WEIGHT LOSS AND BULIMIA TREATMENT
Treating Bulimia Nervosa and Achieving Medically Required Weight Loss: A Case Study
Julia B. McDonald, M.A., & Diana Rancourt, Ph.D.
Department of Psychology, University of South Florida, Tampa, Florida, USA
Author Note
The authors declare having no conflicts of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Correspondence concerning this article should be addressed to Julia B. McDonald, Department of Psychology, University of South Florida, 4202 E. Fowler Avenue, PCD 4118G, Tampa,
Florida, 33620. Email: [email protected]
Preprint draft version 3.0, 06/21/21. Please do not copy or cite without author’s permission. 2 WEIGHT LOSS AND BULIMIA TREATMENT
Abstract
Eating disorder and weight loss interventions have typically been regarded as distinct or antithetical, despite a growing number of individuals with comorbid eating pathology and obesity. This siloing of research and practice has created a clinical conundrum for providers seeking to treat individuals with an eating disorder seeking to lose weight (e.g., required pre- surgical weight loss). To date, integrated treatment research targeting both eating disorders and weight loss is rare and practical guidance is lacking, especially for restrictive/binge-purge subtypes. This case example describes how an integrated approach was applied within a naturalistic outpatient clinical practice setting to successfully treat a client presenting with excess weight and severe bulimia nervosa who was medically required to lose weight for orthopedic surgery. We conclude by reviewing the benefits and challenges of integrating eating disorder and behavioral weight loss treatments and providing practical insights for treatment providers.
Keywords: eating disorder; psychotherapy; obesity; overweight; weight management
Highlights:
Integrated eating disorder and weight loss treatments focus on binge eating. Other eating disorders are overlooked in the integrated treatment literature. Sustained eating disorder remission and weight loss were achieved. Practical guidance for integrating cognitive behavioral treatments is provided. Integrated treatment research is needed for other eating disorders and weight loss.
WEIGHT LOSS AND BULIMIA TREATMENT
Glossary
BN Bulimia nervosa HAPIFED Healthy approach to weight management and food in eating disorders CBT-E Cognitive Behavioral Therapy Enhanced 1 WEIGHT LOSS AND BULIMIA TREATMENT Treating Bulimia Nervosa and Achieving Medically Required Weight Loss: A Case Study
Research on eating disorders and obesity historically have occurred in separate realms, with eating disorders often falling under the umbrella of clinical psychology and obesity being a primary topic in medicine and public health. This siloing of research is problematic given that research suggests that the rate of comorbidity between obesity and eating disorders is growing more rapidly than either problem on its own (da Luz et al., 2017a). Additionally, interdisciplinary work has generated evidence of shared risk factors across eating disorders and obesity, including dieting behaviors, overvaluation of weight and shape/body dissatisfaction, and low self-esteem (e.g., Goldschmidt et al., 2016; Haines et al., 2010). Together these findings underscore the growing need for more integrated research and treatment approaches. Existing integrated treatments for adults have focused primarily on the intersection of binge eating disorder and overweight/obese status (e.g., Evans et al., 2019; Grilo et al., 2020; Jackson et al.,
2018), despite evidence that individuals with excess weight also report problematic restricting
(Chaput et al., 2009; Desai et al., 2008) and compensatory behaviors (e.g., purging; Kelly-
Weeder et al., 2014). This case study illustrates this gap in integrated eating disorder and obesity treatment research and describes the successful treatment of a women with a longstanding history of bulimia nervosa (BN) and excess weight who was required to lose weight to qualify for a knee surgery.
Research on the treatment of co-occurring eating disorders and excess weight is limited, with little guidance for practitioners on how to help adults who are medically required to lose excess weight and also struggle with an eating disorder. Relevant to the current case study, few interventions target both the eating disorder and weight status. Evidence-based interventions for binge eating disorder are not intended to lead to weight loss, though some individuals do lose a 2 WEIGHT LOSS AND BULIMIA TREATMENT modest amount of weight (Hilbert et al., 2019; Linardon et al., 2017). Similarly, evidence-based weight loss interventions are not intended to lead to binge eating disorder symptom reduction, though some individuals experience modest symptoms reductions (Ariel & Perri, 2016;
Peckmezian & Hay, 2017). While some change in weight and disordered eating symptoms may occur for those with comorbid excess weight and binge eating disorder, the same may not be true for individuals with comorbid excess weight and a restrictive (e.g., atypical anorexia nervous) or binge-purge-type (e.g., BN, atypical anorexia nervosa – binge-purge subtype) eating disorder.
One of the challenges to simultaneously addressing weight loss and restrictive/binge- purge-type eating disorders is that evidence-based approaches to weight management may heighten existing disordered eating cognitions and behaviors. For example, frequent and consistent weighing are important for tracking (Goldstein et al., 2019; VanWormer et al., 2009) and maintaining (Phelan et al., 2020) weight loss over time; however, in the context of an untreated restrictive/binge-purge eating disorder, self-weighing is associated with greater symptom severity (Pacanowski et al., 2016; Rohde et al., 2018). Similarly, moderate caloric restriction is a hallmark of effective behavioral weight loss approaches (Jensen et al., 2014), but represents a specific treatment target in cognitive behavioral therapy for eating disorders
(Fairburn, 2008). Importantly, though these findings suggest behavioral weight loss may exacerbate disordered eating cognitions and behaviors among those with pre-existing risk, there is no evidence that behavioral weight loss itself causes eating disorders (Eichen et al., 2019;
Jebeile et al., 2019; Yanovski, 2000). Still, the fact that some core components of effective behavioral weight loss (e.g., frequent self-weighing, moderate caloric restriction) are risk factors for eating disorders presents a clinical conundrum for providers seeking to treat patients 3 WEIGHT LOSS AND BULIMIA TREATMENT presenting with both an eating disorder and who have been medically recommended to reduce excess weight.
Relevant to the present case study, obesity is associated with increased surgical complications and worse outcomes among certain procedures, such as knee replacements
(Collins et al., 2012; Kerkhoffs et al., 2012; Krushell & Fingeroth, 2007). As such, pre-surgical weight loss is a recommendation for patients with excess weight seeking knee replacements
(Inacio et al., 2014). These patients often receive limited or unclear guidance on how exactly to achieve this required weight loss. This lack of guidance puts these patients at increased risk for developing (or worsening) problematic dieting or compensatory behaviors, or even experiencing vital sign instability (e.g., orthostasis, bradycardia) due to losing weight too rapidly (e.g., Sawyer et al., 2016). Given that individuals with excess weight are more likely to develop an eating disorder (Darby et al., 2007) and receive recommendations to lose weight for certain medical procedures (e.g., Inacio et al., 2014), there is a real and present need for clear guidance for practitioners seeking to help patients achieve (or maintain) medically required weight loss and eating disorder remission. Perhaps because weight loss strategies are viewed as a “slippery slope” for individuals with inappropriate restriction behaviors, traditional eating disorder treatments (e.g., cognitive behavioral therapy - enhanced [CBT-E], Fairburn, 2008), provide no guidance on how to use such behaviors for adaptive weight loss.
At present, there exists no treatment that meets the criteria for an empirically supported treatment (EST; APA Presidential Task Force on Evidence-Based Practice, 2006) that targets both weight loss and restrictive/binge-purge eating disorders. Recently, a healthy weight loss protocol was developed specifically for individuals with both excess weight and a current or past history of an eating disorder. This group-based intervention, known as HAPIFED (a Healthy 4 WEIGHT LOSS AND BULIMIA TREATMENT APproach to weIght management and Food in Eating Disorders; da Luz et al., 2017b), aims to address the shortcomings of available treatments for weight loss among persons with comorbid eating disorders; namely, that eating disorder interventions do not address weight management and weight loss interventions do not address psychological factors contributing to eating disorders. Despite the conceptual advantages, HAPIFED is still in the very early phases of evaluative research with only one small (n = 8 completers), single-group, acceptability and feasibility pilot study published to date.
Current Case Study. This case study highlights the need for evidence-based interventions for individuals with eating disorders, specifically restrictive eating or binge-purge subtypes, who also have a medical need to lose weight. We demonstrate a treatment approach that was successful in helping a client with severe and persistent BN achieve both weight loss required for surgery and eating disorder remission in an outpatient clinical setting. Specifically, we describe the sequential use of an established eating disorder intervention (i.e., CBT-E;
Fairburn, 2008), followed by an adaptation of a recently developed behavioral weight loss intervention that is sensitive to eating disorder behaviors (HAPIFED; da Luz et al., 2017b) with a middle-aged woman requiring pre-surgical weight loss as part of a knee-replacement procedure.
Importantly, given that integrated eating disorder and obesity treatment research is rare for restrictive or binge-purge subtypes and practical guidance is lacking, this case study presents real-world insights that could be of value to both practitioners with similar cases and scholars seeking to develop or enhance integrated eating disorder and weight loss treatment approaches.
Importantly, given our single person case study design, this case study is not intended to serve as a model for replication per se or to provide specific intervention strategies. Instead, we hope this 5 WEIGHT LOSS AND BULIMIA TREATMENT case example helps generate ideas for future interventions and provides real-world insights for clinicians working with clients presenting with similar treatment goals.
Case Illustration
Client Background and Characteristics
Presenting Problem and Psychological Diagnosis. Alice (a pseudonym) was a middle aged female seeking treatment for binge eating and purging (self-induced vomiting) behaviors, and help coping with general distress and concern related to her health and lifestyle more broadly. In addition to her eating disorder symptoms, Alice also was worried about disease, wellbeing, and longevity associated with her obese status. Based on the intake assessment,
Alice’s symptoms were best described by a diagnosis of BN. Phase 1 below provides a full description of the case conceptualization.
Eating Disorder and Obesity History. Alice described a nearly 30-year pattern of cycling in and out of binge/purge episodes and symptom remission, beginning when she first vomited as a compensatory behavior during late adolescence. These cycles typically included a period lasting several months in which she would engage in once or twice, daily binge (i.e., both objective and subjective binge eating1) and purge (i.e., self-induced vomiting) episodes, which was then followed by a period of symptom remission for one to two years until the next cycle started. Most recently, Alice reported that she had gone one year without binge eating or purging, but that the binge eating-purging cycle had resumed approximately four months prior to intake after receiving the news that she would need to lose weight to be eligible for knee surgery. When presenting for treatment, Alice reported engaging in at least one episode of self-induced vomiting and at least one episode of either objective or subjective binge eating each day, though on some 1 While Alice’s binges were characterized broadly by loss of control eating, she engaged in both objective binge (i.e., eating “large” amounts of food) and subjective binge episodes (i.e., the amount of food as not “large” but nevertheless viewed as excessive in the client’s mind) (c.f., Fairburn et al., 2014 for binge eating definitions). That said, it was somewhat more common for her to engage in objective, rather than subjective, binge episodes. 6 WEIGHT LOSS AND BULIMIA TREATMENT days (about three days per week) she would engage in two episodes of binge eating and two episodes of self-induced vomiting.
Alice identified focusing on being “healthy” and losing weight as triggers of her eating disorder symptoms. Consistent with this, Alice displayed a preoccupation with her weight and shape. She described a long history of dieting, with typical weight fluctuations of as much as 40 pounds within a single binge-purge cycle. When asked about her eating habits, she reported she often experienced loss of control while eating, which was then followed by feelings of shame and guilt. She described herself as a “control freak” and she interpreted her binge eating-purging behaviors as potentially “the only way [she] can get control.”
Medical and Psychiatric History. Alice expressed general distress related to her physical health (e.g., worry about disease, wellbeing, weight, and longevity) stemming from her current health status and family’s history of health concerns. Alice presented with ongoing medical concerns including osteoarthritis of the left knee, osteopenia, type 2 diabetes, benign essential hypertension, hypercholesteremia, obesity (weight at intake = 222 lbs.; Body Mass
Index = 39.3; Obesity Class II), obstructive sleep apnea, allergic rhinitis, as well as Vitamin B12 and D deficiencies. She also reported a family history of breast cancer, type 2 diabetes, hyperlipidemia, hypertension, kidney disease, and thyroid disease, and that all members of her family were of overweight or obese status. Alice was seeing her primary care physician regularly for symptom management of her ongoing medical concerns.
Most relevant to the current case conceptualization, prior to the first intake session, Alice saw an orthopedic surgeon for a total knee replacement due to pain in her left knee. The orthopedic surgeon told her that she needed to lose weight prior to receiving surgery, which ultimately triggered her current episode of binge-purge behaviors. After not meeting her 7 WEIGHT LOSS AND BULIMIA TREATMENT surgeon-defined weight loss goal during a check-up with her primary care doctor, Alice disclosed her struggles with BN to this provider. This disclosure marked the first time that Alice had ever spoken openly about her eating disorder to anyone. Her provider recognized that in order for her to safely pursue the weight loss required for her surgery, Alice would first need to address her symptoms of BN; thus, he referred her to our clinic for treatment. It is important to note that despite her long history of struggling with disordered eating behaviors, Alice had never received treatment for her eating disorder. She had, however, previously attended a few sessions of talk-therapy to address life stressors (e.g., divorce), which she described as helpful.
In addition to her eating disorder symptoms, Alice also presented with mild symptoms of depression (BDI-II score = 18, Beck et al., 1996) and anxiety (GAD-7 score = 5, Spitzer et al.,
2006), for which she reported taking prescription medication. She reported no side effects related to these medications. Alice’s low levels of overall distress at intake suggested no clinically significant impairments in overall functioning (OQ total score = 51, Beckstead et al., 2003). See
Supplemental Materials for additional information regarding Alice’s depression and anxiety assessment scores.
Psychosocial History. At the time of intake, Alice reported having strong social support.
Specifically, she described having a close group of supportive friends with whom she enjoyed regularly spending time. Alice also reported a very strong and positive relationship with her family. She stated that she was divorced and that for the past few years she has been involved in a good and supportive relationship with her boyfriend, with whom she currently lived. In terms of educational and occupational background, Alice had completed some college and was currently employed full-time.
Assessment and Progress Tracking 8 WEIGHT LOSS AND BULIMIA TREATMENT Consistent with a clinical science framework, diagnostic data were obtained at the beginning and end of treatment, and symptoms were tracked over the course of therapy.
Standardized measures of eating disorders (e.g., eating disorder examination (EDE), Fairburn,
2008), depression (BDI-II, Beck et al., 1996), anxiety (GAD-7, Spitzer et al., 2006), and overall wellbeing (outcomes questionnaire (OQ), Beckstead et al., 2003) were administered at intake and termination (including measures that were administered five- and six-months following treatment). Also, Alice’s weight was monitored during treatment. Each week, prior to the session’s start, the therapist would weigh Alice using a physician (“balance beam”) scale.
Finally, a daily monitoring log was also used to track symptom progress. Specifically, throughout treatment, Alice tracked binge eating and purging (i.e., vomiting) episodes, food/drink intake, and associated factors (e.g., thoughts, emotions, situational context). Later in treatment, her tracking log was expanded to include appetite cues, caloric restriction, and exercise, as well as urges to binge eat, purge, restrict, and exercise. See Supplemental Materials for Alice’s daily monitoring logs and a full description of all assessment measures and scores.
Service Context
Services were provided in an outpatient community mental health training clinic of a clinical psychology doctoral program of a large southeastern university. The clinician was a female in her twenties in the advanced stages of a doctoral clinical psychology training program.
She was supervised by a licensed clinical psychologist who is considered an expert in the fields of both eating disorder and obesity treatment and research.
Throughout treatment, Alice attended regular medical appointments with her primary care provider and orthopedic surgeon as part of her pre-surgery preparation and monitoring. Her primary care provider oversaw general medical management and maintained a line of 9 WEIGHT LOSS AND BULIMIA TREATMENT communication with the therapist so that important treatment updates could be communicated.
Her orthopedic surgeon stipulated her pre-surgical weight loss goal and timeline. If (and when)
Alice did not achieve her weight loss goal by the date set by the orthopedic surgeon, her surgery date would be pushed back. This happened twice over the course of treatment. This was not a problem given that her timelines were set by her orthopedic surgeon were to be aspirational, yet flexible. That said, while we encouraged Alice to first and foremost prioritize losing the weight in a manner that was healthy and sustainable, we also acknowledged Alice’s desire to achieve the required weight loss as soon as possible given the severity of her knee pain which was increasingly limiting her functioning. As such, though her timeline for her weight loss and surgery were flexible, they were also necessarily expedited.
Treatment
Overview of Case Study Treatment, Selected Treatment Modalities, and Adaptations
Alice met with the clinician for 21 sessions from February 2019 to August 2019, followed by two follow-up sessions in December 2019 and January 2020 (total of 23 sessions).
See Figure 1 for an illustration of treatment progress. Treatment included a sequential application of the well-established Cognitive Behavioral Therapy – Enhanced (CBT-E; Fairburn, 2008) to address Alice’s long-standing BN, followed by an adaptation of the recently developed Healthy
APproach to weIght management and Food in Eating Disorders (HAPIFED, da Luz et al.,
2017b) to address Alice’s medically required weight loss.
INSERT FIGURE 1 HERE
Importantly, though HAPIFED shows promise as an integrated weight loss and eating disorder treatment approach, it was (and still is) in the early stages of evaluative research, with only a single published pilot study demonstrating initial feasibility and acceptability. 10 WEIGHT LOSS AND BULIMIA TREATMENT Additionally, only one of the five participants who met criteria for BN at baseline reported vomiting and laxative use as compensatory behaviors. Thus, though HAPIFED results were promising, they were too preliminary to feel confident that the approach would sufficiently treat current BN symptoms prior to orthopedic surgery, especially given that postoperative nausea and vomiting are common complications (Chen et al., 2017) and may increase postoperative risk for a relapse of purging behavior. For these reasons, the decision was made (of which Alice was aware) to first use evidence-based CBT-E to target her symptoms of BN, then to target the weight loss necessary to qualify for her surgery using a HAPIFED-informed approach.
The next sections provide an overview of the treatment modalities and adaptations, followed by an in-depth discussion of each treatment phase. The Supplemental Materials include a summary of treatment phases and session topics for both HAPIFED and CBT-E.
Cognitive Behavioral Therapy - Enhanced. CBT-E (Fairburn, 2008) is a well- established, empirically supported treatment for eating disorders, including BN, that targets eating disorder psychopathology by modifying the thoughts and behaviors that are maintaining the disordered eating behaviors. CBT-E focuses on modification of eating habits, weight-control behaviors, and concerns about eating, shape, and weight by using strategies such as identifying and restructuring of unhelpful thinking patterns, behavioral experiments, exposure, and psychoeducation. In CBT-E, no specific dietary or weight loss goals are prescribed, outside of encouraging regular eating (e.g., three meals and two snacks per day) of a broad range of foods.
This case study mostly adhered to the CBT-E manual (Fairburn, 2008), with a few exceptions. First, though we followed the recommendation that eating disorder symptoms be addressed prior to targeting weight loss, we did not allow for a full 20-week period of eating disorder remission prior to addressing excess weight due to the fact that Alice was already in the 11 WEIGHT LOSS AND BULIMIA TREATMENT orthopedic surgery pipeline. Similarly, we did not explicitly focus on eating disorder relapse prevention prior to shifting our focus to addressing Alice’s weight loss, though eating disorder and weight loss relapse prevention strategies were covered towards the end of treatment. The implications of these adaptations will be discussed in greater detail below.
Healthy APproach to weIght management and Food in Eating Disorders. HAPIFED
(da Luz et al., 2017b) is a recently developed, group-based, healthy weight loss program specifically designed for individuals struggling with both obesity and a current or past history of an eating disorder. This approach blends traditional CBT-E (described above) with behavioral weight loss for obesity strategies (i.e., Sainsbury-Salis, 2007, 2011) to help individuals with excess weight achieve moderate weight loss using sustainable weight management techniques and eating disorder symptom remission. Specific strategies include improving knowledge of nutrition, physical activity, and hunger/satiety cue identification, decreasing eating for emotion regulation purposes, differentiating between healthy and unhealthy exercise habits, and overcoming barriers to weight loss and healthy eating.
Several adaptations to the HAPIFED approach were made during our current case including (a) individual weekly session, as opposed to group-based sessions that meet once or twice per week, (b) a stronger focus on treating the eating disorder prior to introducing weight loss strategies, as opposed to simultaneously addressing both weight loss and disordered eating,
(c) conducting the treatment within an outpatient community setting, without access to a multi- disciplinary treatment team, and (d) relying on self-reports of physical activity, rather than utilizing fitness tracking technology. 12 WEIGHT LOSS AND BULIMIA TREATMENT Phase 1 (Session 1-2): Intake and Case Conceptualization
The first two sessions were devoted to the intake process. See Figure 2 below for an illustration of Alice’s case conceptualization, which is consistent with the transdiagnostic model of eating disorders (Fairburn, 2008).
INSERT FIGURE 2 HERE
Binge eating (i.e., loss of control eating) and purging (i.e., self-induced vomiting) behaviors were the primary behavioral targets2 and specific maintaining factors were identified.
Alice expressed broad concern for her health (e.g., worry about disease, wellbeing, weight, and longevity) and a strong desire for belonging within her group of “obese friends.” This friend group reportedly had a strong preoccupation with weight/shape, food and weight control behaviors (e.g., trying “fad” diets, tracking/comparing weight and caloric intake among the group). These two factors contributed to Alice’s own expressed overvaluation of shape and weight. Her overvaluation of shape and weight was a trigger for weight control behaviors, such as strict dieting and food avoidance, intended to reduce her weight.
Alice’s rigid dieting standards (e.g., specific rules regarding food intake in terms of caloric limits, types of foods that could be eaten, pre-set quantitates of food) resulted in her being more prone to engaging in loss of control eating (i.e., episode of subjective or objective binge eating) because either she was able to adhere to her strict dietary rules and was left feeling hungry and physically vulnerable, or because she was not able to adhere to her unrealistic standards was left feeling emotionally vulnerable and out of control. Indeed, Alice’s need for control emerged as a direct maintaining factor of her binge eating and purging behaviors; she engaged in strict dieting and weight control behaviors in attempts to control her dysregulated
(loss of control) eating. For instance, Alice would skip meals as a way to regain a sense of
2 Later, healthy weight loss via moderate caloric restriction and increased exercise also became a primary target. 13 WEIGHT LOSS AND BULIMIA TREATMENT control and to punish herself for loss of control eating. This meal skipping would then exacerbate her vulnerability for loss of control eating. Negative mood states (e.g., irritability) also increased her likelihood of binge eating. Following a binge eating episode, regardless of whether it was objective or subjective, Alice would immediately engage in purging behavior. The purging functioned as either an attempt to control her weight and/or to give her relief and the physical sensation of “emptiness,” or to mitigate the intense feelings of guilt and shame she experienced as a result of having engaged in binge eating. This experience of guilt and shame following her binge eating and purging further strengthened her need to control her weight, as well as reinforced her overvaluation of weight and shape.
Together, intake revealed that Alice’s main treatment goals were to 1) reduce her binge- purge behaviors, then eventually, 2) lose enough weight to qualify for her surgery. We identified several maintaining factors that would be necessary to target in pursuit of these goals, Alice’s need for control, strict dieting rules, overvaluation of shape and weight, negative mood, and feelings of guilt/shame (see Figure 2 for Alice’s case conceptualization).
Phase 2 (Session 3-15): Bulimia Nervosa Treatment using CBT-E
Treatment for BN began during session 3. During this session, Alice was provided feedback regarding the intake assessment and case conceptualization and presented with psychoeducation on BN. She was then introduced to the treatment plan, which included using
CBT-E first to achieve eating disorder remission before addressing weight loss. Alice agreed to the treatment plan and also agreed to be weighed weekly by the therapist, establish regular eating patterns that included a broad range of foods (rather than adherence to a specific diet), and track her eating and purging behaviors. In particular, Alice was instructed to begin keeping a daily monitoring log of her food and drink intake, as well as the thoughts, behaviors, emotions, and 14 WEIGHT LOSS AND BULIMIA TREATMENT situational context associated with the food/drink intake (see Murphy et al., 2010 for an example of a standard monitoring log used in CBT-E treatment).
Following this initial treatment session, Alice experienced a sharp rebound in her purging behaviors (which had been reduced following the first two sessions of intake, from an average of
14 times per week to an average of 1-2 time per week, see Figure 2). This rebound was attributed to her increased awareness of her disordered eating patterns due to the introduction of the self- monitoring log. The therapist normalized this experience and encouraged Alice to continue completing her daily tracking. The therapist then provided Alice with additional psychoeducation on disordered eating.
By session 5, Alice had learned to identify important patterns related to her disordered eating. Thus, consistent with stage three of CBT-E, treatment began to focus on addressing the processes maintaining her disordered eating problem. In line with this, unhelpful thinking styles were introduced. Alice readily recognized several patterns of unhelpful thinking styles including all-or-nothing thinking (e.g., “food is either healthy or unhealthy”), labeling (e.g., “I am a fat pig”), and mind reading (e.g., “people judge me for eating so much”). Sessions 6-9 focused on challenging these unhelpful cognitions, as well as addressing Alice’s dissatisfaction with her body image and weight. Alice was introduced to strategies to help her be more “body positive” such as using positive self-affirmations to focus on what she liked about her body and the function of her body. Alice found these strategies so helpful that she even encouraged her friend group (most of whom also struggled with preoccupation and dissatisfaction with weight and shape) to try them. Improved body image led to a more positive self-evaluation and subsequently decreased feelings of guilt and shame towards herself and her body. Finally, Alice was also 15 WEIGHT LOSS AND BULIMIA TREATMENT taught mindfulness and relaxation skills during these sessions to help resist urges to binge and purge and reduce her “mindless eating.”
By session 10, it became clear that Alice’s “need for control” was a major schema contributing to her distress. Specifically, if Alice was unable to either avoid or control an unpredictable or uncontrollable situation, she would engage in binge eating and/or purging to relieve her discomfort. For instance, if Alice’s friends “took too long” to decide where to go out for dinner and she was unable to review the menu ahead of time, she either refuse to go (avoid) or insist on going to a restaurant where she already knew exactly what she wanted to order
(regardless of her friends’ preferences for dinner; control). Alice feared that if she could not plan her entire meal in advance, she would end up binge eating and then purging in the bathroom of the restaurant, which would lead to her friends judging her. To address this unhelpful preoccupation with perceived need for control, cognitive restructuring and behavioral experiments were incorporated into sessions 10-14. As one example, Alice was instructed to allow her friends to make dinner plans and practice tolerating her distress related to not being in control. By session 14, she reported feeling liberated by not always trying to plan and control everything. She also observed improvements in her relationships with others by allowing those around her to assert their own wants and needs.
By session 13, Alice reported consistent decreases in her urge to binge eat and purge. She attributed this to having developed a more positive self-evaluation, improved awareness of and ability to challenge unhelpful thoughts, and improved tolerance of discomfort. She also learned to “set herself up for success” by setting realistic goals and engaging in proactive problem- solving strategies rather than “unnecessarily challenging herself.” As evidence of this, Alice began adhering to regular eating patterns (i.e., three meals per day, no skipping meals), prepping 16 WEIGHT LOSS AND BULIMIA TREATMENT frozen meals for when she did not feel like cooking, and no longer “tempting herself” by buying foods to “prove to herself that she could resist it” (e.g., buying fried chicken to see if she could not eat it). By session 15, Alice had begun to accept herself physically and emotionally; this, combined with the remission of her eating disorder symptoms reported on her daily monitoring log (see Figure 1), gave both Alice and the clinician confidence that she was ready to begin
Phase 3 of treatment, focusing on adaptive weight loss.
Phase 3 (Sessions 16-21): Weight Loss Treatment using Adapted HAPIFED Protocol
During session 16, an approach informed by the HAPIFED protocol was introduced to help Alice lose the weight required for her surgery. As such, her daily monitoring log was expanded to include elements from the HAPIFED tracking protocol such as tracking exercise behavior, rating hunger and satiety before and after each meal, and logging behavioral urges (in addition to actual behaviors). See Supplemental Materials for expanded daily monitoring log.
Alice found that recording her appetite cues was not only informative for weight loss, but also increased her mindful eating and reduced her risk of engaging in problematic restrictive and binge eating behaviors. Tracking exercise behaviors (and associated thoughts and urges) was also important to ensure that her exercise remained adaptive and did not develop into a compensatory behavior (i.e., exercise was not obligatory, compulsive, or driven in nature,
Dittmer et al., 2018). Of note, Alice had a preference for paper and pen tracking and opted to self-report her physical activity on her daily monitoring log. This was in contrast to the
HAPIFED pilot study that used fitness tracking technology (e.g., wearable device, smart phone application).3 Finally, as the focus of treatment shifted to weight loss, Alice was re-introduced to
3 Compared to more objective fitness trackers, retrospective recall may be less accurate, especially for moderate and vigorous physical activity (Nelson et al., 2016; Sylvia et al., 2014; Welk et al., 2014). That said, while fitness tracking technology has been associated with weight loss among non-eating disordered samples (Pourzanjani et al., 2016), they have also been associated with increased eating disorder symptomatology (Simpson & Mazzeo, 2017). Treatment providers should work with clients to choose an appropriate method of fitness tracking that can be sustained in an adaptive manner. 17 WEIGHT LOSS AND BULIMIA TREATMENT self-weighing at home once a week so that she could develop the skills and self-efficacy to monitor her weight without experiencing an eating disorder lapse. At this point Alice was no longer experiencing distress related to self-weighing, which was attributed to continued weight exposure and other CBT-E strategies that occurred during Phase 2 of treatment.
Sessions 17-21 focused on identifying and overcoming barriers to healthy eating and physical activity. Barriers to healthy eating included continued struggles with “mindlessly eating” and difficulty with preparing a nutritious meal for herself (e.g., spaghetti squash) while also preparing a less nutritious meal for her partner (e.g., spaghetti and meatballs) who did not want to adapt his diet. Alice overcame these barriers with proactive problem-solving techniques, such as eating dinner at the dinner table and having honest conversations with her partner about her difficulties with dinner preparation. Similarly, barriers to healthy exercise were identified such as feeling tired, not being able to find the time in her schedule, and increasing levels of knee pain. After identifying these barriers, Alice was able to take steps to address them (e.g., modifying her work schedule to allow for scheduled trips to the gym). The HAPIFED protocol
(da Luz et al., 2017b) was particularly helpful in guiding discussions about healthy exercise. For instance, case vignettes (i.e., handout 6) were useful for helping Alice learn to distinguish between healthy and unhealthy exercise habits. These discussions revealed that Alice initially viewed exercise only as a means to weight loss – a motivation for exercise that is associated with poor body image, disordered eating, and maladaptive exercise (Panão, & Carraça, 2020;
Vartanian et al., 2012). To shift her views on the function and utility of exercise, Alice was encouraged to use trial and error to identify a physical activity that she enjoyed and would not cause her physical pain. Eventually, Alice identified swimming as an activity that met both these 18 WEIGHT LOSS AND BULIMIA TREATMENT criteria. By session 20, Alice was eating balanced meals for most meals and exercising regularly five times per week.
Of note, Phase 3 coincided with adaptive weight loss, but also increased urges to binge eat and purge, which led to a brief reoccurrence of binge and purge behaviors (see Figure 1).
Given that Alice’s weight loss and transition from eating disorder remission to targeting weight loss was intentionally rapid (due to her pre-surgical weight loss goal and time frame set by her orthopedic surgeon), the return of binge eating and purging behaviors was not unexpected.
Importantly, this lapse provided a valuable teachable therapeutic moment, as Alice generally had experienced linear improvement during treatment. Alice was reminded that increased awareness of a behavior can exacerbate that behavior, and her increased urges to binge eat and purge when she first began tracking her disordered eating behaviors at the beginning of treatment was used as an earlier example of this. Alice was able to implement the cognitive and behavioral skills she had acquired during CBT-E treatment (e.g., thought challenging) and quickly learned how to cope with the increased urges to binge eat, purge, and restrict associated with her weight loss.
She was able to continue with the adapted HAPIFED program and eventually met her weight loss goal in time for her surgery without another lapse.
Session 21 consisted of relapse prevention focused on pre-coping for the surgery and post-surgical recovery. Going into the surgery, Alice described feeling ready and motivated and was quite proud of the progress she had made in terms reaching both her eating disorder recovery and weight loss goals. She demonstrated a realistic and balanced perspective of the challenges she would likely face during and after the procedure, and pro-actively coped with these challenges by developing a detailed management plan to maintain her physical and emotional wellbeing in the weeks leading up to and following her surgery. 19 WEIGHT LOSS AND BULIMIA TREATMENT Phase 4 (Sessions 22-23): Relapse Prevention, Termination, and Follow-up
Session 22 was scheduled for 14-weeks post-surgery, and consisted of processing her surgery, collaboratively reviewing her progress, and preparing for termination. Alice reported that though the surgery went well, recovery was harder than she anticipated. She described that for two weeks following her operation, she felt depressed and isolated herself. It was during this time that Alice reported purging for the first time in 10 months, stating that she was triggered by her post-surgical weight loss. In particular, she reported having the thought of “I lost weight and
I wasn’t even trying, so what if I actually tried to lose weight?” This lapse included four episodes of self-induced vomiting over the period of two days (but no episodes of binge eating).
Importantly, Alice was able to recognize that she was “falling into old patterns” and used the coping skills that she learned during treatment to engage in healthier behaviors. She described reminding herself that a lapse was not the same as a relapse and that she could use techniques such as behavioral activation and thought challenging to deal with her low mood and disordered eating urges. She also described that once she accepted that she was having a difficult time with her surgical recovery and allowed herself to be vulnerable and accept support from others, she was better able to cope and experienced increased feelings of intimacy and closeness with her loved ones (which had its own lasting benefits).
Alice reported that, despite this brief lapse, she had been feeling great over the past 12 weeks since her psychological and behavioral shift. She described feeling a sense of mastery over her disordered eating symptoms and felt ready for termination. Consistent with Alice’s positive outlook, outcome measures completed during this session revealed clinically significant improvements in her depression, anxiety, and overall wellbeing scores. Importantly, diagnostic 20 WEIGHT LOSS AND BULIMIA TREATMENT interviews revealed that Alice no longer met criteria for BN. See Supplemental Materials for a full review of measures and treatment progress scores.
Given that Alice had achieved her therapy goals, a final termination and booster “relapse prevention” session was scheduled for seven weeks after session 22. This final session (which occurred almost 6-months post-surgery and 11-months after intake), consisted of a review of important skills acquired during therapy, identification of how to recognize and cope with obstacles to recovery, and planning for continued positive treatment outcomes moving forward.
Upon termination, Alice reported that she was satisfied with her therapy progress and motivated to maintain her new more healthful lifestyle.
Results
Treatment Outcomes
This clinical example illustrated how an integrated treatment approach could help a client with a long history of severe BN achieve eating disorder remission and medically required weight loss within a naturalistic, clinical practice setting. Specifically, Alice was able to achieve and maintain her surgeon-defined pre-surgical weight loss goal necessary to qualify for a knee replacement surgery. By the end of treatment, she weighed 208 lbs., which was a loss of 32 lbs. from her maximum weight during treatment of 240 lbs., and a loss of 14 lbs. from intake to termination (see Figure 1). In addition, she achieved remission from BN and demonstrated reductions in disordered eating behaviors (e.g., abstinence from self-induced vomiting and binge eating) that were sustained for the most part at six-months post-treatment/surgery (with the exception of a brief period of purging behaviors two-weeks post-surgery; see Figure 1). Outcome data also indicated that Alice had clinically meaningful improvements in mental health 21 WEIGHT LOSS AND BULIMIA TREATMENT symptoms (BDI-II score dropped from 18 to 2, GAD-7 score dropped from 5 to 0) and overall functioning (OQ total score dropped from 51 to 19).
Discussion
The present case study illustrated the successful sequential application of an established eating disorder treatment, CBT-E (Fairburn, 2008), and a weight loss treatment informed by the newly developed HAPIFED protocol (da Luz et al., 2017b) for a client (“Alice”) seeking to reduce symptoms of BN while also pursuing weight loss required for orthopedic surgery. Within this single case example, we provide evidence that sustained weight loss is feasible within the context of adult eating disorder treatment. We conclude by offering practical insights regarding the benefits and challenges we encountered at each stage of our integrated eating disorder and weight loss treatment. We also provide recommendations based on our experiences for other practitioners and treatment researchers.
Summary of Treatment Challenges and Recommendations
Beginning with Phase 1 (conceptualization and treatment planning), our main challenge involved difficulty finding an appropriate evidence-based approach for weight loss and eating disorder treatment. The HAPIFED protocol, which overlaps considerably with CBT-E (see
Supplemental Materials for HAPIFED and CBT-E comparison), met most of our treatment needs in that it offered a behavioral weight protocol sensitive to eating disorders. Despite its appropriateness, HAPIFED was (and still is) in very early phases of development and is not yet considered an evidence-based treatment. Further, only one participant in the pilot study demonstrated a binge-purge type behavior pattern, so we could not be confident that it would be an appropriate treatment option for Alice. To increase confidence in the utility of HAPIFED for addressing longstanding restricting and binge-purge subtype eating disorders, additional research 22 WEIGHT LOSS AND BULIMIA TREATMENT (including large, randomized control trials) conducted by multiple research groups are needed.
Moderators of treatment outcomes (e.g., specific disordered eating patterns, duration of illness) also need to be investigated. As of this writing, the HAPIFED protocol is being testing against
CBT-E and standard behavioral weight loss treatment as part of a randomized controlled trial for participants with excess weight and BN or binge eating disorder (Palavras et al., 2015; Pattinson et al., 2019).
During Phase 2 (CBT-E treatment to reduce BN symptoms), Alice experienced difficulties including reactivity to tracking disordered eating behaviors, struggles setting realistic goals, and trouble buying into modifying non-food related aspects of her life. These challenges ultimately were relatively straight-forward to address given that the CBT-E manual (Fairburn,
2008) offers practical guidance for addressing these concerns. The real challenge with Phase 2 concerned the transition from the eating disorder treatment to behavioral weight loss. In particular, given that Alice was already in the orthopedic surgery pipeline and her knee pain was severe and impacting her quality of life, it was not be feasible or practical to adhere to the CBT-
E manual recommendation that eating disorder remission be maintained for 20 weeks prior to addressing weight loss. Although her surgery date was somewhat flexible, because Alice was experiencing severe knee-pain, which was increasingly limiting her functioning, the timeline for her weight loss and surgery were necessarily expedited. Thus, we transitioned directly from eating disorder treatment to focusing on weight loss. In retrospect, a greater emphasis on eating disorder relapse prevention would have benefited Alice prior to transitioning to Phase 3. We recommend that researchers and practitioners who are interested in implementing combined eating disorder and weight loss treatments of this kind focus on preparing the client for the experience of weight loss by explicitly discussing how to cope with potential triggers related to 23 WEIGHT LOSS AND BULIMIA TREATMENT pursuing weight loss (e.g., increased focus on tracking weight trajectory, observing changes in weight and shape) prior to initiating weight loss treatment.
Phase 3 (HAPIFED protocol to lose required weight) raised a number of challenges related to pursuing weight loss while maintaining BN symptom remission. Many of these challenges were related to the “slippery slope” of someone with a history of disordered eating pursuing weight loss, which necessarily involves increasing focus on monitoring weight and exercise and modifying behaviors to decrease caloric intake. Due to our sequential treatment approach, Alice had already begun to target many of the factors that contribute to maladaptive approaches to weight loss (e.g., disordered dieting behavior, overevaluation of weight and shape) during CBT-E, thus she was able to build off her existing treatment gains. For instance, though weekly weigh-ins were was initially triggering for Alice, especially when she did not meet her personal weight expectations, Phase 2 CBT-E strategies (e.g., thought challenging and continued weight exposure) allowed her to develop the skills to be non-reactive to her weight. By the time
Alice transitioned to focusing on weight loss, she was able to weigh herself weekly at home without experiencing distress. As another example, because Alice had already established a regular meal pattern and flexibility in her food choices, she was able to moderately reduce her caloric intake without engaging in disordered restricting behavior. Nevertheless, the increased focus on weight during Phase 3 did increase Alice’s eating disorder cognitions and behaviors.
This also provided a valuable opportunity for Alice to learn to cope effectively with weight loss- related stressors within the context of therapy and reinforced the importance of addressing cognitions as part of eating disorder remission. This is consistent with recent eating disorder recovery models that recommend using a cognitive index of recovery (e.g., absence of disordered 24 WEIGHT LOSS AND BULIMIA TREATMENT eating thoughts) in addition other physical and behavioral indices (Bardone-Cone et al., 2010;
Bardone-Cone et al., 2019; Couturier & Lock, 2006).
Phase 3 also brought with it several challenges related to adapting the HAPIFED protocol to a real-world, outpatient setting. For instance, our community clinic did not have access to an interdisciplinary treatment team of psychologists, dieticians, and exercise physiologists such as the one used in the HAPIFED pilot study (da Luz et al., 2017b). Instead, we relied on Alice’s primary care physician to medically monitor her throughout treatment.
While evidence-based treatments for eating disorders do not require an interdisciplinary treatment teams for successful outcomes (e.g., Fairburn, 2008, Lock et al., 2010), for integrated weight loss and eating disorder treatments it may be beneficial to have access to medical providers and registered dieticians (with specific training in eating disorders) to provide expertise and adjunct treatment options related to physical activity and nutritional counseling. Though an interdisciplinary treatment approach would likely be easiest to implement in an integrated medical setting that houses multiple types of professionals, providers in outpatient community clinics may still benefit from establishing working relationships with relevant outside providers for client consultations and referrals.
Of note, while Alice’s treatment progress and success meant we did not need to coordinate treatment timelines with her surgeon, other mental health providers may need to be prepared to advocate for their clients. This may involve navigating how to educate medical providers about eating disorders and collaborating to establish appropriate timelines and expectations regarding treatment outcomes, including weight loss. This is especially true given evidence that medical providers (a) lack knowledge about eating disorders, (b) do not feel 25 WEIGHT LOSS AND BULIMIA TREATMENT competent to treat eating disorders, and (c) have negative attitudes towards individuals with eating disorders (Anderson et al., 2017; Currin et al., 2009; Thompson-Brenner et al., 2012).
Next, Phase 4 (relapse prevention, termination and post-surgical follow-up) raised challenges related to post-surgical increases in eating disorder triggers. In particular, though
Alice had successfully achieved her treatment goals of BN symptom remission and weight loss, her recovery from the surgery proved to be especially difficult due postoperative factors, including weight loss and loneliness; these factors both increased her risk for binge-purge behavior relapse. We recommend treatment provides work with patients to prepare for coping with common postoperative complications such as nausea, vomiting (Chen et al., 2017), and weight loss that may increase disordered eating urges.
We believe our case study more generally highlights several practical insights related to client self-monitoring. First, our case illustrates the benefit of incorporating a more comprehensive and nuanced daily self-monitoring log that includes tracking appetite cues, exercise, and behavioral urges, in addition to the usual tracking topics (e.g., food/drink intake, context, eating disorder behaviors, thoughts/emotions). Indeed, studies have even shown that comprehensive self-monitoring can be therapeutic in and of itself (Klein et al., 2013), as it allows for patients with eating disorders to better understand their patterns of disordered eating. Our case study suggests that traditional tracking logs for eating disorder treatment may be missing important aspects on the food experience. For instance, emerging work underscores the importance of gastric interoceptive awareness in disordered eating behaviors (van Dyck et al.,
2016; Simmons & DeVille, 2017) and that targeting interoceptive awareness could be beneficial in both eating disorder and obesity treatments (Stevenson et al., 2015, Simmons & DeVille,
2017). Thus, improving awareness of hunger and satiety cues may be a useful treatment target 26 WEIGHT LOSS AND BULIMIA TREATMENT for individuals presenting with the full spectrum of eating disorders (i.e., restrictive, binge-purge type, binge eating), as well as for individuals seeking weight loss.
Despite the benefits of a comprehensive self-monitoring log, requiring a more detailed tracking log may present difficulties with client adherence to tracking. Indeed, individuals seeking treatment for an eating disorder often struggle to complete even traditional eating disorder tracking logs (e.g., Keshen et al., 2020). While self-monitoring adherence was not a problem for Alice due to her high levels of motivation and engagement, providers seeking to use an expanded daily monitoring log may find it helpful to incorporate strategies to improve client adherence. For example, Linehan (2015) describes strategies (e.g., behavior chain and missing links analysis) to reduce ‘therapy interfering behaviors’ related to dialectical behavior therapy diary card completion, which have also proven useful with clients presenting with eating disorders (Wisniewski & Kelly, 2003).
Overall, our case study highlights that self-monitoring – whether it be weighing, documenting food/beverage intake, thought tracking, monitoring disordered eating behaviors/urges, appetite awareness, or physical activity tracking – is not inherently helpful or harmful. Instead, treatment providers need to work with clients to (a) prepare them for the difficulties associated with regular self-monitoring and bringing awareness to certain thoughts or behaviors that may be uncomfortable or triggering, (b) choose the tracking method that is right for them, and (c) learn how to use tracking in a way that is adaptive.
Strengths and Limitations
This case study had several strengths and limitations. First and foremost, caution is warranted when generalizing the findings and recommendations of this single person case study.
This case may have been unique in several respects. Alice was relatively high functioning with a 27 WEIGHT LOSS AND BULIMIA TREATMENT straightforward BN presentation and no major mental health comorbidities. Additional case studies and case series are required to understand how integrated weight loss/eating disorder treatments might differ across client presentations. She was also very engaged and motivated, and demonstrated a high degree of buy-in to the case conceptualization and treatment plan, which likely contributed to the overall treatment success. Future studies may also benefit from explicitly examining factors that impact treatment engagement and adherence, such as therapeutic alliance. It is also important to consider that Alice was working toward a specific weight loss target in a short time frame to receive her surgery. It is possible that our findings and recommendations might not generalize to individuals who do not have external factors keeping them motivated for treatment. Finally, while obtaining follow-up data at six months post- treatment was impressive for a community outpatient clinic, it is worth noting that Alice’s cycles of BN occurred every 1-2 years, thus our follow-up period may not have been long enough to fully capture other relevant treatment outcomes.
Conclusion
Though eating disorder and weight loss interventions have typically been regarded as distinct (or even antithetical), the present case study supports the perspective that an integrated treatment approach is possible in clinical practice and that there is a need for an evidence-based treatment approach. Indeed, our clinical example illustrates how sequential eating disorder and weight loss treatment could be used within a naturalistic community clinical practice setting to help a client with a long history of severe BN achieve eating disorder remission and medically required weight loss. Our six-month post-surgery outcome data suggest sustainability of the client’s treatment gains. Overall, individuals with excess weight and an eating disorder may pursue weight loss at some point, whether that weight loss is medically prescribed or 28 WEIGHT LOSS AND BULIMIA TREATMENT individually motivated. The current case study underscores the need for integrated eating disorder and obesity treatments that are appropriate for the full spectrum of eating disorders (i.e., restrictive, binge-purge, binge eating) and provides some insights for practitioners and treatment researchers working with individuals presenting these simultaneous concerns. 29 WEIGHT LOSS AND BULIMIA TREATMENT References
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Note. Frequency of binges and purges were tracked based on the client’s daily monitoring logs (for binge/purge frequency, see Y-axis on the left). Weight was measured prior to each session (for weight, see Y-axis to the right). Phases are illustrated by shaded regions on the graph: Phase 1 – intake and case conceptualization; Phase 2 – bulimia nervosa intervention using CBT-E protocol; Phase 3 – weight loss intervention using adapted HAPIFED protocol; Phase 4 – relapse prevention, termination, and follow-up. 40 WEIGHT LOSS AND BULIMIA TREATMENT Figure 2 Case Conceptualization