PAPER Prevalence of Binge-Eating Disorder in Obese Children and Adolescents Seeking Weight-Loss Treatment

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International Journal of Obesity (2003) 27, 404–409 r 2003 Nature Publishing Group All rights reserved 0307-0565/03 $25.00 www.nature.com/ijo PAPER Prevalence of binge-eating disorder in obese children and adolescents seeking weight-loss treatment

V Decaluwe´* and C Braet

Department of Developmental and Personality Psychology, Ghent University, Ghent, Belgium

OBJECTIVE: The aim of the present study was to examine the extent to which a population of obese children and adolescents developed binge-eating disorder (BED). METHOD: A sample of 196 obese children and adolescents (aged 10–16 y) seeking weight-loss treatment at two treatment facilities (inpatient and outpatient treatment) was screened using the eating disorder examination. RESULTS: Only 1% of the subjects met the criteria for BED and 9% were found to have objective bulimic episodes (OBEs, overeating with loss of control), but did not endorse all of the other DSM-criteria that are required for a diagnosis of BED. OBEs were more common in girls than in boys. Episodic overeating was more common than binge eating. Compared to children without OBEs, children engaging in OBEs were more overweight and showed a greater eating-related psychopathology. The age of the first OBE was 10.88 y (s.d. ¼ 2.60). It appears that overweight precedes binge eating. DISCUSSION: A subgroup of girls and boys seeking treatment for obesity shows considerable eating difficulties. The results highlight the importance of considering binge-eating symptoms when devising treatment programmes for children and adolescents suffering from obesity. International Journal of Obesity (2003) 27, 404–409. doi:10.1038/sj.ijo.802233

Keywords: binge eating; childhood; adolescence; obesity

Introduction diagnostic interview, 30% of the girls were found to engage Binge-eating disorder (BED) is a provisional new diagnosis, in manifest binge eating. Britz et al9 detected binge-eating included in the 4th edition of the Diagnostic and Statistical episodes in 57% of the female and 35% of the male obese Manual of Mental Disorders.1 Although weight is not a adolescents studied. diagnostic criterion of BED, the majority of patients with However, there are some issues that limit the general- BED are overweight.2 Among obese adults seeking help for izability of the prevalence data available. First, in the three obesity, binge eating without purging appears to be a studies, the number of obese adolescents was relatively prevalent problem with an estimated prevalence rate of 20– small.7–9 Moreover, the study by Berkowitz et al8 did not 50%.2–6 include male adolescents. As previous studies suggest that To our knowledge, the prevalence of binge eating in obese BED occurs in a substantial minority of men seeking adolescents has only been dealt with in three studies. Severi treatment for obesity, it is important to include males as et al7 reported that in a sample of obese youngsters, 18% of well as females.2,5,10 Secondly, the data of the studies the boys and 27% of the girls had binge-eating problems. were retrieved from adolescents between the ages of 13 and The second study, by Berkowitz et al,8 examined binge eating 21 y.7–9 To our knowledge, no studies were published about in obese girls seeking treatment for severe obesity. Using a binge eating in obese children younger than 13. Finally, in each of the three studies, the information gathered about binge eating was based on different measures. The preva- *Correspondence: Dr V. Decaluwe´, Department of Developmental and lence rate and the definition of binge eating may differ Personality Psychology, Ghent University, H. Dunantlaan 2, 9000 Ghent, across the studies because of the variety of the assessment Belgium. instruments.11,12 E-mail: [email protected] Received 25 March 2002; revised 14 October 2002; The present study was designed to address some of the accepted 16 October 2002 limitations in current research on binge eating. The first aim Binge-eating in obese children and adolescents V. Decaluwe´ and C. Braet 405 of the study was to investigate the prevalence of BED in a The group had a mean adjusted BMI of 172.69% larger sample of boys and girls seeking help for obesity, using (s.d. ¼ 27.09) with a range of 120–253%. Informed consent the eating disorder examination (EDE).13 The EDE is an was obtained from both the children and their parents. The intensively studied interview having several advantages over group of children that did not participate consisted of 44 alternative methods of assessment. It is considered to be the girls and 37 boys. Their mean age was 12.56 (s.d. ¼ 1.80) and golden standard for the diagnosis of specific eating disorder their mean overweight was 166.75% (s.d. ¼ 25.40). No psychopathology.13–15 It is the only instrument that directly significant differences were found between the participants assesses the diagnostic criteria of all eating disorders and and the nonparticipants as regards age and degree of differentiates between the various forms of overeating. In overweight. A w-quadrate analysis (w2(1) ¼ 0.39, NS) showed order to use the EDE with children, the Child EDE (ChEDE) no significant sex differences between the two groups. The was designed, which is an adaptation of the original adult study was approved by the local research ethics committee. version of the EDE.16 The subjects were visited at their homes before they entered The second purpose of the study was to examine whether into treatment. the severity of binge eating is associated with the degree of overweight. Compared with obese adults who do not binge, those adults that do binge are more likely to weigh Measures more.17–19 However, the results have been mixed with other Body weight The BMI (weight/height2) was calculated for studies reporting no difference between obese individuals each child. In order to make BMI comparisons between obese with and without binge eating.8,20 We expected obese children of different ages, the adjusted BMI is used in this children with binge-eating problems that did not purge to study. The formula is [actual BMI/ percentile 50 of BMI for weigh more because of the excessive energy intake resulting age] Â 100. The 50th percentiles of the BMI for age and sex from the binge-eating episodes. are based on normative data.23 The third objective of the study was to assess the age of onset of binge eating in youngsters experiencing binge- eating episodes. There is evidence that eating disorders Binge-eating pathology The EDE13 is a standard investigator- already occur among 7-y-old children,16 but, to the best of based interview measuring the severity of the core psycho- our knowledge, no studies are published about the age of pathology of eating disorders and generating eating disorder onset of binge eating in children of this age. The evidence diagnoses. The Child EDE was designed for use in popula- available on the subject relies solely on retrospective reports tions of Dutch children following the recommendations in obese adults. An additional aim was to identify a made by Bryant-Waugh et al,16 Bryant-Waugh and Fairburn developmental factor, including the age of onset of over- (personal communication). The ChEDE was modified to weight, which may distinguish children and adolescents make certain questions more concrete for children and some with binge eating from those that do not binge. In obese of the items were reformulated to assess intent rather than adults, it has been demonstrated that binge eaters have an actual behaviour.16 Preliminary findings suggest that the earlier onset of obesity,21 and that overweight precedes binge ChEDE is a sensitive measurement to assess key psycho- eating.22 pathological features among children. The subscale scores are in line with the norms for adults.16 The ChEDE contains four subscales designed to provide a profile of individuals in terms of four major areas of eating Method disorder psychopathology: restraint, eating concern, shape Subjects concern and weight concern. In addition, the ChEDE A sample of 196 obese children and adolescents (78 boys and measures three forms of overeating: objective bulimic 118 girls) between the ages of 10 and 16 participated in the episodes (OBEs), subjective bulimic episodes and objective study (M ¼ 12.73 y, s.d. ¼ 1.75). All subjects were seeking help overeating episodes, and four methods of weight control: for obesity. The sample was selected in such a manner that it self-induced vomiting, laxative misuse, diuretic misuse and consisted both of obese children seeking inpatient and intense exercising. outpatient treatment. All obese children seeking inpatient Tests of the discriminant validity of the EDE among or outpatient treatment between July 1999 and December subgroups of eating disordered individuals24,25, tests of 2001 were invited to participate. The response rate was 72%. inter-rater reliability25–28 and tests of concurrent validity27 Children younger than 10 or older than 16 and mentally all support its use. The EDE has demonstrated good internal retarded children were excluded from the study. All partici- consistency24,29 and the test–retest reliability has been well pating children obtained a diagnosis of primary obesity. The established.28 mean weight was 81.25 kg (s.d. ¼ 19.32) and the mean height The interviewers were trained by two certified trainers for was 160.70 cm (s.d. ¼ 9.89), corresponding to a mean body the adult version and the child version of the EDE. The mass index (BMI) of 31.15 (s.d. ¼ 5.34). The degree of interviewers were clinical psychologists and were provided overweight was expressed in the adjusted BMI (see below). with video and audio tapes.

International Journal of Obesity Binge-eating in obese children and adolescents V. Decaluwe´ and C. Braet 406 The diagnosis of BED was based upon EDE-symptom Table 1 General characteristics of obese children and adolescents seeking ratings as they pertained to research criteria for the BED of help the DSM-IV.1 The DSM-IV requires two binge-eating episodes Total sample Sample 1 Sample 2 a week in the absence of inappropriate compensatory behaviours to make a diagnosis of BED. Additional questions (n=196) (n=158) (n=38) regarding the specific research criteria of the DSM-IV allowed all BED criteria to be assessed. Age (y) 12.73 (1.75) 12.77 (1.81) 12.58 (1.46) Age of onset of 7.17 (3.41) 7.14 (3.33) 7.30 (3.74) Age of onset of binge eating, overeating and overweight overweight (y) Additional questions were asked regarding the age of onset of Sex ratio (M/FM) 78/118 65/93 13/25 Weight (kg) 81.25 (19.32) 81.28 (19.50) 81.12 (18.85) overweight, overeating and binge eating. The age of onset of Height (cm) 160.70 (9.89) 160.50 (10.44) 161.57 (7.25) overweight was defined by asking the parents: ‘At what age BMI (kg/m2) 31.15 (5.34) 31.22 (5.26) 30.87 (5.75) did your child become overweight?’ The age of onset of ABMI (%) 172.69 (27.09) 172.88 (26.31) 171.94 (30.47) overeating, respectively binge eating, was conservatively defined as the age at which the first significant and persistent M, male; F, female; BMI, body mass index; ABMI, adjusted body mass index. behavioural characteristic of an eating disorder began (regular episodes of overeating with or without loss of Table 2 Prevalence of eating patterns control), rather than the age at which the subject first met the full diagnostic criteria for BED. Only when overeating, Total Sample 1 Sample 2 sample (n=196) (n=158) (n=38) respectively binge eating, was relevant, the following question was asked: ‘At what age did you first have an episode of (n) (%) (n) (%) (n) (%) the type we have just described (referring to an episode of overeating, respectively objective bulimic episode)?’ No disturbance of eating 145 74.0 116 73.4 29 76.3 BED 2 1.0 2 1.3 0 0 Subclinical binge eating 18 9.2 15 9.5 3 7.9 Statistics Compensatory behaviour 7 3.6 7 4.4 0 0 OO 24 12.2 18 11.4 6 15.8 The results were expressed as mean (s.d.) or percentage of the sample. Categorical data (gender, presence of BED, presence of OBEs) were analysed using the w2 statistic. Continuous (s.d. ¼ 30.47). The participants had a mean weight of data (age, adjusted BMI, severity of OBEs, ChEDE-subscales, 81.12 kg (s.d. ¼ 18.85) and an average height of 161.57 cm ages of onset) were compared using t-tests, multivariate (s.d. ¼ 7.25), corresponding to a mean BMI of 30.87 analyses of covariance (MANCOVAs) or univariate analyses (s.d. ¼ 5.75). The mean adjusted BMI for sample 2 was of covariance (ANCOVAs). Data were analysed using the SPSS 171.94% (s.d. ¼ 30.47). version 10.0. P-values less than 0.05 were considered The main characteristics of the outpatient sample and the statistically significant. inpatient sample are shown in Table 1. No significant In order to increase the generalizability of the results, we differences were found between the two samples as regards opted to combine the data from both samples. The separate age and degree of overweight. A w-quadrate analysis data from each sample are displayed in the tables. (w2(1) ¼ 0.43, NS) also showed no significant sex differences between the inpatient sample and the outpatient sample.

Results Characteristics of the respondents of the two samples Prevalence of disturbance of eating Sample 1 consisted of 158 children and adolescents (65 boys Table 2 presents the prevalence of the different patterns of and 93 girls) between the ages of 10 and 16, recruited from a overeating found in both samples of obese subjects seeking Medical Paediatric Centre that has a waiting list of 100 help. Combining the estimates of prevalence of the two youngsters a year seeking inpatient treatment for their samples, two subjects (1%), both female, met the full obesity. The mean age of the subjects in sample 1 was diagnostic criteria for BED. In all, 18 subjects (9.2%) 12.77 (s.d. ¼ 1.81). The participants had a mean weight of experienced at least one OBE over the previous 3 months 81.28 kg (s.d. ¼ 19.50) and an average height of 160.50 cm (OBE, overeating with loss of control), but did not endorse (s.d. ¼ 10.44), corresponding to a mean BMI of 31.22 all of the other DSM-criteria that are required for a diagnosis (s.d. ¼ 5.26). The mean adjusted BMI for the sample was of BED. Of these subjects, 13 were female and five were male. 172.88% (s.d. ¼ 26.31). Seven subjects (3.6%) reported they had tried to control their Sample 2 consisted of 38 participants (13 boys and 25 girls) shape or weight by self-induced vomiting, laxative or who had applied for an outpatient weight loss treatment at diuretic misuse, or intense exercising over the previous the University Hospital. The mean age of the sample was 3 months. Three of these subjects were female and four 12.58 (s.d. ¼ 1.46) with a mean adjusted BMI of 171.94% were male. Since the regular use of these inappropriate

International Journal of Obesity Binge-eating in obese children and adolescents V. Decaluwe´ and C. Braet 407 compensatory behaviours occurred in the absence of binge Table 3 Age of onset of binge eating and overweight in obese children and eating, no subject was considered bulimic. Episodic over- adolescents seeking help eating was more common. A total of 24 subjects (12.2%) had Gender Age ABMI No. OBEs over Onset of Onset of Onset of experienced at least one episode of objective overeating (OO, (years) (%) the past overweight first OO first OBE overeating without loss of control) in the past month. Nine 3 months (y) (y) (y) of these were female and 15 were male. In order to compare the present study with previous F 16 150.19 1 12 F ? studies in the subsequent analyses two groups were put F 12 230.65 10 4 8 10 F 14 211.08 2 7 F 13 together: subjects with BED and subjects displaying sub- F 16 167.44 16 8 12 15 clinical binge eating. In this group, the average number of F 14 195.67 30 1 7 10 OBEs was 11.65 (s.d. ¼ 18.50) over the previous 3 months. A F 14 204.79 16 5 12 12 t-test revealed a significant difference between obese girls M 11 157.69 3 7 ? ? M 10 180.40 4 8 6 8 and obese boys in the presence of OBEs, with girls having F 14 175.90 7 12 12 12 significantly more OBEs than boys (t (118) ¼ 2.18, Po0.05). F 10 159.68 9 7 ? ? The mean ChEDE-scores of the full sample (n ¼ 196) were F 11 158.98 1 5 9 10 0.96 (s.d. ¼ 0.92) for restraint, 0.62 (s.d. ¼ 0.75) for eating F 15 142.71 6 4 8 11 F 15 207.57 16 11 14 15 concern, 1.90 (s.d. ¼ 1.11) for weight concern and 1.83 M 11 168.11 1 9 F 11 (s.d. ¼ 1.26) for shape concern. A MANCOVA was conducted M 15 179.83 1 6 ? ? on the eating pathology measures (ChEDE) with two F 13 224.16 84 4 F 11 between-subject factors: binge category (OBE subjects vs M 10 203.48 2 7 6 6 F 12 221.65 8 8 10 12 non-OBE subjects) and sex, while controlling for degree of F 11 199.13 8 0 5 6 overweight (adjusted BMI) and age. The results of the F 13 190.78 8 10 12 12 MANCOVA indicated a multivariate main effect for the binge category, F (4,186) ¼ 2.54, Po0.05. The univariate F-tests M, male; F, female; ABMI, adjusted body mass index, OBE, objective bulimic revealed significant results for eating concern F (1, episode; OO, Episode of objective overeating, ?, subject is unaware of the age of onset, F, irrelevant to the case under consideration. 195) ¼ 3.77, Po0.01 and shape concern F (1,195) ¼ 4.37, Po0.05. There was no significant multivariate main effect for sex. Furthermore, there was no significant interaction effect for sex and binge category. Controlling for age and degree of and the severity of binge eating (r ¼ 0.20, Po0.01). The overweight, subjects with OBEs are more concerned about presence of OBEs was associated with a significantly higher their eating and shape than subjects without OBEs. adjusted BMI. To compare the subjects of the inpatient sample with those of the outpatient sample, a MANCOVA was conducted on eating pathology measures (ChEDE) with the seeking help Age of onset of overeating, binge eating and overweight status (inpatient vs outpatient) as a between-subject factor, As shown in Table 3, the onset of binge eating occurred while controlling for degree of overweight (adjusted BMI) between the ages of 6 and 15. In general, for the entire group and age. The multivariate F-test revealed no significant main with binge-eating problems, the mean age of the first effect for the seeking help status. An ANCOVA was overweight was 6.75 (s.d. ¼ 3.26), the age of the first episode conducted on the severity of binge eating (frequency of of objective overeating was 9.31 (s.d. ¼ 2.90) and the age of OBEs) with seeking help (inpatient vs outpatient) as a the first OBE was 10.88 (s.d. ¼ 2.60). between-subject factor, while controlling for degree of In assessing the progression of mean onset ages, it appears overweight (adjusted BMI) and age. No significant effect that overweight precedes overeating and binge eating. Paired for severity of binge eating was found. Controlling for samples t-tests revealed a significant difference between the overweight and age, subjects seeking inpatient treatment ages of onset of overweight and overeating (t (12) ¼ 3.96, and outpatient treatment do not differ in eating pathology Po0.01), between the ages of overweight and binge eating (t or in severity of binge eating. (15) ¼ 5.90, Po0.001) and between the ages of overeating and binge eating (t (12) ¼ 4.19, P ¼ 0.001). With one single exception, all subjects engaging in OBEs stated that their Binge eating and weight obesity had set in prior to their first binge. An ANCOVA, entering age as a covariate, for degree of In terms of onset of overweight, there was no significant overweight (adjusted BMI) revealed a significant difference difference between subjects with and those without OBEs. between the subjects with OBEs and those without OBEs. Controlling for age, the subjects that suffered from OBEs in Discussion the past 3 months had significantly higher ABMI than those This is the first study that determined the prevalence of BED without OBEs (F (1,194) ¼ 5.805, Po0.05). A significant in obese children. BED was rarely found in the sample of relationship was found between the degree of overweight obese children seeking inpatient or outpatient treatment.

International Journal of Obesity Binge-eating in obese children and adolescents V. Decaluwe´ and C. Braet 408 Only two of the 196 (1%) obese youngsters met the full comparable degree of overweight and eating-related psycho- diagnostic criteria for BED. Eating disturbances such as binge pathology. They even reported comparable frequencies of eating, episodic overeating and the use of inappropriate episodes of intake of large amounts of food. In line with compensatory behaviours were more common. Previous Nicholls et al,36 we suggest the use of more flexible criteria in studies of binge eating in obese adolescents, however, the screening of eating disorders among children. Younger reported much higher prevalence estimates.7–9 Several subjects in particular may not fulfil the criteria, but may factors may explain the low prevalence of binge eating in nevertheless show a considerable psychological distress or this sample. First, the method used in this study is different eating-related psychopathology. Until now, children enga- from those used in previous studies. Secondly, the subjects in ging in overeating (even if it occurs without a sense of loss of the present study may have been too young. It is possible control) seem to be a particularly neglected group at risk. A that a larger number of children in this study may develop practical implication of this result is the necessity to be an eating disorder at a more advanced age, given that vigilant for the potential risk of binge eating when working childhood obesity is related to the development of bulimia with obese children. This underlines the importance of nervosa as well as BED.30,31 finding indicators of binge eating. Binge eating was more prevalent in girls than in boys. The present study has some limitations. The findings Gender differences in anorexia and bulimia nervosa are cannot be generalized to the general paediatric obese substantial. However, our study underlines the fact that population. Obese individuals seeking treatment show a these differences occur to a lesser extent among obese binge greater psychological distress and more eating disorders than eaters. Our findings corroborate the sex ratios that are obese individuals not seeking treatment.20,37,38 It would be reported in the previous studies with obese adolescents.7,9 interesting to assess the prevalence of binge eating in a more Children with binge-eating problems are more concerned representative sample of obese teenagers via a population- about their eating and shape, suggesting that a subgroup of based study. A second limitation is that the data were only obese children suffers from eating-related problems. The available on 72% of the potential participants. This could be present findings confirm those found in adults. This high- a reason why the prevalence rate of binge eating may under- lights the importance of recognizing binge eating in obese estimate the true prevalence among young obese boys and children. Since no weight control programmes are available girls. There is evidence that eating problems are dispropor- for obese children that are successful in reducing symptoms tionately common among those that do not give permission of disordered eating,32 it is not surprising that these children to take part in surveys on eating disorders.39 Finally, the age have a poor treatment outcome given the evidence that of onset of overweight was based on the parents’ report. In binge eating is related to poor treatment outcome.33,34 future research, it would be more reliable to use an objective In line with adult literature,17–19 the present study suggests definition of what is meant by the term ‘overweight’. that subjects with OBEs are more likely to weigh more than Future research may increase our understanding of eating those without OBEs. This is in contrast with other studies.8,20 disorders in obese individuals by providing long-term follow- The present study offers preliminary evidence that binge up assessments of obese children and adolescents at risk of eating can emerge at an early age, before adolescence. The developing diagnosable eating disorders and exploring the results support the assumption that overweight precedes impact of other variables such as self-esteem, depression, binge eating.22 Until now, the evidence available relied psychopathology and family functioning. solely on retrospective reports from adults. The present study is the first to have determined the age of onset of overweight Acknowledgements and binge eating in obese children. So far, little research has This study was funded by a doctoral fellowship awarded to been carried out on risk factors for BED. The results of the the first author by Special Research funds, Ghent University. present study are in line with those of the study of Fairburn The authors thank Christopher G. Fairburn for his comments et al,31 indicating that childhood obesity is a risk factor to and the staff of the Zeepreventorium De Haan and the Youth BED. Obesity Clinic of Ghent University Hospital. All children engaging in OBEs stated that overeating preceded their first OBE. The question is whether overeating without loss of control can be considered as a precursor of binge eating. Our study found a considerably large amount References of children (16%) engaging in OO without describing a loss 1 American Psychiatric Association. 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