Group dialectical behavior therapy adapted for obese emotional eaters; a pilot study

Abstract

Dialectical Behavior Therapy (DBT) has been shown to effectively target binge eating disorder (BED). This study pilots the effectiveness of group DBT for obese "emotional eaters" to reduce eating psychopathology and achieve weight maintenance. Thirty-five obese male and female emotional eaters receiving 20 group psychotherapy sessions of DBT adapted for emotional eating were assessed at end-of-treatment and 6 month follow-up for reductions in eating psychopathology and weight maintenance. DBT resulted in significant reductions in emotional eating and other markers of eating psychopathology at the end-of-treatment that were maintained at follow-up. The drop-out rate was very low, with only 1 participant dropping from treatment. Thirty-three (94%) of the sample provided data at every assessment point. Of these, 80% achieved either weight reduction or weight maintenance after treatment and throughout the follow-up period. The effect size for weight reduction was small. This pilot study demonstrates group DBT targeting emotional eating in the obese to be a highly acceptable and effective intervention for reducing eating related psychopathology at both at end-of-treatment and during follow-up. The ability of DBT to limit the upward trajectory of weight gain in obese patients with high degrees of emotional eating suggests that DBT may also help limit the increase or even prevent onset of obesity related morbidity in these patients.

Full text

1141
Nutr Hosp. 2012;27(4):1141-1147
ISSN 0212-1611 • CODEN NUHOEQ
S.V.R. 318
Original
Group dialectical behavior therapy adapted for obese emotional eaters;
a pilot study
M. A. Roosen
1
, D. Safer
2
, S. Adler
2
, A. Cebolla
3
and T. van Strien
4,5
1
Outpatient clinic for eating disorders and obesity at the Mental Health Care Centre region Oost Brabant. The Netherlands.
2
Stanford University School of Medicine. Department of Psychiatry & Behavioral Sciences. Stanford. California. U.S.A.
3
Universitat Jaume I. Spain.
4
Behavioural Science Institute. Radboud University Nijmegen. The Netherlands.
5
Institute for
Gender Studies. Radboud University Nijmegen. The Netherlands.
TERAPIA DIALECTICO-COMPARTIMENTAL
GRUPAL ADAPTADA PARA EL TRATAMIENTO
“COMEDORES EMOCIONALES” OBESOS;
UN ESTUDIO PILOTO
Resumen
La Terapia Dialéctico-Conductual (TDC) es una tera-
pia eficaz para el tratamiento del trastorno por atracón
(TA). Este estudio piloto pretende estudiar la eficacia de
la TDC grupal para la reducción de psicopatología ali-
mentaria y el logro el mantenimiento del peso, para obe-
sos “comedores emocionales”. Treinta y cinco obesos
“comedores emocionales” de ambos sexos fueron evalua-
dos al final del tratamiento y en seguimiento a los seis
meses en psicopatología alimentaria y reducción de peso
tras recibir 20 sesiones de TDC en grupo adaptado para el
tratamiento del comer emocional. La TDC dio lugar a
reducciones significativas en comer emocional y otros
marcadores de la psicopatología alimentaria al terminar
el tratamiento, que se mantuvieron durante el segui-
miento. La tasa de abandonos fue muy baja, sólo una par-
ticipante abandonó el tratamiento. Treinta y tres (94%)
participantes de la muestra proporcionaron datos en
todos los puntos de la evaluación. De éstos, el 80% obtuvo
una reducción de peso o el mantenimiento del mismo al
finalizar el tratamiento y durante todo el período de
seguimiento. El tamaño del efecto de la reducción de peso
fue pequeño. Este estudio piloto demuestra que el uso de
la TDC para el comer emocional en personas obesas es
una intervención altamente aceptable y eficaz para la
reducción de estilos de ingesta relacionados con psicopa-
tología, tanto al final del tratamiento como en el segui-
miento. La capacidad de la TDC para limitar la trayecto-
ria ascendente de la ganancia de peso en pacientes obesos
con alto grado de comer emocional sugiere que la TCD
también puede ayudar a limitar el aumento o incluso pre-
venir la aparición de morbilidad relacionada con la obesi-
dad en estos pacientes.
(Nutr Hosp. 2012;27:1141-1147)
DOI:10.3305/nh.2012.27.4.5843
Palabras clave: Terapia dialéctica-compartimental. Comer
emocional. Mantenimiento de peso. Psicopatología.
Abstract
Dialectical Behavior Therapy (DBT) has been shown to
effectively target binge eating disorder (BED). This study
pilots the effectiveness of group DBT for obese “emotional
eaters” to reduce eating psychopathology and achieve
weight maintenance. Thirty-five obese male and female
emotional eaters receiving 20 group psychotherapy
sessions of DBT adapted for emotional eating were
assessed at end-of-treatment and 6 month follow-up for
reductions in eating psychopathology and weight mainte-
nance. DBT resulted in significant reductions in
emotional eating and other markers of eating psychopat-
hology at the end-of-treatment that were maintained at
follow-up. The drop-out rate was very low, with only 1
participant dropping from treatment. Thirty-three
(94%) of the sample provided data at every assessment
point. Of these, 80% achieved either weight reduction or
weight maintenance after treatment and throughout the
follow-up period. The effect size for weight reduction was
small. This pilot study demonstrates group DBT targe-
ting emotional eating in the obese to be a highly accep-
table and effective intervention for reducing eating
related psychopathology at both at end-of-treatment and
during follow-up. The ability of DBT to limit the upward
trajectory of weight gain in obese patients with high
degrees of emotional eating suggests that DBT may also
help limit the increase or even prevent onset of obesity
related morbidity in these patients.
(Nutr Hosp. 2012;27:1141-1147)
DOI:10.3305/nh.2012.27.4.5843
Key words: Dialectical behaviour therapy. Emotional
eating. Weight maintenance. Psychopatology.
Correspondence: Tatjana van Strien.
Behavioural Science Institute. Radboud University Nijmegen.
P.O.Box 9104, 6500 HE Nijmegen. The Netherlands.
E-mail: T.vanstrien@psych.ru.nl
Recibido: 7-III-2012.
Aceptado: 13-III-2012.
23. GROUP DIALECTICAL:01. Interacción 04/06/12 12:05 Página 1141

Introduction
Obesity, an increasingly prevalent disorder, is asso-
ciated with severe and often life-threatening medical
co-morbidities.
1
Reduction of body weight can have a
substantial positive impact, such as reversing the
development of diabetes.
2
However, obesity is well-
known as being difficult to treat; calorie restricting
diets, even when combined with behavioural tech-
niques and exercise, seldom result in lasting weight
loss.
3,4,5
A meta-analysis on the long-term effectiveness
of calorie restricting diets showed that between one
third and two thirds of the dieters regain more weight
than was initially lost on their diets
4
. In view of this
disheartening evidence, the World Health Organiza-
tion (WHO
6
) and others suggest clinicians advise their
patients to aim for weight constancy as a means of
preventing further development of obesity-related
morbidity.
7,8
It is therefore important to investigate how weight
constancy could be better achieved for people who fail
to maintain weight loss. One factor may be that most
current lifestyle or behavioral interventions, which
tend to highly emphasize control of food stimuli
within the obesogenic environment, may not be as
effective for individuals whose overeating is predomi-
nantly triggered by negative emotions (emotional
eating) rather than tempting food cues. Evidence is
accumulating that the pathology associated with
excessive external and emotional eating is essentially
different.
9,10,11
Very high levels of emotional eating
have been demonstrated in at least 40% of obese
community samples
12
and are associated with poor
interoceptive awareness, high alexithymia, depression
and problems with affect regulation.
9,10,13,14
Research
also suggests that individuals with high degrees of
emotional eating are especially poor at achieving
weight loss maintenance eating.
15
Originally, Dialectical Behavior Therapy (DBT) was
developed for borderline personality disorder,
16,17
and
was successfully modified to target binge eating
disorder (BED).
18,19,20,21
According to this affect regula-
tion model, binge eating is a behavioral attempt to influ-
ence, change, or control painful emotional states
22,23,24
Binge eating, particularly in obese individuals, is
highly associated with emotional eating.
25,26
This pilot
treatment included obese individuals who showed high
levels of emotional eating but did not meet criteria for
BED. The aim of the present study was to pilot a DBT
intervention focusing on“emotional eating” rather than
binge eating for obese individuals with high emotional
eating scores.
In keeping with the WHO recommendations
6
, this
study aimed to achieve weight maintenance, defined as
a weight change of < 3% of baseline body weight.
27
It
was hypothesized that DBT would successfully reduce
eating psychopathology and that over time improve-
ment in eating psychopathology would be associated
with weight stabilization.
Method
Participants
As is standard practice in the Netherlands, all
participants were directly referred from their general
practitioner to the eating disorders outpatient clinic
of the Mental Health Care Centre region Oost
Brabant in the Netherlands. Inclusion criteria were a
body mass index (BMI) > = 30 and < 40 kg/m
2
, age >
=18 and < = 65 years, and a score > = 2.38 on the
emotional eating subscale of The Dutch Eating
Behaviour Questionnaire (DEBQ),
28
indicating high
levels of emotional eating. Exclusion criteria were
meeting full clinical criteria based on the Diagnostic
and Statistical Manual of Mental Disorders (DSM-
IV) (APA
29
) for binge eating disorder (BED). Sixty-
seven applicants were screened. Of these, 32 (47%)
were excluded for BED. The final pilot group
consisted of 35 patients.
The Medical Ethical Committee (METiGG, Kamer
Zuid) approved the design of the study, and all partici-
pants signed informed consent.
Procedure
Participants completed questionnaires and had their
body weights measured at the Centre at pre-treatment,
post treatment and at the 6 month follow-up. Complete
data are available at all 3 time points for all but 2 of the
35 participants (n = 33; 94%).
Intervention
A therapist manual for treating binge eating with
Dialectical Behaviour Therapy (DBT) was obtained
from Stanford University (USA) and was translated
into Dutch. The published treatment manual in
English is now available
20
. The principal adaptation
from the BED version was the substitution of
“emotional eating” as a treatment target instead of
binge eating. The highly structured treatment
included an initial brief pre-treatment interview
followed by 20 weekly group sessions of 2 hour
group therapy. Groups were led by two trained co-
therapists and included a maximum of 9 patients per
group.
The pre-treatment interview oriented participants to
the goals of treatment, which involved reducing eating
pathology by teaching emotion regulation skills.
During this session, emphasis was placed on the impor-
tance of maintaining body weight (versus a focus on
weight reduction). Also highlighted was the impor-
tance of developing and maintaining a healthy eating
pattern (e.g., three meals a day with healthy snacks in
between) and obtaining sufficient physical exercise.
Because the specifics of developing a healthy pattern
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Nutr Hosp. 2012;27(4):1141-1147
23. GROUP DIALECTICAL:01. Interacción 04/06/12 12:05 Página 1142

of eating are not given special attention in DBT for
eating disorders, participants were given a brochure of
the National Nutrition Centre (available upon request
to the authors) to use as a reference.
Briefly, the focus of the twenty DBT group sessions
was to teach adaptive emotion regulation skills through
the use of three modules (Mindfulness, Emotion Regu-
lation, and Distress Tolerance), with two final sessions
devoted to review and relapse prevention. Mindfulness
skills include the ability to observe and describe
moment-to-moment emotional experiences, thoughts,
and action urges and respond non-judgmentally.
Emotion regulation skills encourage understanding of
how emotions function, decreasing vulnerability to
negative emotions, increasing positive emotions, and
changing specific emotional states (e.g., fear and
anxiety) by acting opposite to one’s current emotion.
Distress-tolerance skills teach adaptive and effec-
tive means for tolerating life’s unavoidable stresses
and pain without turning to emotional eating,
thereby facilitating acceptance of the current
moment’s realities.
Measures
The Dutch Eating Behaviour Questionnaire (DEBQ)
28
was used to measure Emotional, External and Restrained
eating. Response categories range from 1 (“never”) to
5 (“very often”). The scales display good internal
consistency and factorial validity
29
in addition to
adequate predictive validity
30,31,32
for food consumption.
The Revised Eating Disorder Inventory (EDI-II)
33
was
used to measure eating psychopathology. The EDI-II is
a self-report measure of attitudes and behaviours
concerning eating, weight and shape, and psycholog-
ical traits clinically relevant to eating disorders. For the
present study, 5 subscales were used: body dissatisfac-
tion, drive for thinness, bulimia (i.e., the tendency to
binge and purge), poor interoceptive awareness (i.e.,
difficulties adequately identifying emotions and sensa-
tions of hunger or satiety )and impulsivity (i.e., tenden-
cies toward substance abuse, recklessness, hostility,
self-destructiveness). Possible responses ranged from
1 ‘never’ to 6 ‘always’. In contrast with the EDI-
manual
33
, in which a transformation of responses into a
4-point scale is advocated, the present study utilised
untransformed responses, as scale transformation was
found to damage the validity of the EDI among non-
clinical populations
34,35
. The depression subscale of the
validated version of the Hopkins Symptom Checklist-
90 (SCL-90)
36,37
was used as a measure of depressive
symptoms. Body weight was assessed on a balance
beam scale by a trained research assistant, with the
participant being in lightweight clothing and having
shoes removed. Height was measured with a
stadiometer. Body Mass Index (BMI) was calculated as
weight (in kilograms) divided by the square of height
(in meters).
Statistical analysis
To study the effect of the DBT intervention, a General
Linear Model (GLM) with a within subject design (Time:
pre-treatment versus post-treatment) was conducted.
Likewise, to study whether the effects of the treatment
were maintained, a GLM with a within subject design
(Time: post-treatment versus follow-up) was conducted.
Cohen’s d was used to assess the size of the treatment
effect (d = 0.20 stands for a small; d = 0.50 for a medium
and d = 80 for a large effect). Partial eta squared was also
reported (< 0.10 = small, > 0.10 and < 0.20 = median and
> 0.20 = large effect). Primary analyses were run using an
intent to treat (n = 35) sample.
Complete data, including objectively measured body
weights, were available for 33 (94%) of the sample. Of
the two with missing data, a total of 3 assessments were
missing (1 post-treatment assessment and 2 follow-up
assessments). Last observation carried forward was used
for the 2 participants with missing data (i.e., the pre-treat-
ment assessment was carried forward for the participant
with two missing assessments and the post-treatment
assessment was carried forward for the participant
missing the follow-up assessment).
Results
Pre-treatment characteristics
The DBT group consisted of 35 patients (30 females
(86%) and 5 males (4%)) with a mean age of 39.20 (SD =
11.02) years. The mean BMI was 35.42 kg/m
2
(SD =
2.62). The average DEBQ Emotional Eating Score was
3.85 (SD = 0.66). The other DEBQ subscales were:
External Eating 3.58 (SD = 0.58), and Restrained
Eating 3.02 (SD = 0.59), The 5 EDI-II subscales were
reported as: Body Dissatisfaction 47.10 (SD = 7.44),
Drive for Thinness 29.74 (SD = 5.94), Bulimia 23.94
(SD = 7.24), Poor Interoceptive Awareness 32.99 (SD
= 7.24), and Impulsivity 25.89 (SD = 5.69). The
average depression subscale score from the SCL-90
was 2.04 (SD = 0.77) (table I).
Drop-outs from treatment and/or assessment
One patient dropped out of treatment (3%), stating
that learning the mindfulness skills was sufficient for
her. One patient (3%) did not provide a follow-up
assessment. Complete data for all 3 assessment points
were available for n = 33 (94%) of the sample.
Eating style, eating psychopathology
and depressive symptoms
DBT resulted in significant post-treatment reduc-
tions in the DEBQ Emotional Eating scale (3.85 ± 0.66
Treatment for obese emotional eaters 1143Nutr Hosp. 2012;27(4):1141-1147
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M. A. Roosen et al.
Nutr Hosp. 2012;27(4):1141-1147
Table I
Results of the intention-to treat sample (n = 35) before and after treatment and at the 6 month follow-up
Pre-treatment Post-treatment Follow-up Cohens Treatment effectiveness Maintenance
(n = 35) (n = 35) (n = 35) d
Measure M SD M SD M SD
Pre- Pre-
F (1,35)
Partial
F (1,35)
Partial
Post Follow-up éta squared éta squared
BMI 35.42 2.62 34.82 3.33 34.56 3.80 -0.20 0.26 6.26* 0.16 0.73 0.02
Emotional eating 3.85 0.66 2.75 0.49 2.81 0.62 -1.89 1.63 82.96*** 0.71 0.35 0.01
External eating 3.58 0.58 2.66 0.50 2.76 0.54 -1.70 1.46 64.55*** 0.65 2.32 0.06
Restrained eating 3.02 0.59 3.26 0.57 3.12 0.50 -0.41 -0.18 4.41* 0.12 4.43* 0.12
Body dissatisfaction 47.10 7.44 43.30 8.84 44.03 8.94 -0.47 0.37 9.59** 0.22 0.78 0.02
Drive for thinness 29.74 5.94 24.28 6.84 24.23 6.78 -0.85 0.86 28.62*** 0.46 0.004 0.00
Bulimia 23.94 6.05 14.73 4.43 15.94 4.66 -1.73 1.48 64.36*** 0.65 4.570* 0.12
Poor interceptive awareness 32.99 7.24 26.23 6.24 25.46 5.89 -1.00 1.14 19.66*** 0.37 0.99 0.03
Impulsivity 25.89 5.69 23.92 5.34 23.47 4.72 -0.36 0.46 3.66 0.097 0.31 0.01
Depression 2.04 0.77 1.68 0.65 1.61 0.49 -0.51 0.67 8.74** 0.205 0.99 0.03
*p < 0.05; **p < 0.01; ***p < 0.001
23. GROUP DIALECTICAL:01. Interacción 04/06/12 12:05 Página 1144

vs. 2.75 ± 0.49, F(1, 34) = 82.96 , p < 0.001 ) and in the
External Eating (3.58 ± 0.58 vs. 2.66 ± 0.50, F(1, 34) =
64.55, p < 0.001). DEBQ Restraint significantly
increased (3.02 ± 0.59 vs. 3.26 ± 0.57, F(1, 34) = 4.41,
p = 0.043). Four of the 5 EDI-II subscales of eating
psychopathology as well as depressive symptoms
showed significant decreases: Body Dissatisfaction
(47.10 ± 7.44 vs. 43.30 ± 8.84, F(1, 34) = 9.59, p =
0.004), Drive for Thinness (29.74 ± 5.94 vs. 24.28 ±
6.84, F(1, 34) = 28.62, p < 0.001), Bulimia (23.94 ±
6.05 vs. 14.73 ± 4.43, F(1, 34) = 64.36, p < 0.001), Poor
Interoceptive Awareness (32.99 ± 7.24 vs. 26.23 ±
6.24, F(1, 34) = 19.66 , p < 0.001) and Depressive
symptoms (2.04 ± 0.77 vs. 1.68 ± 0.65, F(1, 34) = 8.74,
p = 0.006). There was no significant change in Impul-
sivity (25.89 ± 5.69 vs. 23.92 ± 5.34, F(1, 34) = 3.66, p
= 0.064).
Results from the post-treatment vs follow-up GLM
revealed that the effects of the treatment were main-
tained through the follow-up period except for the
decrease in the DEBQ Restraint scale (p = 0.043) and
the increase in the EDI-II Bulimia subscale (p = 0.040)
(table I).
Body weight
Participants lost 0.60 BMI-points (1.69%) in the
short-term and 0.86 BMI points (2.42%) in the longer
term. The treatment effectiveness analysis showed a
significant time effect meaning that DBT resulted in a
significant weight loss though its effect size was small.
The maintenance analysis showed no significant time
effect, meaning that post-treatment results were main-
tained (table I).
Additional analyses were used to further categorize
the participants. Following Stevens and colleagues,
27
treatment completers (n = 33) were categorized as
those with a weight loss of > 3%, weight maintenance
of ± 3%, or weight gain of > 3% of baseline weight.
They were further categorised as non-gainers (weight
loss or weight maintenance) or gainers (weight gain).
At post-treatment, the percentages with weight loss,
weight maintenance, and weight gain were, respec-
tively, 31.4 %. 65.7% and 2.9%, At the 6-month follow
up, these percentages were, respectively, 40%, 40%,
and 20%. Hence, at follow-up, 80% of were non-
gainers (i.e., showed weight loss or weight mainte-
nance), whereas 20% were weight gainers, with a mean
gain of 1.90 BMI points (SD = 1.61).
Discussion
To our knowledge, DBT has not yet been investi-
gated specifically for the treatment of emotional eating
in people with obesity. Given very high levels of
emotional eating have been demonstrated in at least
40% of obese community samples
12
and that those with
high emotional eating scores appear specifically poor
at achieving weight loss maintenance eating,
15,38
emotional eating may be an especially important and
under-explored target for participants in weight loss
and weight maintenance interventions.
The findings from the present pilot study suggest
that 20 sessions of DBT group therapy targeting
emotional eating among obese individuals was
successful in reducing emotional eating and other
markers of eating psychopathology and was associated
with constancy or even reduction of body weight at
post-treatment and at the 6 month follow-up. It was
expected that DBT-treatment would be successful in
reducing eating psychopathology both in the short and
longer term. While DBT was not expected to result in
weight maintenance or a mild weight loss in the treat-
ment intervention period, improvement in eating
psychopathology did impressively result in weight
stabilization in throughout the 6 month follow-up
period.
Mild weight loss or weight maintenance after DBT
has been observed before.
18,20
However, these findings
were found with patients with BED. The present find-
ings suggest that DBT may also result in weight main-
tenance or weight loss in a large percentage of obese
people without BED who experience high degrees of
emotional eating. Teaching adaptive emotion regula-
tion skills may be a desirable missing component for
this otherwise difficult to treat population of patients
with obesity.
The very low drop-out rate suggests DBT is highly
acceptable for most obese emotional eaters, which is of
importance given typical drop-out rates of obese
patients from treatment are much higher (e.g., 16-
20%).
39,40
One contributing factor may have been the
emphasis placed during the pre-treatment interview on
weight maintenance as a goal.
The finding that many patients increased their
dietary restraint during treatment in addition to weight
loss is consistent with other findings on decreased
overeating or eating binges after dieting.
43
Unlike the
Restraint Scale literature, which links dietary restric-
tion to overeating and eating disorders,
39
the DEBQ
Restrained Eating scale measures “watching exactly
what you eat” and/or moderation of food intake in
response to occasions of overeating (e.g., “When you
have eaten too much, do you eat less than usual the
following day?”).
28
Hence, individuals with higher
DEBQ Restraint scores may have been more successful
in avoiding weight gain because of their tendency to
compensate for occasional bouts of overconsumption
by subsequently eating less.
A possible explanation for the weight gain of 20% at
the 6 month follow-up may come from a recent study in
which Blomquist and colleagues
42
assessed the weight
trajectories in the year prior to commencing treatment
for BED. Weight gainers, in contrast to the weight non-
gainers, had been on a very steep weight gain trajec-
tory, showing an average weight gain of more than 10
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kg during the year before seeking treatment.
42
It is not
known whether the weight gainers in the present study
also were following a steep pre-treatment weight gain.
However, it would be of interest to assess the pre-treat-
ment weight trajectories of patients receiving treatment
in future studies. For patients with a steep pre-treat-
ment weight gain trajectory, a more feasible treatment
goal might be to aim at a less steep weight gain trajec-
tory rather than constancy of body weight, let alone
weight loss.
A limitation of this study is the absence of a control
group. A further limitation is the relatively small
sample size and, given the chronicity of emotional
eating and obesity, the rather brief follow-up period of
6 months. A strength of the study was that body height
and body weight were obtained through by objective
measurements in 94% of the participants. A further
strength is that only one person dropped out of the DBT
treatment.
In conclusion, DBT in this study was associated with
reductions in important aspects of eating psychopathology
in the short term and at the six month follow up—
which took place 1 year after initiation of the study.
These improvements were accompanied by weight
constancy or even a reduction of body weight for the
majority of the patients. The ability of DBT to limit the
customary weight increases of obese patients with high
degrees of emotional eating suggests DBT to be a
promising strategy to inhibit the further growth of
obesity-related morbidity in these difficult to treat
obese patients.
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