TOPICAL SECTION ARTICLE
A Randomized Comparison of Cognitive Behavioral
Therapy and Behavioral Weight Loss Treatment for
Overweight Individuals with Binge Eating Disorder
Simone Munsch, PhD*
Esther Biedert, PhD
Andrea Meyer, PhD
Tanja Michael, PhD
Barbara Schlup, LicPhil
Alex Tuch, BSc
Juergen Margraf, PhD
ABSTRACT
Objectives: The aim of this study was to
determine the efficacy of cognitive-behavioral therapy (CBT) and behavioral weight
loss treatment (BWLT) for overweight
patients with binge eating disorder (BED).
Method: Eighty obese patients meeting
criteria of BED according to DSM-IV-TR
were randomly assigned to either CBT or
BWLT consisting of 16 weekly treatments
and 6 monthly follow-up sessions. Binge
eating, general psychopathology, and
body mass index (BMI) were assessed
before, during, and after treatment, and
at 12-month follow-up.
Results: At posttreatment results favored CBT as the more effective treatment. Analysis of the course of treatments pointed to a faster improvement
of binge eating in CBT based on the num-
Introduction
The prevalence of binge eating disorder (BED),
which is characterized by persistent overeating episodes, feelings of loss of control, and marked distress in the absence of regular compensatory
behaviors (DSM-IV-TR),1 is 0.7–3.3% in community-based studies and rises to 29.7% in weight control samples (Munsch et al., Eur Eat Disord Rev,.
Submitted for publication).2–6 BED is often accompanied by being overweight and represents a serious threat to mental and physical health.7
Research findings show that BED is responsive to
a variety of procedurally and conceptually different
group treatment approaches, with cognitive-behavioral therapy (CBT) being the best-established psychotherapy treatment.8 Rates of abstinence from
binge eating at the end of CBT range from 41 to 79%
Accepted 13 August 2006
*Correspondence to: Dr. Simone Munsch, at: Institute for Psychology,
University of Basel, Missionsstrasse 62a, 4055 Basel, Switzerland.
E-mail: simone.munsch@unibas.ch
Institute of Psychology, University of Basel, Basel, Switzerland
Published online 6 November 2006 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20350
C 2006 Wiley Periodicals, Inc.
V
102
ber of self-reported weekly binges, but
faster reduction of BMI in BWLT. At 12month follow-up, no substantial differences between the two treatment conditions existed.
Conclusion: CBT was somewhat more
efficacious than BWLT in treating binge
eating but this superior effect was barely
maintained in the long term. Further
research into cost effectiveness is needed
to assess which treatment should be conC 2006
sidered the treatment of choice. V
by Wiley Periodicals, Inc.
Keywords: BED; randomized comparison;
cognitive-behavioral therapy; behavioral
weight loss treatment; long-term efficacy;
end point analyses; course of treatment
(Int J Eat Disord 2007; 40:102–113)
and generally remain improved over baseline levels
until 12-month follow-up.3,9–12 Interpersonal psychotherapy (IPT) is a viable alternative for overweight
patients with BED.12 Further, behavioral weight loss
treatment (BWLT)9,13 and very low calorie diets
(VLCD) are also effective in treating BED.14,15 Studies
directly comparing BWLT with CBT show comparable
effects on binge eating at posttreatment.13,16,17
Guided self-help CBT approaches result in remission rates of about 50% assessed by self-monitoring
and according to the EDE-Q,18 as mentioned by
Carter and Fairburn and by Grilo and Masheb,19,20
which is somewhat lower than reported abstinence
rates achieved with individual administration of
CBT. Guided self-help BWLT as investigated by
Grilo and Masheb (2005) resulted in an abstinence
rate of 18.4% assessed by self-monitoring and of
23.7% assessed by EDE-Q.20
One might consider it advantageous to treat BED
with BWLT, as this treatment does not require the
same professional training as CBT and might thus
be easier to disseminate to a greater population.
However, it would be premature to conclude that
BWLT is the treatment of choice, as several methodological considerations need to be kept in mind:
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
COGNITIVE BEHAVIORAL THERAPY AND BEHAVIORAL WEIGHT LOSS TREATMENT
First, the conclusions that can be drawn from the
comparative studies on CBT and BWLT are limited,
as the rationales of these different types of behavioral treatments have not been described in detail
and hence overlap cannot be excluded. For example, Agras et al.16 only report that they removed
materials about overcoming binge eating from the
lifestyle, exercise, attitudes, relationships, nutrition
(LEARN) weight management program21 to minimize overlap between BWLT and CBT.16 In the Porzelius et al.22 study, both the BWLT and the CBT
were based on the LEARN program and differed
only in the extent of CBT cognitive-behavioral
therapy, in the emphasis on the development of peer
support, and with respect to the techniques for coping with stressful events. In Nauta et al.17 both the
cognitive therapy (CT) and the behavioral therapy
(BT) treatments first focused on eliminating binge
eating and only thereafter included treatment-specific interventions.
Second, up to now, only Nauta et al.17,23 have
compared weight loss strategies to cognitive interventions by assessing data concerning short- and
long-term reduction of binge eating and related
symptoms with a standardized interview (eating
disorders examination, EDE)24 and by accounting
for systematic dropouts with intent-to-treat (ITT)
analyses.17,23 Other reports have been based on either self-monitoring records or on self-report questionnaires (binge eating scale, BES)25 and have
relied solely on completer analyses.9,22
Third, the adherence to either CBT or BWLT has
not yet been assessed in a standardized way. Only a
detailed description of treatment protocols and the
introduction of treatment integrity measures would
enable us to draw definite conclusions about the
comparative efficacy of BWLT and CBT.
In the present study we aimed to clarify the comparative efficacy of weight loss management and
CBT in overweight patients with BED. To avoid
overlap of contents of treatments, the CBT aimed at
reducing binge eating, whereas in the BWLT the
reduction of binges was neither a topic nor a goal.
The BWLT focused on achieving moderate weight
loss through behavioral techniques. We assessed
BED and multidimensional symptomatology, evaluating time course repeatedly through treatment
until 1-year follow-up. In addition, we controlled
whether our therapists adhered to the specific
treatment rationale and whether they were judged
to be equally competent through weekly supervised
sessions and by assessing treatment integrity.
We were further interested in the temporal
course of action in the two treatment conditions.
Different speeds of action suggest that effects are
mediated by different mechanisms.26 Furthermore,
early response has been shown to be a useful predictor of therapy outcome and hence an important
element in evaluating the effects of treatment.27 We
hypothesized that CBT exerts its effects directly by
changing eating behavior and problematic coping.
BWLT is assumed to work indirectly, probably by
insuring regular meals and flexible control over eating. To our knowledge, no data yet exist that document the point of action in CBT and BWLT for BED.
Method
Participants
The study was conducted at the Department of Clinical Psychology and Psychotherapy of the University of
Basel (Switzerland). Men and women outpatients were
recruited through newspaper advertisements. Study inclusion criteria required that participants be between 18
and 70 years old, have a body mass index (BMI) (kg/m2)
ranging between 27 and 40, and meet full DSM-IV-TR1
criteria for binge eating disorder (BED). All patients were
free from unstable medical conditions. Participants were
excluded if they met DSM-IV-TR1 criteria for mental disorders warranting immediate treatment such as suicidal
tendency, psychosis, mania, organic dementia, or substance use disorder. Further exclusion criteria were pregnancy, participation in a diet program, or other psychotherapy, treatment with weight loss medication (current
or during the last 3 months), or previous surgical treatment of obesity. Three hundred seventy-five people contacted the department and underwent a telephone screening (see Fig. 1). Sample characteristics are shown in
Table 1. The study was approved by the local ethics
commission for medical research and participants gave
written consent before participating.
Treatments
Treatment groups consisted of up to seven members. Altogether seven cognitive-behavioral therapy (CBT) and six
behavioral weight loss treatment (BWLT) groups were carried through. All CBT and BWLT groups were led by seven
therapists, who conducted both treatment conditions. The
active treatment phase consisted of 16 weekly 90-min
group sessions. During follow-up treatment 6 monthly 90min group sessions were conducted. The last session took
place 12 months after the end of active treatment.
A therapist and a co-therapist led the groups. The
therapists were fully qualified psychotherapists with specialized training in CBT. Co-therapists were master’s students of the department. Therapists and cotherapists
were trained and supervised weekly by the first and sec-
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
103
MUNSCH ET AL.
FIGURE 1. Summary of participant flow in the cognitive behavioral treatment (CBT) and behavioral weight loss treatment (BWLT) conditions.
104
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
COGNITIVE BEHAVIORAL THERAPY AND BEHAVIORAL WEIGHT LOSS TREATMENT
TABLE I.
Sample characteristics
Study Group
No. of female (%)
No. of male (%)
Mean age in years (SD)
Mean BMI (SD)
No. (%) of participants with
Current comorbidity axis I
Depression
Anxiety disorders
Lifetime comorbidity axis I
Depression
Anxiety disorders
Comorbidity axis II
a
Cognitive
Behavioral
Treatment
(CBT)
(n ¼ 44)
Behavioral
Weight
Loss
Treatment
(BWLT) (n ¼ 36)
40 (90.9)
4 (9.1)
44.4 (11.5)
33.7 (4.3), n ¼ 42a
31 (86.1)
5 (13.9)
47.8 (11.8)
34.4 (3.7), n ¼ 33a
18 (40.9)
4 (9.1)
13 (29.5)
22 (50)
17 (38.6)
5 (11.4)
5 (11.4)
15 (41.7)
4 (11.1)
11 (30.6)
15 (58.3)
17 (47.2)
3 (8.3)
5 (13.9)
n specified if different from sample size.
ond authors (S.M. and E.B.). For a detailed overview over
the two treatments see Table 2.
Group CBT. The manual for the group CBT for BED28
was developed according to the treatment approach of
Fairburn et al.,29 which has proved to be successful.
Group BWLT. BWLT was based on the manual \Weight
Loss with Xenical" (xenicalculiertes Abnehmen).30 This
standardized treatment was developed to foster weight
management and aims at instructing patients to normalize fat intake and to achieve balanced nutrition.
Study Design
Following diagnostic interviews, patients were
randomized according to a permuted block design.31 It
was not possible to keep assessors unaware of group
assignment. Each treatment group started when five to
seven patients had been recruited. This recruitment procedure resulted in a slight imbalance in sample size
between the two treatment conditions. In addition, for
the last group of patients recruited in the CBT condition
there was no corresponding BWLT group, resulting in the
sample sizes shown in Table 1.
Assessments
Eating Disorder Psychopathology. Core symptomatology of BED was assessed using Hilbert et al. ’s24 German
version of the EDE.32 BED diagnosis relied on the EDE
and was in accordance with DSM-IV-TR1 research criteria. We assessed number of objective binge days (OBE)
and abstainer rates (proportion of patients not experiencing a binge during the last 28 days of therapy). The
EDE assesses symptoms related to binge eating such as
dietary restraint, eating, and concern about weight and
shape and has been shown to be able to track changes in
binge eating and eating disorder pathology.33 It was not
possible to assess interrater reliability of the interviews.
Further, patients recorded their number of weekly binges
according to DSM-IV-TR criteria by self-monitoring.
Body Mass Index. Weight and height were measured on
a Seca electronic balance scale (Seca, Vogel þ Halke, Germany) and by a stadiometer. BMI was calculated as
weight in kilograms divided by the square of height in
meters.
Assessment of Mental Disorders. The screenings for
mental disorders on axis-I (Diagnostisches Kurzinterview
bei psychischen Störungen, Mini-DIPS)34 and axis-II
(Strukturiertes Klinisches Interview für DSM-IV, Achse-II,
Persönlichkeitsstörungen, SKID-II)35 were administered
to assess current and lifetime mental disorders. Standardized administration of the interviews by master’s students of the department was ensured with weekly supervision by two of the authors (S.M. and E.B.).
Depression and Anxiety. Participants completed the
German version of the Beck depression inventory (BDI)36
from Hautzinger et al.37 and the Beck anxiety inventory
(BAI).38
Life Satisfaction and Estimates of Self-Efficacy. The
questionnaire on life satisfaction (Fragebogen zur LebenszufriedenheitModule, FLZm)39 was administered to assess
overall satisfaction with life, as well as satisfaction with
different areas such as work, income, home, family and
children, friends, and hobbies. Further, satisfaction with
health issues such as energy, mobility, constitution, and
physical appearance were reported.
Additionally the general self-efficacy scale (Allgemeine
Selbstwirksamkeits-Skala, SWE) from Jerusalem and
Schwarzer was administered.40 The SWE is a unidimensional self-report scale with 10 items according to assess
estimation of self-efficacy in critical situations and to
predict subsequent coping behavior.41
Sociodemographics were assessed at baseline. Psychopathology, eating disorder pathology, and BED diagnosis
were assessed at baseline, at the end of treatment, and at
12-month follow-up. Anxiety (BAI), depression (BDI), life
satisfaction (FLZ), and self-efficacy (self-efficacy scale;
SWE) were assessed at treatment start, at the end of treatment, and at 12-month follow-up. BMI was assessed at
baseline, at treatment start, at the end of treatment, and
at 12-month follow-up. Finally, subjective binges were
self-monitored weekly during treatment and in the week
before each of the 6 monthly follow-up sessions until 12month follow-up.
Note that BMI was assessed before the treatment sessions, whereas other outcome variables were assessed
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
105
106
Long-term success of weight reduction
Relapse prevention
Introduction of follow-up treatment
13
14
15
16
2
3
4
5
6
1
Maintaining changes and problem solving
Modification of body concept
Cognitive therapy of irrational cognitions
associated with eating behavior
Cognitive therapy of dysfunctional
shape concerns
Etiology of overweight
10
11
12
Understanding of the development of
body concept and its influence on
BED maintenance; modification
of body concept
9
8
6
7
4
5
Goal setting; stabilizing reductions
of binge eating
Regulating eating behavior; identifying binge
eating cues
Identifying binge eating cues
Symptom management
3
2
Understanding etiology and treatment
of BED; identifying problem behavior
Goal setting; clarifying treatment motivation
Goals
1
Session
Overview of treatments
Note: FUT, Follow-up treatment.
FUT
3
2
1
Phase
TABLE 2.
Reappraisal of goal achievement
and new goal setting
Reappraisal of goal achievement and new
goal setting; individual problem solving
Body exposure training
Identification and modification
of irrational cognitions
Identification and modification of dysfunctional
cognitions about the own body
Psychoeducation about balanced nutrition;
realistic weight goals
Psychoeducation about fat-normalized nutrition;
increasing physical activity
Coping with actual and future risk situations
Reappraisal of goal and new goal setting;
identification of individual risk
situations and development of
coping strategies
Psychoeducation
Establishing an individual daily food intake plan;
behavioral analysis (ABC-model)
ABC-model; cue and reaction control techniques
Identifying individual binge eating cues and
developing individual coping strategies
Psychoeducation; self-monitoring of
eating behavior
Individual problem and goal analysis
Techniques/Interventions
CBT
Weight loss maintenance
Relapse prevention
Fat-normalized eating
in social situations
Understanding triggers
of unplanned eating
Increasing physical activity
Understanding etiology and
treatment of obesity
Weight loss goals; fat-reduced
nutrition (sessions 2–8)
Goals
Repetition: weight course
Repetition: physical activity
Repetition: fat-normalized nutrition
Repetition: eating in social situations
Realistic weight goals
Repetition: flexible control of eating
Identifying and coping with
risk situations
Coping with possible risk factors for
high-fat nutrition
Psychoeducation about stress-related
eating
Psychoeducation about the role
of physical activity in weight
reduction; establishing individual
plan to increase physical
activity (sessions 9–10)
Practical exercise; cooking
fat-normalized meals
Practical exercise; fat-normalized
eating out
Self-monitoring of fat intake;
establishing balanced
nutrition in daily life;
flexible control of eating
(sessions 2–6)
Psychoeducation
Techniques/Interventions
BWLT
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International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
COGNITIVE BEHAVIORAL THERAPY AND BEHAVIORAL WEIGHT LOSS TREATMENT
through mailed questionnaires or during separate interview dates. As a consequence the number of nonmissing
values varied slightly among the different outcome variables (see Table 3 in Results).
Integrity of Treatment. After completion of all treatment groups, two independent raters (students of clinical
psychology holding a bachelor’s degree) coded 10 CBT
and 10 BWLT videotaped sessions using a 29- or 35-item
questionnaire (number of items depended on treatment;
unpublished questionnaire, available from the authors).
Neither rater acted as a therapist or cotherapist in the
treatment trial. For both CBT and BWLT four sessions
from phase 1 and 3 each from phases 2 and 3 were randomly selected. Raters were blind regarding the session
and condition they were rating. The ratings included
questions about treatment modality (CBT vs. BWLT),
treatment phase (beginning, middle, end of treatment),
treatment-specific features (e.g., for CBT: \Did the therapist train the participant to cope with binge eating?"; for
BWLT: \Were realistic weight loss goals targeted?"), and
nonspecific treatment indices (e.g.: \Did the therapist
structure the session clearly?").
Suitability of Treatment. Suitability of treatment was
assessed after the first group session, after treatment,
and at 12-month follow-up. Participants rated the statement \I think another procedure would be more suitable
for me"42 on a scale ranging from \not at all" (3) to
\exactly" (þ3).
Statistical Analyses. The primary outcome measures
included number of OBE, diagnosis of BED, abstainer
rates, number of weekly binges assessed by self-report,
and BMI. The secondary outcome measures included the
number of weekly binges assessed by self-report, eating
behavior (four different EDE scores), BDI, BAI, participant ratings of self-efficacy, and life satisfaction.
We used two different models to analyze the data.
First, changes in outcome variables between baseline
and posttreatment and between posttreatment and 12month follow-up were analyzed using linear mixed models for normally distributed outcomes43 and generalized
linear mixed models (GLMMs) for dichotomous and
counted data.44 These models tested whether the two
treatments, when taken together, were effective in treating BED patients. In mixed models, participants with
missing data are not omitted from the analysis and missing values are estimated. The number of measurement
times varied across the different outcomes (see above).
The number of self-reported weekly binges and BMI
were measured most frequently for practicality reasons
and to account for the core symptoms of BED and the
major medical complication. For these two outcome
measures, we were able to test how the temporal course
of an outcome changed throughout the study period and
whether it was affected by treatment (Time Treatment
interaction).
Second, we used univariate models to compare outcome variables between the two treatments at two specific time points: end of treatment and end of follow-up.
For all outcome measures, except those mentioned
below, we used analysis of covariance with the therapy
condition as a planned factor and, to increase test power,
the baseline value of the outcome variable as the covariate.45 For the analysis of the number of weekly binges
and of OBE, we used a generalized linear model assuming Poisson-distributed data. For the diagnosis of BED
we used a logistic model. We used intent-to-treat (ITT) as
well as completer analyses for the univariate models. For
the ITT analysis missing values were replaced with the
last observed value of each patient (last observation carried forward).
Finally, to test whether BMI at the end of follow-up
was influenced by the binge status at the end of treatment, we used univariate analysis of variance with the
number of OBE at posttreatment, treatment group, and
BMI at baseline as independent variables.
Results
Dropouts
Twenty-two participants (27.5%) dropped out
during treatment: 13 (29.5%) in CBT and 9 (25.0%)
in BWLT. During follow-up 3 participants withdrew
from CBT and 4 from BWLT. There were no significant differences in dropout rates between the two
treatment conditions between baseline and 12month follow-up (w21 ¼ 0.001, p ¼ .582). We further
tested for possible differences in participant characteristics between completers and dropouts of the
BED treatment for the following variables: sex, age,
BMI, depression (BDI), anxiety (BAI), EDE global
score (EDE), and comorbid mental disorders. None
of the comparisons between dropouts and completers reached statistical significance (p-values >
.05 for all comparisons; analyses based on t -tests or
Fisher’s exact tests/Pearson’s w2 test, respectively).
Compliance and Suitability
Patients attended on average 10.77 (64.8) or
67.3% and 10.75 (64.7) or 67.1% of all sessions during the active treatment phase in CBT and BWLT,
respectively. During follow-up, participants attended 2.7 (62.3) or 45% and 3.3 (62.3) or 55% of
the six monthly sessions in CBT and BWLT, respectively. There were no significant differences in com-
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
107
108
43
42
Abstainers
BMI
33.66
0%
100%
14.23
M
4.31
—
—
7.66
SD
33
36
36
35
N
34.36
0%
100%
14.17
M
BWLT
3.74
—
—
8.09
SD
30
44
Intent-to-treat
44
Intent-to-treat
Completer
25
44
Intent-to-treat
Completer
26
44
Intent-to-treat
Completer
25
Completer
N
33.58
33.62
41%
80%
50%
4%
6.20
0.56
M
CBT
4.53
4.70
—
—
—
—
8.66
2.06
SD
36
27
36
22
36
22
35
23
N
Posttreatment
32.29
33.08
58%
36%
78%
32%
7.54
2.70
M
BWLT
4.00
3.69
—
—
—
—
9.38
4.43
SD
¼ 33.3
p <.001a,b,c
21 ¼ 2.91
p <.088a,b
21 ¼ 7.26
p <.007d
21 ¼ 2.40
p ¼.12d
21 ¼ 9.56
p ¼ .002d
21 ¼ 6.74
p ¼ .010d
F1,61 ¼ 8.8
p ¼ .004b
F1,61 ¼ 17.5
p < .001b
21
44
23
44
16
44
17
44
15
N
33.10
32.36
52%
94%
43%
6%
4.84
0
M
CBT
5.04
5.38
—
—
—
—
8.00
0
SD
36
21
36
18
36
19
35
18
N
33.18
33.62
50%
89%
53
16
5.77
1.00
M
BWLT
12-Month Follow-up
4.17
3.99
—
—
—
—
9.15
2.93
SD
p <.001a,b,c
21 ¼ 0.01
p <.92a,b
21 ¼ 0.92
p ¼ .33d
21 ¼ 0.04
p ¼.84d
21 ¼ 0.254
p ¼.614d
21 ¼ 0.74
p ¼ .39d
F1,61 ¼ 0.15
p ¼ .70b
F1,61 ¼ 2.3
p ¼ .13b
21 ¼ 15.94
Notes: Values denote sample size (N), mean (M) and standard deviation (SD) and are not based on any statistical model. Test statistics and p-values refer to a univariate model comparing the CBT and BWL
treatments and therefore do not correspond directly to the means in the table. Note that the sample size in the intent-to-treat analysis does not necessarily correspond to the number of patients as they were
randomized. This is because these univariate models use the baseline value of the outcomes as covariate, which were not available for all patients, leading to a slight reduction in sample size.
a
Based on generalized linear model with Poisson errors.
b
Based on analysis of covariance model.
c
Problematic fit due to high number of zeros.
d
Based on logistic regression model.
44
43
Objective
binge days
BED diagnosis
N
CBT
Pretreatment
Primary outcomes by treatment and measurement time
Variable
TABLE 3.
MUNSCH ET AL.
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
COGNITIVE BEHAVIORAL THERAPY AND BEHAVIORAL WEIGHT LOSS TREATMENT
pliance between the two treatment conditions (t78
¼ 0.02, p ¼ .98 for active treatment phase; t78 ¼
1.0, p ¼ .29 for follow-up).
Patients in CBT rated suitability of treatment
(1.32 6 1.42) similarly to patients in BWLT (0.63
6 1.14) after the first session (t64 ¼ 1.95, p ¼ .06).
At posttreatment suitability ratings were improved
in both modalities and were again comparable
(1.74 6 1.42 in CBT and 1.10 6 1.42 in BWLT; t40
¼ 1.56, p ¼ .12). At 12-month follow-up patients
in CBT rated suitability higher (5.50 6 1.03) than
did patients in BWLT (1.25 6 1.13; t26 ¼ 3.03,
p < .01).
Treatment Integrity
Raters identified 100% of CBT and BWLT sessions
correctly. Video tapes were classified into treatment
phase with an accuracy of 95% (w24 ¼ 34.29, p <
.001; Cohen’s ¼ 0.92, p < .001). Treatment-specific criteria significantly differentiated among
treatment modalities (t18 ¼ 6.17; p < .001 for CBTspecific index and t18 ¼ 5.86; p < .001 for BWLTspecific index), whereas nonspecific features did
not (t18 ¼ 1.93; p ¼ 0 .07). Interrater reliability was
satisfactory with a coefficient of 0.82 (p < .001)
for specific indices and 0.62 (p < .001) for unspecific indices. Overall ratings of therapeutic skills did
not differ between the two treatment conditions
(t18 ¼ 1.93, p ¼ .07).
Primary Outcomes
Efficacy of Treatment Conditions. Both treatments for
BED proved to be efficacious, as all primary variables were strongly improved between baseline and
posttreatment. Number of OBE, percentage of
patients with a diagnosis of BED, and BMI were all
significantly reduced, and abstainer rates significantly increased until the end of treatment (p <
.001 for all outcomes using linear mixed models or
GLMMs; see Table 3).
However, progression between posttreatment and
end of follow-up showed a somewhat different picture. Whereas for the number of OBE (p ¼ .014) and
for the abstainer rates (p ¼ .008) significant improvements were observed, nonsignificant changes were
found for the percentage of patients with a diagnosis
of BED (p ¼ .38) and for BMI (p ¼ .068).
Comparison Between CBT and BWLT.
Post treatment. Completer analyses revealed that
CBT usually performed better than BWLT with respect to primary outcomes at posttreatment. Thus
OBE, BED diagnoses, and abstainer rates were all
significantly improved in CBT compared with
BWLT, whereas the BMI was significantly higher in
CBT than in BWLT (Table 3). The ITT analyses lead
to results that were comparable to those of the completers, though less in favor of the CBT treatment as
only abstainer rates were still significantly improved
in the CBT compared with BWLT (Table 3).
12-month follow-up. At 12-month follow-up effects
of both CBT and BWLT groups on primary outcomes were comparable in both ITT and completer
analyses (Table 3).
ITT (F1,74 ¼ 20.76, p < .001) and completer analyses (F1,46 ¼ 22.38, p < .001) both revealed a significant influence of rates of abstinence from binge
eating on BMI at 12-month follow-up. Thus at posttreatment, participants who abstained from binge
eating lost more weight than participants who still
engaged in binge eating behavior.
Secondary Outcomes
For the secondary outcomes, we found strong and
significant decreases between baseline and posttreatment for the EDE subscales, number of selfreported weekly binges, and the BDI (p < .001 for
each outcome, using linear mixed models). With
regard to the BAI we found no change (p ¼ .19),
whereas for self-efficacy (p < .001) and life satisfaction (p ¼ .02) significant increases between baseline
and posttreatment were observed (Table 4). Secondary outcomes did not differ between posttreatment
and end of follow-up (p > .10) except for self-efficacy, which increased (p ¼ .036), and the BAI, which
decreased (p ¼ .009) in that period.
Both ITT and completer analyses revealed no significant differences between CBT and BWLT at the
end of treatment and at the end of follow-up for
any secondary outcome (p > .10 for each outcome
and both time points using univariate models;
Table 4, only results of completer analyses are
shown) with two exceptions: for both ITT and completer analyses the number of self-reported weekly
binges was significantly smaller in CBT compared
with BWLT at both posttreatment and 12-month follow-up, and BAI values were higher in BWLT compared with CBT at the end of follow-up (Table 4).
For the number of self-reported weekly binges
and BMI, we were particularly interested in the
comparison of their trajectories between the two
treatment conditions. Figures 2 and 3 show the fitted lines that follow hyperbolic curves, which
explain the data of both outcome measures better
than straight lines or additional quadratic and cubic
polynomials (main effect for reciprocal of time suggesting a hyperbolic curve, p < .001 for both outcomes, linear mixed model). Strong declines were
observed during the first 8 weeks of treatment fol-
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
109
110
1.31
1.08
1.01
1.06
9.16
12.95
4.87
2.80
2.20
3.98
3.71
1.85
15.14
13.79
28.08
4.94
36
36
36
36
33
34
30
27
1.81
3.41
3.13
1.69
11.82
10.74
26.03
5.13
4.10
3.47
3.81
29
M
N
SD
M
1.23
1.22
1.37
1.22
6.72
9.43
5.74
2.93
3.71
SD
M
0.14
0.97
2.04
2.06
0.35
9.16
9.72
29.78
6.10
N
28
25
25
25
25
31
32
32
25
CBT
1.12
1.48
1.36
0.67
7.80
10.15
4.21
3.07
0.45
SD
23
23
23
23
26
27
27
23
26
N
Posttreatment
0.83
1.85
1.69
0.37
9.19
11.07
28.85
5.55
1.15
M
BWLT
0.82
1.45
1.13
0.45
6.54
9.46
4.11
2.97
1.89
SD
*
F1,45 ¼ 0.15, p ¼ .70
F1,45 ¼ 0.04, p ¼ .84
F1,45 ¼ 0.37, p ¼ .55
F1,45 ¼ 0.18, p ¼ .67
F1,51 ¼ 1.30, p ¼ .26
F1,52 ¼ 1.67, p ¼ .20
F1,55 ¼ 0.53, p ¼ .49
F1,40 ¼ 0.62, p ¼ .81
¼ 13.4, p <.001
2
Test Statisics
and p-Values
16
16
16
16
22
23
23
22
23
N
1.14
1.87
1.75
0.23
8.23
6.30
31.91
7.81
0.52
M
CBT
1.03
1.39
1.33
0.31
11.31
10.10
4.81
3.92
1.59
SD
18
18
18
18
21
21
21
20
14
N
1.06
1.44
1.37
0.14
7.76
11.00
29.90
5.92
1.50
M
BWLT
12-month follow-up
0.88
1.32
1.01
0.15
6.48
12.17
4.10
3.41
2.14
SD
F1,31 ¼ 0.06, p ¼ .81
F1,31 ¼ 0.15, p ¼ .71
F1,31 ¼ 0.01, p ¼ .92
F1,31 ¼ 0.39, p ¼ .54
F1,38 ¼ 2.26, p ¼ .14
F1,38 ¼ 9.16, p ¼ .004
F1,41 ¼ 3.02, p ¼ .09
F1,34 ¼ 0.24, p ¼ .63
2 ¼ 4.0, p <.045*
Test Statistics and p-Values
Notes: Values denote sample size (N), mean (M) and standard deviation (SD) of completers and are not based on any statistical model. Test statistics and p-values refer to an analysis of covariance model
(except for * which is based on generalized linear model with Poisson errors) comparing the CBT and BWL treatments with the baseline variable of the outcome as covariate. Note that the results of the mixed
models testing for changes between pre- and posttreatment and between posttreatment and 12-month follow-up are shown in the text only and not in the table.
44
44
44
44
37
34
39
39
37
N
BWLT
CBT
Pretreatment
Secondary outcomes of completers by treatment and measurement time
Nuber of weekly binges
(self-reported)
EDE: dietary restraint
EDE: shape concern
EDE: weight concern
EDE: eating concern
BDI
BAI
Self-efficacy
FLZ: total score
Variable
TABLE 4.
MUNSCH ET AL.
FIGURE 2. Temporal course of the number of selfreported weekly binges by treatment. Estimates are based
on a linear mixed model.
FIGURE 3. Temporal course of BMI by treatment. Estimates are based on a linear mixed model.
lowed by very weak declines thereafter. These early
declines were significantly stronger in CBT than in
BWLT (Treatment Time interaction, F1,76.4 ¼ 5.5,
p ¼ .022) for the number of weekly binges, whereas
for BMI the opposite trend was observed (F1,165.3 ¼
6.54, p ¼ .011; see Figures 2 and 3).
Conclusion
In general both CBT and BWLT reduced binge eating and related symptoms significantly. In other
words, our group-administered BWLT was efficacious in reducing BED-associated symptoms, confirming the findings of Gladis et al.46 and Goodrick
et al.47 The treatment outcomes with respect to abstinence and BED diagnosis rates in our ITT analy-
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
COGNITIVE BEHAVIORAL THERAPY AND BEHAVIORAL WEIGHT LOSS TREATMENT
ses corroborate response rates reported in several
previous studies3,9,13,16,48 but were lower compared
to the Nauta et al.17,23 and Wilfley et al.12 studies.
This difference can be partially explained by our
data-processing procedure: because we replaced
missing values by carrying the last observed values
forward to account for our rather high drop-out
rate, obtained estimates might have been biased,49
especially for variables that were measured less often. Hence, for example, the abstainer rates at posttreatment (44% for ITT, 80% for completers) and
12-month follow-up (52% for ITT, 94% for completers) were considerably higher for completers.
The major aim of the study was to compare CBT
with BWLT for obese BED patients. This design was
chosen because both treatment modalities have
been shown to be superior to wait-list conditions.50
We avoided overlap of CBT and BWLT rationales
and ensured therapists’ adherence to treatment
protocols. Participants were equally compliant in
the two treatment conditions. Their suitability ratings were in favor of CBT, but they judged both
treatments as appropriate for coping with their disordered eating behavior. Further, participants in
our treatment trial presented with substantial
comorbidity rates of mental disorders that are
comparable to those mentioned by Wilfley et al.12
Thus the treatment outcome cannot be attributed
to exclusion of poor-prognosis patients. The results
are likely to stem from different but equally efficacious techniques in the two treatments rather than
from nonspecific factors. At posttreatment, CBT
was somewhat superior to BWLT with respect to
the core symptoms of binge eating, particularly
when analyzing completers and less when applying
ITT analyses. At the12-month follow-up the two
groups performed equally well.
Our analyses further showed that patients in the
BWLT condition had reduced their BMI to a greater
extent at posttreatment than patients in the CBT
condition, and that at follow-up patients in both
CBT and BWLT maintained their weight relative to
posttreatment. Although our patients’ BMI reductions were not of clinical relevance, these findings
can be positively interpreted in light of the ongoing
weight gain observed in untreated BED patients.51
This result is especially noteworthy for BWLT, as it
contrasts with a recent study by Grilo and Masheb,20
who found that guided self-help BWLT resulted in
reduction of neither binge eating nor body weight.
Results of the secondary analyses underlined the
similarity of treatment outcomes in CBT and BWLT.
All patients showed a similar improvement in measures of concerns about shape, weight, and eating,
depression, life satisfaction, and estimates of self-efficacy.52,53 In line with previous research, posttreatment abstinence rates were significantly related to
weight at 12-month follow-up in both CBT and
BWLT.10,12,17
Our results contradict findings of Nauta et al.17,23
who reported equal efficacy of behavioral and cognitive strategies at posttreatment but better outcome
of cognitive interventions at 6- and 12-month follow-up. How can this be explained? First, according
to the Nauta et al.17,23 study, it is possible that participants in our CBT condition might have suffered
from a more comprehensive but less pure and intensive treatment whereas participants in the BWLT
condition might have benefited from a more intensive training in weight-loss strategies. But in the
Nauta et al.17,23 study patients in both treatment
conditions first focused on ceasing binge eating, so
the argument about the positive effect of pureness of
therapy on treatment outcome has to be questioned.
Second, if we consider studies reporting similar
effects for CBT, weight loss programs, and IPT,54 it
could also be hypothesized that BED responds to
general mechanisms of psychotherapy such as
structuring, care giving, and therapeutic alliance
(Munsch S. In preparation). Because for ethical reasons we could not add an unspecific but \credible"
control group condition12 to account for nonspecific influences of attention12,20,51 we cannot draw
definite conclusions about the specificity of CBT
and BWLT for BED nor about the level of the placebo response that has been shown in some BED
treatment studies.55
Third, the partial lack of treatment differences
could be explained by the operation of common factors such as the reduction of irregular eating behavior.56 But as IPT and CBT are shown to have similar
effects on BED, this argument is weakened.12
There are two other limitations of our study that
should be considered: First, the randomization procedure resulted in a slightly unequal number of
groups treated with BWLT and CBT. The last CBT
group was run without a corresponding BLWT
group, leading to a possible confounding between
treatment condition and seasonal effects on weight
loss.57,58 Second, due to our small sample size it
might be argued that we were simply unable to
detect meaningful differences between treatment
conditions. Our conclusion that BED participants
benefit equally from CBT and BWLT should be verified in studies using larger sample sizes.
Considering the temporal course of our treatments, treatment-specific strategies seem to work
through different mechanisms, acting differently
International Journal of Eating Disorders 40:2 102–113 2007—DOI 10.1002/eat
111
MUNSCH ET AL.
within particular phases of therapy but resulting in
a comparable treatment outcome. In other words,
CBT focuses on and reduces weekly binges faster
and to a greater extent than BWLT does throughout
treatment. In contrast, BWLT, which is designed to
target weight management, exerts its effect on
body weight earlier than CBT.
To determine the treatment of choice, future
research should acknowledge cost effectiveness
and test whether BWLT could also be applied by
nutritionists, making it easier and less expensive to
disseminate. In an ongoing study we are reevaluating our results of a fast, significant reduction in
binge eating within the first 8 weeks of a CBT treatment (Schlup B. In preparation). If a shortened
CBT turns out to be equally effective in the longterm, then CBT might be superior and similarly
cost effective, because it acts earlier on the core
symptomatology of binge eating.
13.
14.
15.
16.
17.
18.
19.
20.
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