articles nature publishing group

behavior and psychology

Loss of Control Is Central to Psychological

Disturbance Associated With Binge
Eating Disorder
Susan L. Colles1, John B. Dixon1 and Paul E. O’Brien1

Objective: Binge eating disorder (BED) is positively associated with obesity and psychological distress, yet the
behavioral features of BED that drive these associations are largely unexplored. The primary aim of this study was to
investigate which core behavioral features of binge eating are most strongly related to psychological disturbance.
Methods and Procedures: A cross-sectional study involved 180 bariatric surgery candidates, 93 members of a
non-surgical weight loss support group, and 158 general community respondents (81 men/350 women, mean age
45.8 ± 13.3, mean BMI 34.8 ± 10.8, BMI range 17.7–66.7). Validated questionnaires assessed BED and binge eating,
symptoms of depression, appearance dissatisfaction (AD), quality of life (QoL) and eating-related behaviors. Features
of binge eating were confirmed by interview. BMI was determined by clinical assessment and self-report.
Results: The loss of control (LOC) over eating, that is, being unable to stop eating or control what or how much was
consumed was most closely related to psychological markers of distress common in BED. In particular, those who
experienced severe emotional disturbance due to feelings of LOC reported higher symptoms of depression
(P < 0.001), AD (P = 0.009), and poorer mental health–related QoL (P = 0.027).
Discussion: Persons who report subjective binge episodes or do not meet BED frequency criteria for objective
binge episodes may still be at elevated risk of psychological disturbance and benefit from clinical intervention.
Feelings of LOC could drive binge eaters to seek bariatric surgery in an attempt to gain control over body weight and
psychologically disturbing eating behavior.

Obesity (2008) 16, 608–614. doi:10.1038/oby.2007.99

Introduction causes of distress. Striegel-Moore et al. (12,13) considered binge

An “eating binge” is characterized by the uncontrolled con-
sumption of an objectively large amount of food (1). Binge
eating disorder (BED) is a recognized eating disorder where
bingeing occurs at an average frequency of 2 days per week
over the previous 6 months. A strong relationship with psycho-
logical markers of distress and self-condemnation character-
izes BED (1–3). Higher general psychopathology (4), elevated
symptoms of depression (4,5), and higher ratings of body
image distress and weight and shape concern (6–8) are com-
mon associates. Prevalence estimates are typically high among
bariatric surgery candidates, and the association with severe
emotional disturbance occurs beyond that produced by the
obese state (9). Quality of life (QoL) may also be reduced (10),
but not all reports agree (11).
The increased risk of obesity and psychological distress in
BED is established. What is not established is the association
between the specific diagnostic features of BED and markers of
psychological disturbance. The binge frequency, binge size, and
experience of loss of control (LOC) over eating are all potential
1
Centre for Obesity Research and Education (CORE), Monash University, The Alfred Hospital, Melbourne, Victoria, Australia. Correspondence: Susan L. Colles
(susan.colles@med.monash.edu.au)
Received 8 March 2007; accepted 16 July 2007; published online 24 January 2008. doi:10.1038/oby.2007.99
frequency but found few distinctions in measures of psychologi-
cal disturbance between obese subjects bingeing ≥1 to <2 vs. ≥2
binges per week. Niego et al. (14) compared persons with BED
differing in binge size (objectively large vs. subjectively large
volumes) but also reported similar levels of depression and
psychological disturbance. The relationship between the LOC
over eating and psychological distress has also received little
attention in those with BED. However, women with BED have
identified a binge episode by feelings of LOC and less so by
the amount of food consumed (15). Work comparing full and
partial syndrome bulimic nervosa suggests that the experience
of LOC is more strongly associated with psychological distress
than binge volume (16–18). A number of researchers have pro-
posed LOC to be the most important and consistent feature of
a binge (15,19,20).
Improved understanding of the link between BED and
psychological distress will inform intervention strategies
and patient management. This study investigated interre-
lationships between the central behavioral features of BED

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behavior and psychology

and three markers of psychological distress—symptoms of ­ istress related to overeating and/or feelings of LOC, as indi-
d
depression, appearance dissatisfaction (AD), and mental cated by a response of 4 or 5 to criterion C1 or C2 (Table 1). An
health–related QoL. Subjects included three community objective bulimic (binge) episode was defined as an LOC during
the consumption of an amount of food considered abnormally
groups varying in BMI and current weight control endeav- large for the circumstances by both the subject and the inter-
ors. Additional data were collected on usual dietary intake viewer (24).
and other aspects of eating behavior. The association between 2) “Subjective LOC”: persons experiencing feelings of LOC during
features of binge eating and BMI was also considered. We subjective bulimic (binge) episodes. A subjective bulimic episode
hypothesized that psychological distress related to BED and was defined as an LOC during the consumption of an amount of
food considered abnormally large for the circumstances by the
binge eating would be most closely associated with the LOC subject but not the interviewer (24). No minimum criterion for
related to eating. subjective binge frequency was set. This group did not include
persons reporting objective bulimic episodes.
Methods and Procedures 3) Non-binge eaters (NBEs): persons reporting no sense of LOC
Subjects associated with consumption of either subjectively or objectively
Participants were recruited between August 2004 and January 2006 large amounts of food.
in a cross-sectional design. Data were obtained from three separate
groups: (i) Members of the general community who were not trying It should be noted that 40 subjects reported an LOC related to eating
to lose weight. These participants responded to flyers placed on notice but did not meet any subgroup criteria. For example, some ­subjects
boards in two large metropolitan hospitals and a large Australian uni-
versity. (ii) Persons attending a weight loss support group (“Take Off Table 1  BED criteria and the distribution of central behavioral
Weight Naturally,” a company consisting of over 130 support groups features of BED within the “Full BED” and “Subjective LOC”
within Victoria). These participants responded to flyers posted at group
groups
meetings. And (iii) bariatric surgery candidates who were accepted into
the surgical program at The Centre for Bariatric Surgery, The Avenue Subjective
Hospital, Melbourne, Australia. One stipulation for program inclusion Full BEDa LOCb
BED
was a BMI ≥ 40 kg/m2, or BMI ≥ 35kg/m2 with significant comorbid criterion Description n = 38 n = 46
disease (21). These participants were invited to join the study at the
time of acceptance into the program. A1 Consume a truly large amount 100% 0%
Subjects were men or women aged between 18 and 70 years and were of food
excluded if they had undergone previous bariatric surgery. Six hundred A2 Loss of control (LOC)/unable to 100% 100%
and forty-eight survey packs were distributed. A total of 431 eligible sur- stop eating
veys were returned representing an overall response rate of 66.5%. The
B1 Eating more rapidly than usual 87% 57%
study was approved by the Monash University Standing Committee on
Ethics in Research involving Humans and conducted in accordance with B2 Eating until uncomfortably full 92% 74%
the Helsinki Declaration of 1975 as revised in 1983. All subjects were B3 Eating when not physically 82% 76%
informed regarding the nature of the questionnaires and consented to hungry
study involvement.
B4 Eating alone because 76% 52%
embarrassed
Anthropometry
Heights and weights reported by the surgery candidates were verified B5 Feeling disgusted/depressed/ 97% 85%
against recent clinic measurements. Demographic data from the com- guilty
munity respondents and support group were based on self-report. C1c How upset by perceived 4.0 (4–5) 3.5 (3–4)
Within these two groups, 87% stated they had weighed themselves overeating
within the previous month.
C2c How upset by LOC 5.0 (4–5) 4.0 (3–4)

Bed D Objective binges/week in last 3.6 ± 0.8 d

0
The Questionnaire on Eating and Weight Patterns—Revised (22,23) 6 months
was used to screen for binge eating behaviors. Subjects who reported Average episodes LOC/week 3.6 ± 0.8d 2.1 ± 1.2
any characteristics of a binge underwent a semistructured clinical in last 6 months
(70%) or phone interview (30%). This interview aimed to accurately
E Regular compensatory No No
determine (i) the amount consumed during self-reported binge epi- behaviors
sodes, (ii) the experience of LOC, (iii) the extent of associated distress,
and (iv) the frequency of binge eating. A single experienced clinician Commonest time of day Evening Afternoon
conducted all interviews according to Diagnostic and Statistical Manual episode began (7–10 pm) (4–7 pm)
of Mental Disorders, 4th Edition criteria (1). Subjects were provided How long since last meal or 2.6 ± 2.3 hd 2.2 ± 2.2 h
with fuller descriptions of difficult concepts such as the experience of snack
LOC, that is, feelings that they could not stop eating or control what or
Average length of eating 2.0 ± 2.0 hd 1.1 ± 0.7 h
how much they were eating. To assess the extent of the distress associ-
episode
ated with feelings of LOC over eating, subjects self-rated their emo-
tional disturbance between a score of 1 (no disturbance) to 5 (extreme BED, binge eating disorder; LOC, loss of control.
disturbance). The interviewer was not blinded to recruitment group.
a
Diagnosis required positive responses to criterion A1, A2, B (3 or more), C (a rat-
ing of 4 or 5 for either statement), D (≥2days/week), E (absence of compen-
Subjects were subsequently divided into three groups: satory behaviors). bDiagnosis required a positive response to criterion A2 and
the absence of objective bulimic episodes. cCategorical data, presented as
1) “Full BED”: persons reporting a frequency of ≥2 objective binge median  ±  interquartile range. For items C1 and C2; 1 = not at all, 2 = slightly,
episodes/week in association with significant psychological 3 = moderately, 4 = greatly, 5 = extremely. dData presented as mean ± s.d.

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behavior and psychology

reported less than two objective binge episodes/week. Others A P value of <0.05 was considered statistically significant. A P value of
reported objective or subjective bulimic episodes that were not >0.05 and <0.10 was ­considered a statistical trend.
accompanied by ­significant psychological distress. These 40 subjects
were excluded from the binge eating subgroups and were not con-
sidered NBEs but have been included in some subsequent analyses Results
where indicated in the text. Participant description
The three recruitment groups differed according to intent to
Other eating behavior lose weight: (i) community respondents not actively seek-
The Three-Factor Eating Questionnaire (25) collected information ing weight loss (BMI range 17.7–45.5 kg/m2), (ii) weight loss
on three dimensions of human eating behavior: (i) cognitive restraint support group members (BMI range 21.3–60.2 kg/m2), and
(the amount of intentional restriction of food intake; the intent
(iii) bariatric surgery candidates (BMI range 31.9–66.7 kg/m2).
to diet), (ii) disinhibition of eating (the inability to resist social,
emotional, or external eating cues), and (iii) subjective feelings of As anticipated, demographic, clinical, and psychological fea-
hunger. tures varied between groups (Table 2).
The Cancer Council Victoria Food Frequency Questionnaire (26,27) The distribution of binge eating subgroups within the origi-
was used to assess subject’s usual dietary intake. This optically scanna- nal recruitment groups is also shown in Table 2. Rates of “Full
ble, semiquantitative questionnaire contains 74 foods with 10 frequency
BED” were significantly higher among bariatric surgery candi-
options and four diagrams of different foods with seven options to define
average portion sizes of each. Validity of the Cancer Council Victoria dates compared to the two other recruitment groups. The dis-
Food Frequency Questionnaire relative to 7-day food records has proven tribution of those reporting a “Subjective LOC” did not differ.
acceptable (26). A binary logistic regression model which included “recruit-
ment origin,” gender, BMI, and age showed that membership
Psychological health and QoL
The Beck Depression Inventory (BDI) (28) assessed for the presence
of symptoms of depressive illness. A score of 0–9 was considered Table 2 Descriptive characteristics and comparison of the
“Normal”; 10–16 “Mild depression”; 17–29 “Moderate depression”;
three original recruitment groups*
and 30–63 “Severe depression” (29).
The Multidimensional Body Self-Relations Questionnaire (30) pro- Group 1 Group 2 Group 3
vided a measure of AD or body image distress. The difference between General Weight loss Bariatric
the appearance orientation subscale (how one values physical appear- community support surgery
ance in general) and the appearance evaluation subscales (how one respondents group candidates P value
rates their own physical appearance) was used to indicate the degree
of AD (31). n 158 (36%) 93 (22%) 180 (42%)
The Medical Outcomes Trust Short Form-36 (SF-36) was used to Men/ 34/124 8/85 39/141 0.018
assess health-related QoL (32,33). This survey measures eight health- women
related domains, which can be divided into physical and mental com-
Mean age 41.3 ± 13.5a 55.1 ± 12.4b 44.8 ± 11.2c <0.001
ponents to calculate the SF-36 physical component summary (PCS)
and mental component summary (MCS) scales (33). These two health Mean BMI 24.8 ± 5.1 a
32.7 ± 7.3 b
44.5 ± 6.8 c
<0.001
summary scales were adjusted to achieve a community mean value of 50 Non-binge 139 (88.0%) 74 (79.6%) 94 (52.2%) <0.001
with an s.d. of 10. The MCS score was considered a measure of mental eaters
health–related QoL and used as a ­measure of psychological distress.
Subjective 12 (7.6%) 10 (10.8%) 24 (13.3%) 0.089
LOC
Data analyses
Descriptive statistics were used to express the mean ± s.d. for all con- Full BED 3 (1.9%) 3 (3.2%) 32 (17.8%) <0.001
tinuous variables. Recruitment groups were considered in an ordinal BDI score †
4 (1–8) a
8 (5–12) b
15 (10–22) c
<0.001
manner at analysis: community = 1, support group = 2, and those
seeking surgery = 3. One-way ANOVA with Tukey post-hoc analyses AD score 0.14 ± 1.0a 1.0 ± 0.88b 1.8 ± 1.0c <0.001
were conducted to assess differences between the recruitment groups Importance 2.2 ± 0.78 a
2.5 ± 0.69 b
3.0 ± 0.87 c
<0.001
and between the three eating subgroups. χ2 analyses assessed for dif- of weight/
ferences between categorical values, and the Kruskal–Wallis test for shape
ordinal data. The “Full BED” and “Subjective LOC” subgroups were SF-36 MCS 49.7 ± 6.5a 49.8 ± 6.9a 46.3 ± 8.2b <0.001
compared to groups matched for gender, BMI, age, and “recruitment
origin” from NBE using independent t-tests, χ2 analysis, and the SF-36 PCS 53.2 ± 8.1 a
46.2 ± 10.9 b
36.9 ± 9.5 c
<0.001
Mann–Whitney test as appropriate. Restraint 8.5 ± 4.9a 12.6 ± 3.9b 8.2 ± 3.9a <0.001
Binary logistic regression explored to what extent recruitment origin
predicted membership of the binge eating subgroups. Factors entered Disinhibition 5.7 ± 3.6 a
9.0 ± 4.0 b
11.7 ± 3.3 c
<0.001
into the model included “recruitment origin,” gender, BMI, and age. Hunger 4.4 ± 3.2 a
6.0 ± 3.4 b
8.8 ± 3.6 c
<0.001
Within the total cohort, linear regression identified which BED diagnos-
Data presented as mean ± s.d. except where indicated. Binge eating groups
tic criteria were independently predictive of higher BDI and AD scores, presented as n (% of recruitment group).
a lower SF-36 MCS score, and increasing BMI. ­Factors entered stepwise AD, appearance dissatisfaction; BDI, Beck Depression Inventory; BED, binge
into the models included age, gender, “recruitment origin,” BMI, BDI eating disorder; LOC, loss of control; MCS, mental-health component score;
score and AD score as appropriate, and all BED diagnostic criteria as PCS, physical component score; SF-36, Short Form-36.
binary, ordinal, or continuous variables. Diagnostic criteria that did not *Forty subjects who did not meet criteria for any binge eating subgroup have
been included in this descriptive analysis. †Data log transformed for analysis and
contribute to the predictive model were systematically removed. All presented as median (interquartile range). Statistical analysis using ANOVA with
variables were normally distributed except BDI score, which required Tukey post-hoc analysis for continuous variables and χ2 for categorical variables.
log transformation. SPSS ­version 12.0.1 was used for statistical analysis. a,b,c
Means with different superscript letters differ significantly.

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of the surgical group explained 8% (P < 0.001) of the variance
in the “Full BED” subgroup.
Characteristics of the binge eating subgroups
The mean demographic, clinical, behavioral and psycho-
logical characteristics of the three binge eating subgroups
are listed in Table 3. The BMI range for “Full BED” was
22.2–62.1 kg/m2; 20.1–66.6 kg/m2 among “Subjective LOC,”
and 17.7–66.7 kg/m2 in NBE. Mean BMI differed between all
subgroups. BMI was highest in “Full BED”; the “Subjective
LOC” subgroup had a higher BMI than NBE. There was
no difference in gender distribution or age between the
three subgroups (columns 2, 4, and 6 in Table 3). AD and
the emotional upset associated with feelings of LOC were
highest among “Full BED” and differed between all groups.
Mental health–related QoL was also highest in “Full BED”
but did not differ between “Subjective LOC” and NBE. The
BDI score did not differ significantly between “Full BED” and
“Subjective LOC,” although the median score for “Full BED”
was in the range for “moderate” depressive symptoms, com-
pared to “mild” in “Subjective LOC.”
The “Full BED” and “Subjective LOC” subgroups were
carefully matched for recruitment origin, BMI, age, and
gender to comparison groups derived from NBE (Table 3).
Compared to matched controls “Full BED” reported sig-
nificantly higher symptoms of depression, greater AD, and
poorer mental health–related QoL. The median BDI depres-
sion score for the “Full BED” group was 20.0, representing
moderate depressive symptoms. The median score for the
control group was 12.0 (“mild depression”). “Full BED”
reported higher emotional distress related to feelings of
LOC. Dietary disinhibition, hunger, and usual dietary intake
were also increased.
Higher levels of psychological distress were also apparent
when the “Subjective LOC” group was compared to matched
controls (Table 3). The “Subjective LOC” group showed
higher symptoms of depression, more appearance-related dis-
tress, far greater emotional upset related to their perceived LOC
over eating, and higher dietary disinhibition and hunger.
In order to further explore the emotional upset related to
LOC, the “Subjective LOC” subgroup was divided into those
with “great” or “extreme” emotional disturbance due to feelings
of LOC (score 4 or 5 for criterion C2) and those reporting “no”
to “moderate” disturbance (score 1, 2, or 3 for criterion C2). The
group with more severe emotional disturbance related to feel-
ings of LOC (n = 23) scored higher on the BDI (median (inter-
quartile range); 15 (12–21) vs. 7 (6–12), P < 0.001) and AD
scales (1.9 ± 0.8 vs. 1.1 ± 1.2, P = 0.009). Mental health–related

Table 3 Comparison between the three eating subgroups; “Full BED,” “LOC,” and “Non-binge eaters” (columns 2, 4, and 6)
Full BED BED comparison group Subjective LOC LOC comparison group Non-binge eaters
n 38 38 46 46 307
Men/women 7/31 7/31 7/39 7/39 58/249
Mean age 42.7 ± 8.2 43.9 ± 8.5 46.8 ± 14.0 47.6 ± 13.8 46.1 ± 14.0
Mean BMI 42.8 ± 8.1a 42.6 ± 7.6 37.0 ± 10.4b 37.4 ± 10.3 32.5 ± 10.6c
Current weight 118.6 ± 24.3a 117.8 ± 20.5 101 ± 27.1b 103 ± 27.8 90.3 ± 29.7c
BDI score †
20 (15–31) a
12 (6–16)*** 12 (6–18) a
7.5 (3–15)* 7 (3–13)b
AD score 2.1 ± 0.84a 1.4 ± 1.2** 1.5 ± 1.1b 0.84 ± 1.3* 0.75 ± 1.2c
Emotional upset re: LOC‡ 5 (4–5)a 3 (2–4)*** 3.5 (3–4)b 2 (2–3)*** 2 (1–3)c
SF-36 PCS 37.5 ± 9.7 a
42.0 ± 11.1 42.9 ± 11.5 45.4 ± 10.5 47.0 ± 11.5b
SF-36 MCS 41.9 ± 7.4a 47.3 ± 6.1** 47.5 ± 8.1b 48.8 ± 7.4 49.3 ± 6.6b
Restraint 8.2 ± 3.9 9.0 ± 4.6 9.4 ± 4.8 8.9 ± 4.6 9.5 ± 4.8
Disinhibition 14.3 ± 1.5 a
9.6 ± 3.7*** 12.0 ± 3.0 b
8.1 ± 3.7*** 7.4 ± 4.1c
Hunger 11.2 ± 2.6 a
7.2 ± 3.8*** 8.4 ± 3.4 b
5.6 ± 4.1** 5.5 ± 3.6c
Energy (Kj) 11,693 ± 4,634a 7,710 ± 2,413*** 8,794 ± 3,013b 7,834 ± 3,463 7,672 ± 2,861c
CHO (gm) 282 ± 124a 187 ± 70.0*** 221 ± 73.4b 177 ± 67.5** 189 ± 72.5c
Fat (gm) 124 ± 56.3 a
73.5 ± 27.7*** 82.9 ± 34.6 b
77.3 ± 39.8 71.2 ± 31.7b
Protein (gm) 129 ± 47.3a 92.2 ± 28.3*** 100 ± 33.1b 99 ± 63.1 91.3 ± 38.7b
In general the “Full BED” scored highest on psychological and eating-related measures, and “Non-binge eaters” scored lowest. Comparison between “Full BED”
and “BED Comparison Group” again showed numerous psychological and behavioral differences, while comparison between “LOC” and “LOC Comparison Group”
showed no distinctions in markers of psychological distress. Data presented as mean ± s.d. except where indicated.
AD, appearance dissatisfaction; BDI, Beck Depression Inventory; BED, binge eating disorder; CHO, carbohydrate; LOC, loss of control; MCS, mental component
score; PCS, physical component score; SF-36, Short Form-36.
Comparison groups are “Non-binge eaters” matched for age, gender, BMI and recruitment origin. †Data log transformed for analysis and presented as median (inter-
quartile range (IQR)). ‡Ordinal data analyzed using Mann–Whitney test and presented as median (IQR) for paired groups and Kruskal–Wallis test for the three eating
subgroups. Statistical analysis between the three eating subgroups using AVOVA with Tukey post-hoc analysis; a,b,cMeans with different superscript letters differ signifi-
cantly at or >P < 0.05. Statistical analysis between eating subgroups and their matched controls using Independent t-tests for continuous variables, and  2for categorical
variables; *P < 0.05; **P < 0.01; ***P < 0.001 indicate significant differences between eating subgroups and matched controls.

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Table 4  Central behavioral features of binge eating predicting the regression equation, higher ratings of emotional distress
an elevated BDI or AD score, or low SF-36 MCS score in the related to feelings of LOC continued to predict a proportion
total cohort of 431 of variance in all three markers of psychological distress. The
BDI score AD score frequency of objective bulimic episodes continued to predict a
(n = 417) (n = 418) SF-36 MCS degree of variance in the SF-36 MCS.
Analysis with no controlling variables
  C2 Upset by feelings β = 0.32, β = 0.34, β = −0.29, BMI and binge eating
  of LOC P < 0.001 P < 0.001 P < 0.001 In a similar way, linear regression was used to explore the asso-
  C1 Upset by overeating β = 0.18, β = 0.26, NS ciation between the central behavioral features of binge eat-
P = 0.034 P = 0.001 ing and increasing BMI. Without controlling for demographic
  Frequency of objective NS NS β = −0.11, and psychological factors, higher ratings of emotional distress
  binges P = 0.023 related to feeling of LOC predicted most variance in BMI
  Total variance (r2) 22.7% 33.6% 12.1% (β = 0.23, P = 0.006). Higher ratings of emotional distress
Analysis controlling for gender, age, BMI, and recruitment origin
related to criterion C1, “eating more than you think is best
for you” (β = 0.17, P = 0.030), and criterion C3, “eating when
  Age β = 0.15, NS β = 0.15,
P < 0.001 P = 0.001
not physically hungry” (β = 0.15, P = 0.002), also predicted a
proportion of variance in BMI (total variance (r2) = 22.5%).
  Women gender β = −0.08, β = −0.18, β = 0.11,
  (F = 1, M = 2) P = 0.05 P < 0.001 P = 0.015 Owing to the significant co-linearity between BMI and mem-
bership of the bariatric surgical group, the subsequent linear
  Higher BMI β = 0.14, β = 0.13, NS
P = 0.049 P = 0.040 regression analysis controlled for gender, age, BDI score, and
AD score but not recruitment group. The central behavioral
  Recruitment origin β = 0.22, β = 0.33, β = −0.22,
P = 0.003 P < 0.001 P < 0.001 features of binge eating that contributed to the association with
BMI were higher ratings of emotional distress for criterion C2
  Sub total of variance (r2) 27.6% 41.0% 7.1%
(β = 0.19, P < 0.001) and criterion A1, “consumption of a truly
  C2 Upset by feelings β = 0.27, β = 0.29, β = −0.26,
large amount of food” (β = 0.16, P < 0.001).
  of LOC P < 0.001 P < 0.001 P < 0.001
  Frequency of objective NS NS β = −0.10,
Discussion
  binges P = 0.041
The primary aim of this study was to explore the relationship
  Additional variance 4.7% 5.5% 6.5%
between the central behavioral features of binge eating and
  Total variance (r2) 32.3% 46.5% 13.6% markers of psychological distress in BED. In support of our
Demographic and weight-related factors influenced all three measures of hypothesis, the feeling of LOC related to eating was the fac-
­psychological distress; however, scores were further predicted by higher ratings
of emotional distress related to the experience of being unable to “stop eating
tor most closely associated with psychological disturbance.
or control what or how much” was consumed, and to a lesser extent by the Persons who experienced “great” or “extreme” emotional dis-
­frequency of objective binges. Statistical analysis using linear regression. Bold turbance due to feelings of LOC reported significantly higher
face has been used to highlight the total and subtotal variance from the β and
P values. AD, appearance dissatisfaction; BDI, beck depression inventory; LOC,
symptoms of depression, greater dissatisfaction with appear-
loss of control; MCS, mental component score; NS, not significant; SF-36, Short ance, and poorer mental health–related QoL. The association
Form-36. between feelings of LOC and psychological disturbance was
highest among those meeting full BED diagnostic criteria
QoL assessed by the SF-36 MCS was significantly poorer (44.9 but was also elevated in persons reporting subjective bulimic
± 8.6 vs. 50.2 ± 6.8, P = 0.027). episodes.
Although binge frequency and binge size (objectively or
Psychological distress and binge eating subjectively large) were less strongly associated with psy-
Linear regression was used to explore which central behav- chological distress, after controlling for covariables, a higher
ioral features of binge eating (listed in Table 1) best predicted objective binge frequency was associated with poorer mental
an elevated BDI and AD score, and lower SF-36 MCS score health–related QoL. Poorer mental health–related QoL also
(Table 4). The total cohort of 431 was used in the analysis. This occurred among those with BED when compared to matched
included all subjects in the three binge eating subgroups, plus controls and was positively associated with emotional distur-
the 40 subjects with characteristics of binge eating who did not bance related to LOC. This supports the notion that frequent
meet any subgroup criteria. Without controlling for demo- objective bulimic episodes inherent in BED have the potential
graphic or psychological factors, higher ratings of emotional to negatively influence QoL, independent of the burden of
distress related to feelings of LOC (criterion C2) predicted obesity. This relationship may also occur in reverse, where per-
BDI, AD, and SF-36 MCS scores. Higher ratings of emotional sons with lower psychological well-being are more susceptible
distress for criterion C1—“eating more than you think is best to binge eating.
for you”—also contributed to BDI and AD scores. The SF-36 In research and clinical practice, the diagnostic features of
MCS was associated with the frequency of objective bulimic BED and the robust association with psychological distur-
episodes. With gender, age, BMI, and recruitment origin in bance are increasingly recognized. Yet, this is the first empirical

612 VOLUME 16 NUMBER 3 | MARCH 2008 | www.obesityjournal.org


evidence to support the greater potential significance of feel-
ings of LOC as an associate of psychological distress in BED.
Those who report subjective bulimic episodes or who do not
meet the frequency criteria for objective bulimic episodes may
still be at elevated risk of psychological disturbance.
As a single group, those experiencing a “Subjective LOC”
reported higher symptoms of depression, more dissatisfac-
tion with appearance, and greater emotional distress related
to feelings of LOC than NBE. In particular, those who were
emotionally disturbed by their experience were a subgroup
with distinctly higher psychological impairment. Persons
who engage in subjective bulimic episodes also appear vul-
nerable to weight gain and obesity. However, in this study,
the risk of significant psychological dysfunction and extreme
obesity was lower in those reporting a “Subjective LOC” than
persons meeting full BED criteria. Nevertheless, individu-
als who experience repeated feelings of LOC may still ben-
efit from clinical assessment and intervention. Furthermore,
the assessment of eating behavior and perceived control over
eating may benefit the clinical investigation of psychological
disturbance.
In this cross-sectional study, those with BED constituted
a distinctive group. They were more prevalent among obese
bariatric surgery candidates than members of a weight loss
support group and community controls not seeking weight
loss. Compared to matched controls binge eaters were
severely distressed about their recurrent LOC over eating, had
more symptoms of depression, higher AD, and poorer men-
tal health–related QoL. Their hunger drive was elevated, and
they reported a reduced ability to resist social, emotional, or
external eating cues. The BED group also reported a higher
usual energy and macronutrient intake. All these character-
istics would tend to generate weight gain and have a nega-
tive impact on efforts to control or lose weight. Those with
BED may, therefore, be more inclined to undergo bariatric
surgery in an attempt to gain control over their body weight
and control over adverse, psychologically disturbing eating
behaviors.
Debate persists over the suitability of bariatric surgery in per-
sons with BED (34–36). Based on the findings of this study, it
could be hypothesized that surgically augmented eating control
may contribute to the reliable improvement in psychological
state that occurs following surgery (37,38). However, feelings
of LOC can continue after surgical intervention (39–42), even
though the ability to eat objectively large amounts of food is
altered substantially. The relationship between perceived con-
trol over food intake and psychological status after surgery is
not known.
In this study, a number of robust associations emerged;
however, the cross-sectional design of the study does not
allow the determination of causality. Binge eating and feel-
ings of LOC were carefully assessed using the Questionnaire
on Eating and Weight Patterns as a screening tool, as previ-
ously suggested (43). The extent of disordered eating was then
determined in a semistructured clinical or phone interview.
Although the three original recruitment groups differed, this
obesity | VOLUME 16 NUMBER 3 | MARCH 2008
articles
1930739x, 2008, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1038/oby.2007.99 by Cochrane Philippines, Wiley Online Library on [11/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
behavior and psychology
diversity highlighted the setting in which binge eating is more
likely to occur, and the disparity between recruitment groups
was statistically controlled.
In conclusion, the feature of binge eating most strongly asso-
ciated with psychological disturbance was the emotional upset
driven by feelings of LOC over eating. Persons who engage
in subjective bulimic episodes were also at elevated risk for
psychological distress, particularly if their experience of per-
ceived LOC was accompanied by strong feelings of upset and
remorse. Clinicians and researchers should be aware of the
potential relationship between feelings of LOC related to eat-
ing and psychological disturbance. It is also possible that the
uncontrolled eating patterns inherent in BED, along with the
burden of obesity, may drive individuals with BED toward sur-
gical weight loss intervention.
Future studies could investigate variations in the experience
of LOC and the association with psychological impairment.
For example, whether long-term binge eaters who accept their
inevitable binges are less distressed than persons who attempt
failed restraint. Prospective research should also assess the
association between presurgical BED and feelings of LOC and
postsurgical control over eating behavior, weight outcomes,
and psychological state.
Acknowledgments
We thank the study participants for their time and involvement, and the
staff at the Centre for Obesity Research and Education (CORE) and the
Centre for Bariatric Surgery in Windsor, Victoria for their ongoing support
and assistance.
Disclosure
The authors declared no conflict of interest.
© 2008 The Obesity Society
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