Esteem Being assertive Relapse prevention Glasgow & Clyde Weight Management Service
Measures Questionnaire on Eating and Weight Patterns-Revised Presence & Frequency of binge eating Control over eating Eating related distress Body shape and weight concerns Psychometrically sound Categorical data Spitzer, Yanovski & Marcus, 1994 Hospital Anxiety and Depression Scale Widely used self rating scale Psychometrically sound Zigmond & Snaith, 1983 www.nhsggc.org.uk/gcwms
Outcomes
Demographics n mean sd median range Whole Cohort Age 167 43.45 10.89 43 20-71 Years Weight 134 120.17 22.42 119.25 79.55-208 Kg Completers Age 101 42.78 10.33 41 20.68 Years 49.7 12.6 20-88 Weight 101 121.68 23.19 120.80 82.40-208 114.5 23.4 Kg
Change in BED % 80 70 60 50 40 30 20 10 Yes No 0 Pre Group Post Group McNemar: x 2 =17.93, df=1, p<0.001, N=58
Change in Binge Frequency 60 50 N = 62 40 30 20 10 0 Stopped Reduced Stable Increased
Eating Related Distress Pre-Intervention Post-Intervention p value N Mean (SD) N Mean (SD) Distress 46 4.17 (0.82) 46 3.76 (0.95) <.008 Control 47 4.23 (0.81) 47 3.62 (1.13) <.001 Body Image 56 3.50 (0.76) 56 3.02 (0.82) <.01
HADS Scores Pre and Post Intervention n median median median 95% p pre* post* change CI Anxiety 90 13 (3-21) 10 (2-20) 1.50 1, 2.50 <0.001 Depression 90 11 7 2.50 1.50, <0.001 (1-19) (0-18) 3.50 Statistics for completers who had baseline values (per protocol analysis) * Median (Range)
Kg 2006/7 1 in 3 2012 1 in 2 vs 1 in 4 N 59 Mean Median 2.70 2.00 Std. Deviation 4.53 Range 22.6 Percentiles Glasgow & Clyde 25 Weight Management.000 Service
Summary Successful BED treatment Improvements in mood, self esteem, body image Successful weight loss Efficient Initial Follow Up Retaining clients through the next step of the program Catching up with standard group outcomes Indicates this group are ready to focus on weight loss www.nhsggc.org.uk/gcwms
marie.prince@ggc.scot.nhs.uk www.nhsggc.org.uk/gcwms 0141 201 6115 Glasgow & Clyde Weight Management Service
References Background Information National Institute for Health and Clinical Excellence (NICE). (2006). Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. London. Retrieved 25 th July 2011, from http://guidance.nice.org.uk/cg43. The Scottish Government. (2010). Preventing overweight and obesity in Scotland: a route map. Retrieved 25 th July 2011 from http://www.scotland.gov.uk/publications/2010/02/17140721/0. Foresight-Tackling Obesities: Future Choices, Project Report 2nd Edition Government Office for Science.2008 Scottish Executive, (2004), Review of bariatric surgical services in Scotland, SEHD, Edinburgh
References Glasgow & Clyde Weight Management Service Morrison, D., Boyle, S., Morrison, C., Allerdice, G., Greenlaw, N., & Forde, L. (2011). Evaluation of the first phase of a specialist weight management programme in the UK National Health Service: prospective cohort study. Public Health Nutrition, First View. Retrieved 19th August 2011, from http://journals.cambridge.org/action/displayjournal?jid=phn DOI: 10.1017/S1368980011001625 www.nhsggc.co.uk/gcwms
References American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. Blaine, B., & Rodman, J. (2007). Responses to weight loss treatment among obese individuals with and without BED: A matched-study meta-analysis. Eating and Weight Disorders, 12, 54-60. Brownley, K., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. (2007). Binge eating disorder treatment: A systematic review of randomized controlled trials. International Journal of Eating Disorders, 40, 337-348. DOI: 10.1002/eat Fairburn, C. G., Cooper, Z., Doll, H., O Connor, M., Bohn, K., Hawker, D., Wales, J., & Palmer, R. (2009). Transdiagnostic cognitive-behavioural therapy for eating disorders: A two site trail with 60 week follow up. American Journal of Psychiatry, 166, 311-319. DOI: 10.1176/appi.ajp.2008.08040608 Hudson, J. I., Hiripi, E., Pope, H. G., Kessler, R. C.(2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61 (3), 348-358. DOI: 10.1016/j.biopsych.2006.03.040 Jirik-Babb, P., & Geliebter, A. (2003). Comparison of psychological characteristics of binging and nonbinging obese, adult, female out. Eating and Weight Disorders, 8, 173-177.
References Onyike, C. U., Crum, R. M., Lee. H. B., Lyketsos, C. G., & Eaton, W. W. (2003). Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. American Journal Epidemiology. 158 (12), 1139-1147. DOI: 10.1093/aje/kwg275 Spitzer, R. L., Yanovski, S. Z., & Marcus, M. D. (1994). Questionnaire on Eating and Weight Patterns-Revised. Pittsburgh PA: Behavioural Measurement Database Services (Producer). McLean, VA: B. Wilson, T. G., Wilfley, D. E., Agras, W. S., & Bryson, S. (2010). Psychological Treatments of Binge Eating Disorder. Archives of General Psychiatry, 67 (1): 94-101. Zigmond, A. S., & Snaith, R. P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67 (6), 361-370. DOI: 10.1111/j.1600-0447.1983.tb09716.x