Body Checking Questionnaire: psychometric properties and clinical correlates in obese men and women with binge eating disorder

OBJECTIVE: Body checking is considered a behavioral manifestation of the overevaluation of shape and weight, which is characteristic of patients with eating disorders. We examined the initial psychometric properties of the Body Checking Questionnaire (BCQ) and the frequency and nature of body checking behaviors in obese men and women with binge eating disorder (BED). METHOD: Participants were a consecutive series of 73 (22 men, 51 women) treatment-seeking obese adults who met research criteria for BED as defined in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). Participants were administered measures to assess body checking, body image concerns, and the core psychopathology of eating disorders, and general psychological functioning. Semistructured interviews were used to establish the diagnosis of BED. RESULTS: Psychometric evidence was found to support the reliability and validity of the BCQ in patients with BED. Women reported significantly greater levels of body checking than men. Participants with greater body dissatisfaction reported more frequent checking than participants with less dissatisfaction. Among women, the frequency of checking was related to younger age, lower body mass index (BMI), body dissatisfaction, overevaluation of body shape and weight, greater depression, and lower self-esteem. CONCLUSION: There exist significant gender and age-related differences in both the frequency and correlates of body checking behaviors. Among obese women with BED, body checking is related to the overevaluation of shape as well as with associated psychopathology.     

Body checking and its avoidance in eating disorders

OBJECTIVE: One expression of the core psychopathology of eating disorders is the repeated checking and avoidance of shape or weight. Two studies are reported. The primary purpose of the first was to describe the phenomenology of such body checking and avoidance. The aim of the second was to compare body checking and avoidance in women with and without a clinical eating disorder. METHOD: In Study 1, 64 female patients with clinical eating disorders participated in a semistructured interview assessing the features of body checking and avoidance. In the second study, a self-report questionnaire was used to compare body checking and avoidance in women with and without a clinical eating disorder (n = 110). RESULTS: The majority (92%) of the patients in Study 1 checked their bodies to assess their shape or weight and this was associated significantly with eating disorder symptoms. In Study 2, the clinical group had significantly more body checking and avoidance than the comparison group, and there was a strong association between eating disorder psychopathology and body checking and avoidance. CONCLUSIONS: These findings support the view that body checking and avoidance are direct expressions of the overevaluation of shape and weight. Further work is needed to determine whether these expressions contribute to the maintenance of eating disorders.     

Using the eating disorder examination to identify the specific psychopathology of binge eating disorder

OBJECTIVE: The clinical features of binge eating disorder (BED) are not well established. Therefore, a comprehensive assessment of the specific psychopathology of BED as compared to anorexia nervosa (AN) and bulimia nervosa (BN) is warranted. This comparison was the aim of the present study. METHOD: Detailed ratings from an investigator-based interview, the Eating Disorders Examination (EDE), were compared across three groups of female patients: those with BED, AN, and BN, as well as normal-weight and overweight control subjects. RESULTS: When comparing BED to AN and BN, patients with BED had lower levels of restraint, eating concerns comparable to AN patients but lower than BN patients, and weight and shape concerns comparable to BN patients but higher than AN patients. Significantly more eating disorder psychopathology was found for BED patients as compared to the overweight controls on all bar the EDE restraint subscale. On the majority of individual EDE items, BED patients' scores were similar to those of AN and BN patients, including importance of shape and weight in self-evaluation and preoccupation with shape and weight. No significant relationship was found between BED patients' degree of overweight and eating psychopathology. DISCUSSION: Our findings support the status of BED as an eating disorder and suggest that the elevated EDE scores reflect the combined impact of being objectively overweight and having disordered cognitions and behaviors about eating, shape, and weight.     

On the relation of attempting to lose weight, restraint, and binge eating in outpatients with binge eating disorder

OBJECTIVE: To examine the relationship among attempts to lose weight, restraint, and eating behavior in outpatients with binge eating disorder (BED). RESEARCH METHODS AND PROCEDURES: Participants were 93 consecutive outpatients evaluated for a clinical trial who met Diagnostic and Statistical Manual, Fourth edition criteria for BED. The Eating Disorder Examination Interview was administered to assess attempts at weight loss, restraint, different forms of overeating, and the attitudinal psychopathology of eating disorders (i.e., concerns regarding eating, shape, and weight). In addition, the Three-Factor Eating Questionnaire was used to assess cognitive restraint, hunger, and disinhibition. Psychometrically established measures were given to assess body dissatisfaction, depression, and self-esteem. RESULTS: The majority of participants (75.3%; N = 70) reported attempting to lose weight, but only 37.6% (N = 35) reported dietary restraint on at least half the days of the month. Dietary restraint and cognitive restraint were not associated with any form of binge eating or overeating. Dietary restraint and cognitive restraint were positively correlated with weight concern, shape concern, and body dissatisfaction, and negatively correlated with body mass index. To further examine the interplay between attempting to lose weight and restraint, three study groups were created: unrestrained nonattempters (21.5%, N = 20), unrestrained attempters (40.9%; N = 38), and restrained attempters (34.4%; N = 32). The three groups did not differ significantly on binge eating or other eating behaviors; however, significant differences were observed for weight concern, shape concern, and body dissatisfaction. DISCUSSION: Attempts to lose weight and restraint are not synonymous for patients with BED. Although 75.3% of BED patients reported that they were attempting to lose weight, only 37.6% reported dietary restraint on at least half the days of the previous month. While restraint was negatively associated with body mass index, it was not related to binge eating or overeating. Our findings raise questions about prevailing models that posit restraint as a predominant factor in the maintenance of binge eating in BED.     

Timing and sequence of the onset of overweight, dieting, and binge eating in overweight patients with binge eating disorder

OBJECTIVE: To examine the self-reported sequence and timing of onset of overweight, binge eating, and dieting in adult patients diagnosed with binge eating disorder (BED). METHOD: Participants were 284 treatment-seeking adults (73 men and 211 women) who met DSM-IV research criteria for BED. Patients were interviewed with structured diagnostic interviews and were queried regarding history of overweight, dieting, and binge eating behaviors. Questionnaires were also administered to assess current eating disturbances, body dissatisfaction, and general functioning. Participants were classified as Overweight First, Binge First, or Diet First, and the three groups were compared on developmental sequence and using the battery of measures. RESULTS: Sixty-three percent of the 284 participants reported becoming overweight prior to the onset of dieting or binge eating. Participants who reported they were overweight first had significantly greater BMI at the time of assessment. The 16% of the participants who reported binge eating first were significantly younger at the onset of BED diagnosis and reported significantly less dietary restraint. Onset order differed significantly by gender; proportionally more women (25%) than men (11%) reported that dieting preceded overweight or binge eating. CONCLUSION: Weight problems preceded dieting and binge eating behaviors for a majority of treatment-seeking overweight participants diagnosed with BED.     

Effectiveness of spouse involvement in cognitive behavioral therapy for binge eating disorder

OBJECTIVE: This study examined whether involving the spouse in group cognitive behavioral therapy (CBT) for binge eating disorder (BED) enhances treatment outcome relative to standard group CBT. METHOD: Ninety-four overweight women with BED were randomly assigned to either (1) standard group CBT, (2) group CBT with spouse involvement, or (3) a wait-list control group. Eating and general psychopathology assessments were completed at baseline, after treatment, and at 6-month follow-up. RESULTS: Although both CBT groups fared significantly better than the wait-list control group on measures of binge eating, weight, eating psychopathology, and general psychopathology, CBT with spouse involvement did not result in any additional benefit over and above standard CBT. DISCUSSION: These results are in contrast to the success of spouse involvement in the treatment of several other physical and psychological disorders. Possible reasons for this disparity, and suggestions for improving spouse involvement in BED treatment, are discussed.     

The nature of body image disturbance in patients with binge eating disorder

OBJECTIVE: This study examined the distinction between body dissatisfaction and self-evaluation unduly influenced by body shape and weight, and their longitudinal relationships to depressive symptomatology and self-esteem in patients with binge eating disorder (BED). METHOD: Ninety-seven patients with BED completed measures tapping these constructs at baseline and again 4 weeks later. RESULTS: Change in body dissatisfaction was significantly correlated with both change in depressive symptomatology and change in self-esteem over time, whereas change in self-evaluation was significantly correlated only with change in self-esteem. In addition, change in shape concern, but not change in weight concern, was significantly correlated with change in self-esteem only. DISCUSSION: These findings suggest that self-evaluation unduly influenced by body shape is a more useful indicator for BED than body dissatisfaction or self-evaluation unduly influenced by weight.     

Gender differences in patients with binge eating disorder

OBJECTIVE: This study examined gender differences in patients with binge eating disorder (BED). METHOD: Participants were 182 adults (35 male, 147 female) who were consecutively evaluated for outpatient clinical trials and met criteria for BED as outlined in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. They were administered a battery of measures to examine developmental, eating and weight-related disturbances, and psychological features associated with BED. RESULTS: Men and women did not differ significantly on several developmental variables (age at first overweight, age at first diet, age at onset of regular binge eating, or number of weight cycles). Men had significantly higher current body mass index (BMI), highest adult BMI, and were significantly more likely to be classified as obese. Men and women did not differ significantly on measures of current eating disorder features (binge eating, eating concerns, weight or shape concerns) but women reported significantly greater body image dissatisfaction and drive for thinness. Men and women did not differ significantly on current depression or self-esteem but men reported a greater frequency of past drug abuse problems. DISCUSSION: Although men and women who present for treatment for BED show many similarities in current eating disorder features, we observed a number of gender differences on important developmental and physical variables as well as associated psychological features.     

Teasing history, onset of obesity, current eating disorder psychopathology, body dissatisfaction, and psychological functioning in binge eating disorder

OBJECTIVE: The primary goal of this study was to examine associations among teasing history, onset of obesity, current eating disorder psychopathology, body dissatisfaction, and psychological functioning in women with Binge Eating Disorder (BED). RESEARCH METHODS AND PROCEDURES: Subjects were 115 female adults who met DSM-IV criteria for BED. Measurements assessing teasing history (general appearance [GAT] and weight and size [WST] teasing), current eating disorder psychopathology (binge frequency, eating restraint, and concerns regarding eating, shape, and weight), body dissatisfaction, and psychological functioning (depression and self-esteem) were obtained. RESULTS: History of GAT, but not WST, was associated with current weight concerns and body dissatisfaction, whereas both GAT and WST were significantly associated with current psychological functioning. Patients with earlier onset of obesity reported more WST than patients with later onset of obesity, but the groups did not differ significantly in GAT, current eating disorder psychopathology, body dissatisfaction. or psychological functioning. Obese women reported more WST than non-obese women, but no differences in GAT or the other outcome variables were observed. Higher frequency of GAT was associated with greater binge frequency in obese women, and with greater eating restraint in non-obese women. DISCUSSION: Although physical appearance teasing history is not associated with variability in most eating disorder psychopathology, it is associated with related functioning, most notably body dissatisfaction, depression, and self-esteem. Our findings also suggest that the age of onset of obesity and current body mass index status in isolation are not associated with eating psychopathology or associated psychological functioning in adult patients with BED.     

Symptom severity in obese women with binge eating disorder as a function of smoking history

OBJECTIVE: To compare obese female former smokers with binge eating disorder (BED) to women with BED with no smoking history in the severity of binge eating and associated symptoms. METHOD: A consecutive series of 91 obese women with current diagnoses of BED were administered structured diagnostic and investigator-based interviews and self-report questionnaires to assess symptoms associated with eating disorders. Participants were classified as "never" or "former" smokers and symptom profiles were compared across smoking groups. RESULTS: Former and never-smoking groups did not differ in age, body mass index, or current binge frequency. Former smokers reported significantly higher levels of dietary restraint, rigid dieting strategies, and avoidance of eating. CONCLUSION: Former smokers were significantly more likely than never-smokers to endorse specific symptoms of eating pathology (i.e., rigid dieting strategies). Despite the average 15-year interval since smoking cessation, the former smokers in this patient group resembled current smokers with other eating disorders in terms of rigid and restrictive weight control methods. Obese patients with a smoking history may benefit from treatment to address rigid/pathological dieting and strategies.     

Comparison of the child and parent forms of the Questionnaire on Eating and Weight Patterns in the assessment of children's eating-disordered behaviors

OBJECTIVE: The assessment of eating-disordered behaviors in middle childhood is challenging. Frequently, both child and parents are queried about the child's eating behavior. However, no direct comparisons between parent and child reports of child eating disturbance have been published. We compared results from the adolescent and parent versions of the Questionnaire on Eating and Weight Patterns (QEWP-A and QEWP-P, respectively) in a nontreatment sample of overweight and normal weight children. METHOD: The QEWP-A and QEWP-P were administered to 142 overweight (body mass index [BMI] > or = 85th percentile) and 121 normal weight (BMI 15th-84th percentile) children, age 9.7 +/- 1.9 years, recruited from the community. RESULTS: The QEWP-A and QEWP-P showed good agreement for the absence of eating-disordered behavior but were not concordant in terms of the number or type of binge eating, overeating episodes, or compensatory weight control behaviors in the past 6 months. Children categorized by their own reports (QEWP-A) as engaging in no overeating, simple overeating, or binge eating behaviors did not differ significantly in body composition or in eating and general psychopathology. Children categorized according to their parents' reports (QEWP-P) as engaging in binge eating had significantly greater body adiposity, eating-disordered cognitions, body dissatisfaction, and parent-reported problems (all ps <.001) than children engaging in no overeating or simple overeating according to the QEWP-P. DISCUSSION: Child and parent reports of eating behaviors are not concordant regarding the presence of binge eating or compensatory behaviors. Further investigation of the utility of these questionnaires is needed before either can serve as a surrogate for a clinical interview.     

Correlates of body image dissatisfaction in treatment-seeking men and women with binge eating disorder

OBJECTIVE: We examined body image dissatisfaction (BID) in patients with binge eating disorder (BED). METHOD: Six predictors were considered in 343 consecutive treatment-seeking BED patients (76 men, 267 women): body mass index (BMI), age onset of overweight childhood teasing about weight or size childhood teasing about general appearance, depression, and self-esteem. RESULTS: Women reported higher BID than men. In women, depression, self-esteem, and childhood teasing about weight or size jointly accounted for 28.4% of the variance in BID. In men, depression, self-esteem, and BMI jointly accounted for 47.4% of the variance in BID. DISCUSSION: Findings highlight gender differences and the importance of adult psychological functioning (depression and self-esteem) for predicting BID in treatment-seeking men and women with BED.     

Binge eating and binge eating disorder in a small-scale, indigenous society: the view from Fiji

OBJECTIVE: Although the cross-cultural prevalence of anorexia and bulimia nervosa has been investigated in multiple studies, little is known about the prevalence and correlates of binge eating and binge eating disorder (BED) cross-culturally. No published studies to date have explored BED in small-scale, indigenous, or developing societies. The current study investigated the prevalence and correlates of binge eating in a community sample of Fijian women living in rural Fiji. METHODS: Fifty ethnic Fijian women completed a self-report measure developed for this study on dieting and attitudes toward body shape and change, a Nadroga-language questionnaire on body image, and the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R). Their height and weight were also measured. Patterns of dieting, high body mass index (BMI), and attitudes toward eating and body image were compared between women with and without a history of binge eating. RESULTS: Ten percent of respondents reported at least weekly episodes of binge eating during the past 6 months and 4% endorsed symptoms consistent with BED. Binge eating in this sample was associated significantly with a BMI value above 35, a history of dieting, and a high concern with body shape. Binge eating was not associated with several markers of acculturation in this sample, although it was associated with a key, nontraditionally Fijian (i.e., acculturated) attitude toward the body. DISCUSSION: Binge eating occurred in a social context with traditions concerning weight and diet widely disparate from Western populations. However, correlates of binge eating in this sample suggest that nontraditional Fijian attitudes toward weight and body shape play a contributory role.     

Emotional overeating and its associations with eating disorder psychopathology among overweight patients with binge eating disorder

OBJECTIVE: The current study examined emotional overeating in overweight patients with binge eating disorder (BED). A new measure--the Emotional Overeating Questionnaire (EOQ)--was developed to measure the frequency of overeating in response to emotions. The internal consistency, test-retest reliability, and factor structure of this measure were examined, and its associations with eating disorder psychopathology, depression, and gender were explored. METHOD: Two hundred twenty consecutive overweight (body mass index [BMI] > or = 25) treatment-seeking BED patients (48 men and 172 women) were administered the EOQ, which assesses overeating frequency in response to six emotions (anxiety, sadness, loneliness, tiredness, anger, and happiness). A subset of patients (n = 83) completed the measure again approximately 1 week later. BMI was measured, and participants completed measures of eating disorder psychopathology. RESULTS: The EOQ was internally consistent (alpha =.85), its items were significantly and moderately correlated (range .32 to .70) with each other, and principal components analysis revealed one factor accounting for 58% of the variance. The EOQ items and total score were characterized by good test-retest reliability (intraclass correlation coefficients [ICCs] ranged from .62 to .73). Significant correlations were found between the emotional overeating items and total score, and binge frequency, eating disorder features, and depressive symptomatology. Emotional overeating was unrelated to BMI, and men and women reported similar rates of emotional overeating. CONCLUSION: Emotional overeating was significantly associated with binge frequency, eating disorder features, and depression, but was not related to BMI or gender.     

Subtypes of binge eating disorder based on psychiatric history

OBJECTIVE: This investigation sought to identify subtypes of binge eating disorder (BED) based on history of mood disorder (MOOD) and substance use disorder (SUD). METHOD: Eighty-four women who met criteria for BED were administered semistructured interviews and completed self-report questionnaires assessing eating pathology, depressive symptoms, self-esteem, body dissatisfaction, and personality traits. RESULTS: Thirty-nine participants (46.4%) had a lifetime history of a SUD and 60 (71.4%) had a lifetime history of a MOOD. The SUD subtype was associated with a greater impulsivity and frequency of binge eating episodes compared with the no SUD subtype. The MOOD subtype participants reported greater distress, more psychopathology, less dietary restraint, lower self-esteem, more frequent binge eating, higher levels of negative affect, and more frequent trauma and abuse history than the no MOOD subtype. DISCUSSION: The results of this study indicate that subtypes of BED on the basis of MOOD and SUD may be associated with a more severe variant of the disorder.     

On the relation of flexible and rigid control of eating to body mass index and overeating in patients with binge eating disorder

OBJECTIVE: To examine the relationship of flexible and rigid dimensions of restrained eating to body mass index (BMI) and overeating in outpatients with binge eating disorder (BED). METHOD: Participants were 148 consecutive outpatients who met criteria for BED. The Three-Factor Eating Questionnaire (TFEQ) was administered to assess Cognitive Restraint, Hunger, and Disinhibition. The TFEQ also contains two Cognitive Restraint subscales--Flexible Control and Rigid Control. The Eating Disorder Examination-Questionnaire version (EDE-Q) was administered to assess frequency of different forms of overeating during the past 28 days and the attitudinal features of eating disorders. RESULTS: Flexible Control and Rigid Control were significantly correlated with each other. They were both negatively correlated with BMI, but neither was significantly correlated with the frequency of binge eating or other forms of overeating. In addition, Flexible Control and Rigid Control predicted almost the same amount of variance in BMI. DISCUSSION: BED patients exhibit flexible and rigid control of eating that is related to BMI, but not to the frequency of binge eating or other forms of overeating. Results of the present study provide preliminary evidence that flexible and rigid control of eating may not be a useful distinction in BED patients. However, increased restraint, regardless of type, may prove to be of benefit with regard to weight control and may not have adverse effects on binge eating in obese BED patients.     

Prevalence and utility of DSM-IV eating disorder diagnostic criteria among youth

OBJECTIVE: To examine the prevalence and utility of DSM-IV eating disorder (ED) criteria and anorexia (AN), bulimia (BN), and binge eating disorder (BED) among adolescents. METHOD: An ethnically diverse population-based sample of 4,746 public middle and high school students completed anthropometric measures and Project EAT survey items. RESULTS: Many youth endorsed body shape perception disturbance (41.5% female; 24.9% male), undue influence of body shape/weight on self-esteem (36.4% female; 23.9% male), and compensatory behavior (9.4% female; 13.5% male). Prevalence among females and males, respectively, was: AN = 0.04%, 0%; BN = 0.3%, 0.2%; BED = 1.9%, 0.3%. Analyses of individual criteria showed high sensitivity and negative predictive values for each disorder and corresponding criteria, low specificity for several AN (27.8%) and BN (32.0%) criteria, and low positive predictive values (0.06-40.2%). CONCLUSION: Body disparagement and compensatory behaviors indicate eating disturbance, despite low prevalence of EDs. Diagnostic classification may be clinically useful, but is complicated for use in epidemiological populations.     

A randomized comparison of cognitive behavioral therapy and behavioral weight loss treatment for overweight individuals with binge eating disorder

OBJECTIVES: The aim of this study was to determine the efficacy of cognitive-behavioral therapy (CBT) and behavioral weight loss treatment (BWLT) for overweight patients with binge eating disorder (BED). METHOD: Eighty obese patients meeting criteria of BED according to DSM-IV-TR were randomly assigned to either CBT or BWLT consisting of 16 weekly treatments and 6 monthly follow-up sessions. Binge eating, general psychopathology, and body mass index (BMI) were assessed before, during, and after treatment, and at 12-month follow-up. RESULTS: At posttreatment results favored CBT as the more effective treatment. Analysis of the course of treatments pointed to a faster improvement of binge eating in CBT based on the number of self-reported weekly binges, but faster reduction of BMI in BWLT. At 12-month follow-up, no substantial differences between the two treatment conditions existed. CONCLUSION: CBT was somewhat more efficacious than BWLT in treating binge eating but this superior effect was barely maintained in the long term. Further research into cost effectiveness is needed to assess which treatment should be considered the treatment of choice.     

Food thought suppression: a matched comparison of obese individuals with and without binge eating disorder

Preliminary studies of non-clinical samples suggest that purposely attempting to avoid thoughts of food, referred to as food thought suppression, is related to a number of unwanted eating- and weight-related consequences, particularly in obese individuals. Despite possible implications for the treatment of obesity and eating disorders, little research has examined food thought suppression in obese individuals with binge eating disorder (BED). This study compared food thought suppression in 60 obese patients with BED to an age-, gender-, and body mass index (BMI)-matched group of 59 obese persons who do not binge eat (NBO). In addition, this study examined the associations between food thought suppression and eating disorder psychopathology within the BED and NBO groups and separately by gender. Participants with BED and women endorsed the highest levels of food thought suppression. Food thought suppression was significantly and positively associated with many features of ED psychopathology in NBO women and with eating concerns in men with BED. Among women with BED, higher levels of food thought suppression were associated with higher frequency of binge eating, whereas among men with BED, higher levels of food thought suppression were associated with lower frequency of binge eating. Our findings suggest gender differences in the potential significance of food thought suppression in obese groups with and without co-existing binge eating problems.     

Binge eating disorder and night eating syndrome: psychological and behavioral characteristics.

OBJECTIVE: The present study was designed to examine the psychological and behavioral characteristics associated with both night eating syndrome (NES) and binge eating disorder (BED) in 42 males and 41 females who were enrolled in a university-based weight loss center. METHOD: Individuals were classified into one of four groups: NES only (N = 23), BED only (N = 13), both NES and BED (N = 13), or no diagnoses of an eating disorder (N = 34). Analyses of covariance (covarying for age and gender) were conducted to compare patients with BED and NES. RESULTS: NES patients scored lower on disinhibition than BED patients (p <.01). Also, individuals who met criteria for both disorders scored higher than NES only patients on state anxiety (p <.01), disinhibition (p =.08), and trait anxiety (p =.08). DISCUSSION: These results suggest that NES represents a subcategory among the obese, which also overlaps with binge eaters. In addition, anxiety distinguished individuals who met criteria for both disorders from patients who were diagnosed with either NES or BED.