Recognizing disordered eating in primary care patients with obesity

ObjectiveIn clinical practice, behavioral approaches to obesity treatment focus heavily on diet and exercise recommendations. However, these approaches may not be effective for patients with disordered eating behaviors. Little is known about the prevalence of disordered eating behaviors in primary care patients with obesity or whether they affect difficulty making dietary changes.MethodsWe conducted a telephone interview of 337 primary care patients aged 18–65 years with BMI ≥ 35 kg/m² in Greater Boston, 2009–2011 (58% response rate, 69% women). We administered the Three-Factor Eating Questionnaire R-18 (scores 0–100) and the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) (scores 0–100). We measured difficulty making dietary changes using four questions regarding perceived difficulty changing diet (Scores 0–10).Results50% of the patients reported high emotional eating (score > 50) and 28% reported high uncontrolled eating (score > 50). Women were more likely to report emotional [OR = 4.14 (2.90, 5.92)] and uncontrolled eating [OR = 2.11 (1.44, 3.08)] than men. African-Americans were less likely than Caucasians to report emotional [OR = 0.29 (95% CI: 0.19, 0.44)] and uncontrolled eating [OR = 0.11 (0.07, 0.19)]. For every 10-point reduction in QOL score (IWQOL-lite), emotional and uncontrolled eating scores rose significantly by 7.82 and 5.48, respectively. Furthermore, participants who reported emotional and uncontrolled eating reported greater difficulty making dietary changes.SummaryDisordered eating behaviors are prevalent among obese primary care patients and disproportionately affect women, Caucasians, and patients with poor QOL. These eating behaviors may impair patients' ability to make clinically recommended dietary changes. Clinicians should consider screening for disordered eating behaviors and tailoring obesity treatment accordingly.     

A survey of binge eating and obesity treatment practices among primary care providers

OBJECTIVES: Obesity is an increasingly prevalent condition and many obese individuals binge eat. It is unclear how much knowledge physicians possess regarding binge eating, but the limited existing data suggest that primary care physicians frequently do not identify obesity as a clinical problem. The objective of this study was to examine physician knowledge and treatment recommendations regarding binge eating and obesity. METHOD: A survey on binge eating and obesity assessment and treatment was mailed to 700 licensed physicians. The survey was returned by 272 (38.9%) respondents. RESULTS: Greater than 40% of physicians never assessed binge eating. Body mass index (BMI) was calculated "often or always" by 36.2% of physicians and "rarely or never" by 39.7%. The pattern of obesity treatment methods offered by providers was quite different from the pattern of treatment requested by their patients. Physicians who made higher estimates of binge eating prevalence were more likely to make treatment referrals. DISCUSSION: In this study, physicians frequently did not assess binge eating. Only a minority of physicians utilize BMI in the assessment and management of obesity. Also, physicians report that the obesity treatments they recommend differ from the treatments patients request of them.     

Diabetes and eating disorders in primary care

OBJECTIVE: To determine the relationship between diabetes and eating disorders among primary care patients. METHOD: Data on 3,000 patients were obtained from eight primary care and family practice settings, including the PRIME-MD Patient Health Questionnaire (PHQ), self-reported physical illness, and social functioning information. Multivariate logistic regression analyses were used to determine the association between diabetes and eating disorders. RESULTS: Diabetes was associated with an increased likelihood of eating disorders [OR = 2.3 (1.4, 3.9)], after adjusting for differences in demographic characteristics and comorbid mental disorders. This effect was specific to diabetes. Eating disorder was the only mental disorder associated with a significantly increased risk of diabetes, odds ratio (OR) = 2.4 (1.4, 4.0), after adjusting for demographic characteristics and comorbid mental and physical disorders. Patients with both diabetes and eating disorders had significantly higher levels of comorbid anxiety, panic attacks, and alcohol use disorders, compared with those with one but not both. DISCUSSION: Consistent with reports from community-based samples, these data suggest that diabetes may be associated with an increased likelihood of eating disorders among patients in primary care. Clinicians who treat patients with diabetes, a common condition in primary care, should screen for eating disorders. In addition, patients with eating disorders may be at risk for the development of diabetes. Further work is needed to determine the generalizability of these findings and to understand the mechanism of this association.     

Help-seeking for insomnia among adult patients in primary care

OBJECTIVE: To clarify the patient characteristics associated with seeking medical help for insomnia. METHODS: A consecutive sample (n = 700) of adults attending a non-urgent primary care appointment was screened for sleep problems. A follow-up mailed survey then assessed insomnia symptoms, daytime impairment, beliefs about sleep, medication use, sleepiness and fatigue, and medical help-seeking. RESULTS: Fifty-two percent of patients with probable insomnia reported discussing this with a physician. Multivariate logistic regression analyses indicated that discussing one's probable insomnia with a physician was independently associated with having a greater number of medical conditions (OR, 2.19 [95% CI, 1.13 to 4.22]), being more highly educated (1.67 [95% CI, 1.11 to 2.51]), sleeping less per night (OR, 0.71 [95% CI, 0.52 to 0.96]), and greater perceived daytime impairment due to insomnia (OR, 2.07 [95% CI, 1.06 to 4.03]). CONCLUSIONS: Primary care patients often seek medical help when they experience insomnia. Clinical treatment ought to especially target poor sleepers presenting with significant insomnia-related impairment, medical morbidity, or both. Future research should further clarify the role of medical and psychiatric comorbidities and determine whether resolution of insomnia and its consequences improves the outcomes of common medical conditions.     

Association between eating patterns and obesity in a free-living US adult population

Some studies have suggested that eating patterns, which describe eating frequency, the temporal distribution of eating events across the day, breakfast skipping, and the frequency of eating meals away from home, may be related to obesity. Data from the Seasonal Variation of Blood Cholesterol Study (1994-1998) were used to evaluate the relation between eating patterns and obesity. Three 24-hour dietary recalls and a body weight measurement were collected at five equally spaced time points over a 1-year period from 499 participants. Data were averaged for five time periods, and a cross-sectional analysis was conducted. Odds ratios were adjusted for other obesity risk factors including age, sex, physical activity, and total energy intake. Results indicate that a greater number of eating episodes each day was associated with a lower risk of obesity (odds ratio for four or more eating episodes vs. three or fewer = 0.55, 95% confidence interval: 0.33, 0.91). In contrast, skipping breakfast was associated with increased prevalence of obesity (odds ratio = 4.5, 95% confidence interval: 1.57, 12.90), as was greater frequency of eating breakfast or dinner away from home. Further investigation of these associations in prospective studies is warranted.     

Binge eating disorder,retention, and dropout in an adult obesity program

Objective: The purpose of this study was to identify factors associated with dropout in a weight reduction program among obese, nonpurging binge and nonbinge eaters. Method: We categorized 156 obese, nonpurging women previously randomized to a behavior modification-based (BM) or a food addiction theory-based (FD) weight reduction intervention by binge status using the DSM-IV criteria for binge eating disorder (BED). Subjects were monitored prospectively for dropout during the 6-month intervention period. Results: Results of a Cox proportional hazards survival analysis indicated binge status had a statistically significant (p = .04) protective effect against dropout. Binge eaters were half as likely to dropout versus nonbinge eaters. Discussion: We conclude that (1) the DSM-IV criteria for BED is a useful method of classifying obese individuals in weight loss interventions and (2) the identification of subgroups among obese subjects is an important step in understanding retention in weight loss programs. Future research can confirm this finding. © 1995 by John Wiley & Sons, Inc.     

Feasibility and acceptability of screening for eating disorders in primary care

BACKGROUND: Earlier diagnosis of disordered eating is linked to improved prognosis, but detection in primary care is poor. OBJECTIVES: To assess the feasibility of screening for disordered eating within primary care, in terms of the proportion of patients accepting screening, yield of cases, action taken by staff and staff views on screening. METHODS: Data were collected in open GP surgeries, midwife (MW) antenatal clinics and health visitor (HV) child health surveillance clinics in two GP practices, using face-to-face surveys and semi-structured interviews. Female patients aged 16-35 were asked to complete the SCOFF questionnaire, which was scored by researchers and taken by the patient into their consultation. If the result indicated possible disturbed eating, the health professional (HP) running the surgery/clinic was asked to complete a questionnaire and interview. One hundred and eleven women were screened and 11 HPs (GPs, MWs, HVs) were interviewed. RESULTS: Forty-six percent of patients agreed to be screened. Of these, 16% produced a positive result. The staff survey suggested that HPs found screening acceptable. However, concerns arose in the interviews, principally over what action to take in response to positive results. Positive results were rarely recorded in medical notes, and treatment was rarely offered. CONCLUSION: In order for a screening programme for eating disorders to be implemented in primary care, HP concerns about options for dealing with positive results would need to be addressed. Feasibility of screening would be enhanced by production of a protocol to be followed in the case of positive results.     

Laboratory eating behavior in obesity

The eating behavior of 49 obese and 47 normal weight controls of both sexes was compared in laboratory. A universal eating monitor according to the Kissileff-instrument was used to obtain cumulative intake curves with chocolate pudding as laboratory food. Compared to controls the obese had a significantly higher initial eating rate (p<.002), larger spoonfuls (p<.005), and a greater total intake (p<.03) for the laboratory food. For initial eating rate a significant sex x weight interaction was found (p<.04). Higher values for males emerged only for overweight, but not for normal weight subjects. On the one hand, these data suggest an eating behavior of obese, which will promote a high energy intake in the natural environment. On the other hand, the observed differences can also be interpreted as a consequence of cognitive factors, impacting the eating behavior of obese under specific conditions.     

Recognition and therapy of eating disorders in young women in primary care

Objective To evaluate the prevalence of eating disorders (ED) in a general population sample of young German women, compare those to primary care diagnoses, and investigate their medical treatments.Methods In a prospective epidemiological study, a representative sample of young women (n=1555, between 18 and 25 years of age) was questioned twice during a structured psychological interview (F-DIPS) for mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). At the same time, personal health insurance data were recorded and primary care physicians diagnoses and payments for services rendered were analyzed.Results The lifetime prevalence of eating disorders was 3.3% (2.3% anorexia nervosa, 1.1% bulimia nervosa). The primary care physicians diagnosed eating disorders in only about 20% of the women concerned. Eating disorders were often overlooked, although physicians detected physical and mental complaints (e.g., menstrual cycle disorders, abnormal weight loss, flatulence, depression, anxiety disorders), which are closely related to eating disorders. If the primary care physicians had diagnosed eating disorders, they mostly recommended psychotherapeutic treatment as the only measure, or in combination with pharmacological therapy.Conclusion The study indicates that primary care physicians need better training, particularly in diagnostic procedures for eating disorders. Screening methods and systematic assessment might be helpful in improving the detection of eating disorders in primary care     

Association between breakfast composition and abdominal obesity in the Swiss adult population eating breakfast regularly

Background

Evidence from experimental and observational studies is limited regarding the most favorable breakfast composition to prevent abdominal fat accumulation. We explored the association between breakfast composition (a posteriori derived dietary patterns) and abdominal obesity among regular breakfast eaters from a Swiss population-based sample.

Methods

The cross-sectional survey assessed diet using two 24-h dietary recalls in a nationally representative sample of adults aged 18 to 75?years. We derived dietary patterns using principal component analysis based on the intake of 22 breakfast-specific food groups. All regular breakfast eaters were predicted an individual score for each identified pattern, and then classified into tertiles (T1, T2, T3). We defined abdominal obesity as waist-to-hip ratio (WHR) ≥ 0.9 in men and?≥?0.85 in women. Logistic models were adjusted for sociodemographic characteristics, relevant nutrition- and health-related behaviors, and diet quality during the rest of the day.

Results

Of the 2019 included survey participants, 1351 (67%) were regular breakfast eaters. Among them, we identified three breakfast types: 1) ‘traditional’???white bread, butter, sweet spread, 2) ‘prudent’???fruit, unprocessed and unsweetened cereal flakes, nuts/seeds, yogurt, and 3) ‘western’ – processed breakfast cereals, and milk. The ‘prudent’ breakfast was negatively associated with abdominal obesity. After full adjustment, including diet quality during the rest of the day, the association was weaker (T3 vs. T1: OR 0.72, 95% CI: 0.47 to 1.08). People taking a ‘prudent’ breakfast (in T3) had 1.2% lower WHR compared to people taking a breakfast distant from ‘prudent’ (in T1) (P?=?0.02, fully adjusted model with continuous log-WHR). We found no association between ‘traditional’ or ‘western’ breakfasts and WHR (OR 1.00, 95% CI: 0.67 to 1.50 and OR 1.16, 95% CI: 0.79 to 1.71, respectively). Findings were in the same directions for the three breakfast types when defining obesity with waist circumference, waist-to-height ratio, or body mass index (≥ 30?kg/m², for ‘prudent’ breakfast: OR 0.51, 95% CI: 0.31 to 0.85).

Conclusions

Regular breakfast consumers had less abdominal obesity if their breakfast was composed of fruit, natural cereal flakes, nuts/seeds and yogurt. This association was partly explained by their healthier diet during the rest of the day.

Trial registration

ISRCTN16778734.

     

An eating disorder curriculum for primary care providers.

OBJECTIVE: Primary care providers frequently lack adequate training in treating eating disorders. This study examined the effectiveness of an eating disorder curriculum designed to address the lack of knowledge among primary care providers. METHOD: Medical social workers completed four intensive training sessions, each lasting 75 min. Participants completed questionnaires assessing eating disorder knowledge, perceived ability to treat eating disorders, and practice behaviors, before and after training as well as at 6-month follow-up. RESULTS: The eating disorder curriculum resulted in a significant increase in eating disorder knowledge and a moderate improvement in practice behaviors such as screening new patients for an eating disorder. Training did not significantly change providers' perceived ability to intervene. DISCUSSION: The results of this pilot study suggest that brief intensive training can increase providers' knowledge and change their routine clinical practices, resulting in increased rates of detection and intervention in the primary care setting.     

The impact of obesity on primary care visits

OBJECTIVE: To investigate the influence of patient obesity on primary care physician practice style. RESEARCH METHODS AND PROCEDURES: This was a randomized, prospective study of 509 patients assigned for care by 105 primary care resident physicians. Patient data collected included sociodemographic information, self-reported health status (Medical Outcomes Study Short Form-36), evaluation for depression (Beck Depression Index), and satisfaction. Height and weight were measured to calculate the BMI. Videotapes of the visits were analyzed using the Davis Observation Code (DOC). RESULTS: Regression equations were estimated relating obesity to visit length, each of the 20 individual DOC codes, and the six DOC Physician Practice Behavior Clusters, controlling for patient health status and sociodemographics. Obesity was not significantly associated with the length of the visit, but influenced what happened during the visit. Physicians spent less time educating obese patients about their health (p = 0.0062) and more time discussing exercise (p = 0.0075). Obesity was not related to discussions regarding nutrition. Physicians spent a greater portion of the visit on technical tasks when the patient was obese (p = 0.0528). Mean pre-visit general satisfaction for obese patients was significantly lower than for non-obese patients (p = 0.0069); however, there was no difference in post-visit patient satisfaction. DISCUSSION: Patient obesity impacts the medical visit. Further research can promote a greater understanding of the relationships between obese patients and their physicians.     

Overweight and obesity and the utilization of primary care physicians

We investigate whether overweight or obese individuals utilize more medical care than normal weight individuals by estimating a finite mixture model which splits the population into frequent and non-frequent users of primary care physician (GP) services. Based on a survey sample aged 25-60 years from the National Health Interview (NHI) 2000 merged to Danish register data, we compare differences in the impact of being overweight and obese relative to being normal weight on the utilization of GP services. Estimated bodyweight effects vary across latent classes and show that being obese or overweight does not increase the utilization of GP services among infrequent users but does so among frequent users. Obese (and to a lesser extent, overweight) infrequent users are observed 5 years later to substantially increase their health-care usage as measured by doctor visits, hospitalizations, and number of bed days.     

Biology of eating behavior in obesity

Understanding normal and dysfunctional energy regulation and body weight regulation requires neural evaluation of the signals involved in the control of food intake within a meal, as well as signals related to the availability of stored fuels. Work from our laboratory has focused on peripheral and central nervous system studies of behavior and physiology designed to improve our understanding of the role of gut-brain communication in the control of food intake and energy homeostasis. Gastrointestinal administration of nutrients reduces subsequent meal size, suggesting a potent role for peripheral nutrient sensing in the negative feedback control of ingestion. Vagal afferent nerves supply gastrointestinal sites stimulated during food intake, and these nerves are responsive to mechanical and nutrient chemical properties of ingested food. In addition, the presence of nutrients in these gastrointestinal sites stimulates the release of peptides that affect energy intake. These gut peptides also modulate the activity of peripheral gastrointestinal sensory nerves in ways that may contribute to their effects on food intake. In the central nervous system, adiposity hormones and their downstream mediators have been shown to work at both hindbrain and forebrain sites to affect food intake and metabolism. Importantly, recent data has shown that adiposity hormones acting in the brain increase the behavioral and neural potency of feeding inhibitory gastrointestinal stimuli. These data support the suggestion that insensitivity to adiposity hormones in obesity may be characterized by alterations in their ability to modulate the neural processing of food signals important in determining how much food is consumed during a meal.