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Weight Loss and Bulimia Treatment 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
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