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Berkman ND, Brownley KA, Peat CM, et al. Management and Outcomes of Binge-Eating Disorder [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. (Comparative Effectiveness Reviews, No. 160.)
Background
Definition of Binge-Eating Disorder
Binge-eating disorder (BED) is characterized by recurrent episodes of binge eating (i.e., eating episodes that occur in a discrete period of time [≤2 hours] and involve the consumption of an amount of food that is definitely larger than most people would consume under similar circumstances). Other core features of BED are a sense of lack of control over eating during binge episodes, significant psychological distress (e.g., shame, guilt) about binge eating, and the absence of recurrent inappropriate compensatory behaviors.
In May 2013, the American Psychiatric Association (APA) recognized BED as a distinct eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).1 Previously (in the DSM-IV), BED had been designated as a provisional diagnosis in need of further study for two main reasons: the literature on BED was insufficient in size and scope and the available tools for measuring and diagnosing the syndrome in clinical and community settings were too inconsistent to consider BED a distinct eating disorder. The provisional diagnostic criteria gave clinicians and researchers a working definition of BED with a common language they could use for studying BED.
Table 1 presents the DSM-IV and DSM-5 diagnostic criteria for BED. In the shift from provisional to formal diagnosis for BED itself, APA experts changed the criteria for frequency and duration of BED based on the expanded peer-reviewed literature. Specifically, the frequency criterion was reduced from twice per week to once per week, and the duration criterion was reduced from 6 months to 3 months, bringing the criteria in line with those for bulimia nervosa.
Table 1
DSM-IV and DSM-5 diagnostic criteria for binge-eating disorder.
Experts expect that the shift from provisional to formal diagnosis will facilitate reimbursement for clinicians and insurance coverage for patients. In addition, the changes in frequency and duration criteria will likely result in more individuals being diagnosed with BED (i.e., individuals previously labeled as having “subthreshold” BED because their binge-eating frequency or duration was below criterion levels will now meet full diagnostic criteria). In a study of more than 13,000 adult females in Sweden, the BED lifetime prevalence estimate increased linearly as the binge frequency criterion decreased.2 Similarly, the percentage of bariatric surgery patients diagnosed with BED increased by 3.4 percent when using DSM-5 compared with DSM-IV criteria.3 In this review, we highlight which of the two definitions of BED investigators used in individual studies to examine whether any differences affected outcomes.
Prevalence of BED
According to the National Comorbidity Survey Replication, the lifetime prevalence of BED among adults in the United States is 2.8 percent based on DSM-IV criteria;4 it may be slightly higher based on DSM-5 criteria.2,3 BED is more common among women (3.5 percent) than men (2 percent) and among younger and middle-aged adults than among those over age 60 years.4 In a recent community-based World Health Organization survey of more than 24,000 adults older than 18 years of age living in 14 mostly upper-middle and high-income countries, the lifetime prevalence ranged from 0.2 percent to 4.7 percent; the United States had the second highest prevalence (2.6 percent) overall.5
Field- and community-based screening studies suggest the prevalence of BED may be higher among obese than nonobese individuals, particularly when those screened are individuals seeking treatment for their obesity.6–9 According to the National Latino and Asian American Study of over 4,500 adults living in the United States, the lifetime prevalence of BED appears to be slightly lower among Latino- and Asian-Americans (1.9 percent and 2.0 percent, respectively) compared with the general population.10,11 Smaller studies using various assessment methods have yielded mixed findings regarding differences in binge-eating behavior among whites and blacks.12,13
BED is typically first diagnosed in young adulthood (early to mid-20s),14 and symptoms often persist well beyond midlife.15 The general course of illness sometimes includes crossover to and from other eating disorders such as bulimia nervosa and anorexia nervosa.14,16,17 BED is associated with significant role impairment4,5 and relationship dissatisfaction;18 it is considered a significant public health problem independently as well as for its association with chronic pain, other psychiatric disorders, obesity, and diabetes.19–21
Loss of Control (LOC) Eating
A sense of LOC during binge episodes is a core feature of BED. The term “LOC eating” is used to describe these episodes, but it is also used more broadly throughout the literature to describe binge-like eating behavior accompanied by a sense of LOC that occurs across a wide spectrum of individuals. That spectrum includes, among others, individuals who exhibit some features of BED but do not meet full diagnostic criteria for the disorder (i.e., subthreshold BED) and individuals with other eating disorders (bulimia nervosa, anorexia nervosa binge-eating/purge subtype).
The spectrum of those described as exhibiting LOC eating also includes individuals for whom diagnosis of threshold BED is challenging for unique reasons, such as postbariatric surgery patients and young children. Bariatric surgery significantly reduces the stomach size and capacity, effectively rendering it physically impossible for a patient to meet BED criterion 1a (Table 1; i.e., to consume a “definitely large” amount of food). In the bariatric surgery literature, LOC eating is used not only to describe binge-like behavior that falls short of meeting criterion 1a, but also to describe eating behavior that is contraindicated based on meal size and meal content. Children, especially young children, may not meet the BED criterion 1a because their parents or others limit the quantity of food they consume or because they are unable to provide accurate quantification of the amount they eat. For the purposes of our review, LOC eating treatment and outcomes are limited to postbariatric surgery patients and children and does not include individuals in other groups who may meet sub-clinical diagnosis of BED.
LOC eating has detrimental psychological and physical health effects,22,23 including significant distress and symptoms of depression,24,25 and may be related to excess weight gain in children and suboptimal weight loss and weight regain in postbariatric surgery patients.26 As bariatric surgeries have become more commonplace in the treatment of severe obesity, clinical observations suggest that persistent binge eating as a continuation of presurgical BED or as de novo LOC eating subsequent to bariatric surgery may be an important risk factor for poorer outcomes; these may include less initial excess weight loss and impaired quality of life.22,27–29 In light of these significant concerns about the health impact of LOC eating in bariatric surgery patients and children, for the purposes of this review, we elected to focus on studies of LOC eating in these two subgroups. Because this literature is emerging and no consensus definition of LOC eating exists, for our review we did not attempt to define LOC eating strictly a priori; rather we included studies of participants that met the definition of LOC eating as set forth by the study authors.30
Prevalence of LOC Eating
The prevalence of LOC eating is unknown. In postbariatric surgery patients, it may be as high as 25 percent.31,32 In children at risk for adult obesity, because of either their own overweight (body mass index [BMI] at or above the 95th percentile) or that of their parents (BMI greater than 25 kg/m2), prevalence may be as high as 32 percent.23 Adolescents who identify as lesbian or gay are 2.1 and 7.2 times, respectively, more likely to report LOC eating than their heterosexual counterparts.33 In a study of 409 obese, weight loss treatment-seeking youth, based on parents’ reports of their children’s eating behavior, white and Hispanic youth were more likely to engage in LOC eating (defined by criteria 1a and 1b in Table 1 above) than black youth.34
Current Challenges and Controversies in Diagnosing These Conditions
In making a diagnosis of BED, assessing whether a patient is eating an atypically large amount of food is not wholly quantitative. In the diagnostic process, it is not uncommon for the patient to describe binge-eating episodes that vary greatly in size and to have difficulty distinguishing between objective and subjective episodes because both are associated with a sense of LOC and engender significant distress. The diagnosis is sensitive to detection bias because the clinician must make the distinction between objective and subjective binge-eating episodes without clear metrics for either and based on a patient’s self-report.30
Nevertheless, assessment by a structured clinical interview is considered the gold standard. The most widely used and accepted interview methods include the Structured Clinical Interview for DSM Disorders (SCID),1,35 the Eating Disorder Examination (EDE),36 and the Structured Interview for Anorexic and Bulimic Syndromes (SIAB-EX).37 For this review, we included only studies in which participants were identified as meeting DSM-IV or -5 criteria for BED as determined through a structured interview. Table 2 describes instruments that may be used to make these diagnoses, along with other tools used to assess BED-related psychopathology.
Table 2
Common diagnostic and outcome measures used in the included trials.
Assessing BED and LOC eating in children poses unique challenges. Neither the DSM-IV nor DSM-5 established a minimum age for a diagnosis of BED. In practice, when assessing adolescents, some clinicians focus on LOC eating and others assess more broadly the criteria for BED. Typically, the term LOC eating is used more consistently when focusing on preadolescents or younger children who may not meet the BED criterion 1a with respect to the amount of food consumed. An added challenge stems from the difficulty that some children have in describing LOC. LOC eating has no consistently endorsed definition, and assessment techniques lack standardization. For this review, using input from our Technical Expert Panel (TEP), we included studies of LOC eating in children ages 6 years or older. We set this lower age limit partly to avoid capturing studies of infant feeding in our literature searches; it is consistent with the direct experience of one of our TEP members in assessing LOC eating by questionnaire in children as young as 6 years old.
In the postbariatric setting, the definition of LOC eating is not straightforward, and the assessment of LOC eating also lacks standardization but for reasons different from those for children. The definition is not straightforward because some patients may report their disordered eating behaviors as a general subjective sense of lack of control over their eating rather than in terms of specific overconsumption based on the amount of food. Also, LOC eating may manifest in the consumption of food types and patterns of intake that are contraindicated after surgery, so the lack of control is related to adhering to the recommended nutritional plan. Using TEP input, for this review we included studies that measured both subjective and objective LOC eating; including subjective LOC eating as an outcome permitted us to examine nonstandardized detrimental eating behaviors that are relevant to the well-being of postbariatric surgery patients.
Current Challenges and Controversies in Treating These Disorders
Current Treatment Options for BED
Treatment for BED includes various approaches that target the core behavioral features (binge eating) and psychological features (i.e., eating, weight, and shape concerns; distress) of this condition. Other important targets of treatment include metabolic health (in patients who are obese, diabetic, or both) and mood regulation (in patients with coexisting depression or anxiety, for example). Commonly used approaches are described in Table 3.
Table 3
Psychological and behavioral treatments commonly used for binge-eating disorder.
Psychological and behavioral approaches include cognitive behavioral therapy (CBT),70–79 interpersonal psychotherapy,80–82 dialectical behavior therapy,83,84 and behavioral weight loss.73,85,86 In January 2015, lisdexamfetamine became the first medication to receive Food and Drug Administration (FDA) approval for treating BED.87 Numerous other medications are used off-label in the clinical management of BED patients; among these, the most commonly used are antidepressants88–98 and anticonvulsants.97,99
Three recent meta-analyses addressed the benefits of treatment across broad categories of approaches (i.e., pharmacotherapy consisting of antidepressants;100 pharmacotherapy consisting of antidepressants, anticonvulsants, antiobesity agents, and other medications;101,102 and psychotherapy102). These meta-analyses included data from nonrandomized and randomized trials and single-arm studies using a variety of study designs (e.g., open label, single blind, and double blind). For this review, we compared the findings from the two systematic reviews that focused on randomized controlled trials and searched for additional evidence that would allow us to expand or refine them and to address, through further meta-analyses, the efficacy of specific approaches. We also expanded the evidence base by including any new studies of alternative or novel approaches published since the prior systematic review of managing eating disorders from the Agency for Healthcare Research and Quality (AHRQ);103 for example, we searched for studies using complementary and alternative medicine and dietary interventions, among others.
Currently available treatment options all have relative advantages and disadvantages. Pharmacological interventions have negative physical side effects. For example, antidepressants and anticonvulsants are commonly associated with diarrhea, dizziness, dry mouth, fatigue, sexual dysfunction, and somnolence, which can interfere with treatment compliance.104–106 However, pharmacological treatment may be more easily accessible than psychological and behavioral interventions that require access to practitioners with specialized training in BED. Individuals living in geographically remote areas may be especially disadvantaged with limited access to specialized care providers. In addition, most psychological treatments are relatively lengthy (approximately 16 to 20 weeks) and are thus less scalable, which limits the extent to which these treatments can be widely disseminated to more generalist practices. We address not only benefits but also harms associated with treatment and their impact on treatment dropout.
Current Treatment Options for LOC Eating
Treatments for LOC eating for postbariatric surgery patients and children reflect the treatment options described above for BED. Family-based treatments have proven effective in treating children with anorexia nervosa,107 so theoretically they may be of interest for BED and LOC eating as well. To date, no treatments specifically addressing LOC eating have been developed.
Existing Clinical Practice Guidelines for Treating Patients With BED or LOC Eating
The APA,108,109 the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom,110 the Task Force on Eating Disorders of the World Federation of Societies of Biological Psychiatry,111 and the American Dietetic Association (now the Academy of Nutrition and Dietetics)112 have issued treatment recommendations for BED. Generally, these strongly support use of CBT and selective serotonin reuptake inhibitors, but they give less strong support for other psychological, behavioral, and pharmacological approaches.
Recommendations differ markedly about the manner and timing with which treatment is offered. First, the APA recommends that CBT be incorporated into a team approach (including psychiatrists, psychologists, dietitians, and social workers); by contrast, NICE recommends that treatment begin with a course of CBT-based self-help that is followed, if necessary for nonresponders, by CBT adapted specifically for BED. Second, within the APA’s recommended team approach, medication is considered as adjunctive therapy; the NICE guidelines indicate that medication monotherapy may be sufficient treatment for a subset of patients. Third, because of very limited data on efficacy, support is minimal (only from the APA) for non-weight-directed psychosocial approaches (e.g., Health at Every Size [HAES]), Overeaters Anonymous), and nutritional approaches, although the latter approaches are consistent with the American Dietetic Association’s endorsement of nutrition counseling by a registered dietitian to support health-centered behaviors rather than weight-centered dieting. The organizations do agree, however, that the long-term effects of selective serotonin reuptake inhibitors are unknown. Our previous AHRQ review highlighted this gap in knowledge and the need for additional studies on novel agents and approaches in more diverse patient samples.103
Considerable uncertainty surrounds the question of which treatment(s) is best suited for a particular patient; efficacy needs to be understood as a function of the presence or level of coexisting psychopathology, metabolic complications, or other physical or psychiatric conditions.113 Patients enter treatment for BED with varying levels of concern about body shape and weight; they also seek treatment having different levels of health care insurance. These factors can strongly influence choice of first-line treatment; formulation of a comprehensive treatment plan; and, ultimately, treatment outcome. In addition, individuals with BED seeking bariatric surgery can be denied coverage for their surgery even though no evidence base exists indicating that patients with BED may have poorer outcomes from surgery than those without BED.114 Thus, considerable clinical and policy interest exists in understanding BED as a negative prognostic indicator for bariatric surgery, the extent to which nonsurgical interventions (e.g., psychotherapy) for BED may be beneficial in reducing or preventing LOC eating after surgery, and the appropriate timing of these nonsurgical interventions (before or after surgery).
In addition, Federal legislation enacted since the previous AHRQ review established or improved parity for mental health services relative to services for physical health and increased access to health insurance.115 The 2008 Mental Health Parity and Addiction Equity Act required insurers offering mental health and substance use disorder benefits to provide coverage comparable to that for general medical and surgical care. Subsequently, the 2010 Patient Protection and Affordable Care Act, which took effect in 2014, is making health insurance more accessible for previously uninsured or underinsured Americans. Nonetheless, the impact of these laws on access to treatment options for BED or LOC eating is yet to be determined.
Children and adolescents with LOC eating are presenting for treatment and, in increasing numbers, for bariatric surgery. Also, patients are entering treatment using over-the-counter products and dietary supplements with known or suspected effects on appetite, mood, and weight regulation. These scenarios pose additional challenges for providers evaluating treatment options, but currently no guidelines are tailored to the specific needs of these subgroups. We addressed the need for evidence regarding individual factors that influence treatment outcome by examining efficacy in subgroups defined by factors such as age, sex, race, and ethnicity.
Additional Considerations or Questions About Treatment for Patients With These Disorders
Many BED patients initially seek and obtain treatment through primary care physicians, who may be able to offer only a limited number of treatment options directly (usually just pharmacotherapy) or through referral to psychologists, dietitians, and psychiatrists, who may also lack specific expertise in BED or (especially) LOC eating. Patients often present as seeking treatment for obesity rather than a complaint of binge eating, and they are hesitant to admit to binge eating unless asked. In this setting, assessing patients believed to be at high risk with a screening tool, such as the Patient Health Questionnaire, Eating Disorder module,116 may be useful. Whether treatment protocols that are used in research studies and that require clinically trained personnel with expertise in BED-specific interventions can be delivered effectively in more commonly available frontline settings is largely unknown. Some untapped areas of interest include stepped-care models and treatment efficacy in residential settings. In this review, we describe treatment settings and delivery methods and report, to the extent possible, their impact on treatment outcomes.
Commonly, along with achieving binge abstinence and reducing distress, weight reduction and improved metabolic health have been key outcomes in BED treatment studies and important treatment goals in clinical settings. According to the National Task Force on the Prevention and Treatment of Obesity, behavioral weight loss treatment including moderate caloric restriction is associated with improvements in binge eating and psychological health in overweight and obese adults with recurrent binge eating (but not BED per se).117 In contrast, however, some advocates, including the HAES group (www.haescommunity.org/resources.php), have strongly endorsed removing weight-based outcomes in caring for patients with BED while emphasizing greater body acceptance and intuitive eating. Intuitive eating is an approach to healthy weight that focuses on increasing one’s awareness of hunger signals and eating only when hungry. HAES maintains that weight-loss interventions are not only ineffective for treating BED patients but are also detrimental because they contribute to the development and perpetuation of disordered eating behavior and psychopathology (restrictive eating, food and body preoccupation, yo-yo weight cycles, reduced self-esteem) and to weight stigmatization and discrimination. Weight stigma awareness is also a central issue of another advocacy group, the Binge Eating Disorder Association (http://bedaonline.com/binge-eating-disorder-blog/#.Up9vItIwldw). In light of these stakeholder perspectives, the current report includes traditional weight-related outcomes and, when available, nontraditional, non-weight-focused body image and eating behavior outcomes and interventions.
Rationale for This Evidence Review
Previous systematic reviews have addressed psychological treatments for bulimia nervosa and BED (2009),118 self-help and guided self-help for eating disorders (2006),119 and management of eating disorders including BED (the AHRQ review, 2006).103 The authors of the 2006 AHRQ review were unable to draw definitive conclusions concerning the best treatment choices for BED because many of the available treatments had been evaluated in only single studies with small sample sizes or too few studies of sufficient quality.103 Since that report appeared (see also Brownley et al., 2007120), the literature on treatment of BED has expanded, the diagnostic criteria have changed, and a greater interest in BED and LOC eating in bariatric patients and children has emerged. These factors underscored the need for the current systematic review that captures the new information and presents it in a format that can bridge the old and new diagnostic criteria; doing this should improve understanding of BED and LOC eating across the lifespan and clarify factors that influence the progression, maintenance, and resolution of these conditions.
Scope and Key Questions
This review is designed, first, to address the effectiveness of the interventions described above for individuals meeting DSM-IV or DSM-5 criteria for BED, for children with LOC eating, and for postbariatric surgery patients with LOC eating. We had a secondary interest in examining whether treatment effectiveness differed in subgroups based on sex, race, ethnicity, sexual orientation, BMI, duration of illness, or coexisting conditions. Given advice from TEP members, we did not attempt to review studies related to the genetics of BED because genetic risk factors for BED are as yet unknown. We placed few limitations on our review so we could be as inclusive as possible of the available literature.
Broadly, we included in this review psychological, behavioral, pharmacological, and combination interventions. We considered their efficacy with respect to physical and psychological health outcomes across four major categories: (1) binge behavior (binge eating or LOC eating), (2) binge-eating-related psychopathology (e.g., weight and shape concerns, dietary restraint), (3) physical health functioning (e.g., weight and other indices of metabolic health such as diabetes), and (4) general psychopathology (e.g., depression, anxiety). Additional outcomes of interest included health care costs, social and occupational functioning, harms of treatment, and intermediate factors associated with the primary outcomes such as blood levels of hormones associated with obesity and appetite regulation.
A third aim of this review was to examine the life course of BED and of LOC eating, especially as they relate to the primary outcomes. At the population level, diagnostic stability is low for all eating disorders, and within-patient diagnostic crossover is not uncommon, including BED to bulimia nervosa, for example. Given the recent inclusion of BED as a distinct diagnosis in the DSM-5, obtaining a better understanding of the course of illness in BED is important, particularly given its relatively high comorbidity with other medical conditions. In addition, clinical interest is considerable in understanding whether LOC eating is a reliable predictor of poorer weight outcomes and new-onset BED over time. However, little is known about the temporal stability of BED in the community, generally, and of LOC in postbariatric surgery patients and children, specifically. Increasing knowledge of BED and LOC course of illness would help inform the consolidation and concentration of early detection and prevention efforts to reduce these eating difficulties and their potentially deleterious effects on physical health outcomes.
The impetus for this review was primarily the continuing uncertainty about efficacy, harms, and long-term outcomes of common therapies for BED. Voids in knowledge regarding the course of illness of BED were another motivation for the review. In addition, novel approaches have become more popular since the previous AHRQ systematic review. Moreover, glaring gaps in knowledge about both treatment and course of illness related to LOC eating in children and postbariatric surgery patients have become more important in clinical circles. Clinicians and patients who are faced with these uncertainties need better guidance.
In sum, as reflected in our Key Questions (KQs) and analytic frameworks, we aim to increase knowledge about treatment efficacy, to determine whether efficacy varied because of any particular patient characteristic(s), and to describe the course of BED and LOC over time. Ultimately, the information produced in this review is intended to contribute to improved care for patients, better decisionmaking capacity for clinicians, and more sophisticated policies from those responsible for establishing treatment guidelines or making various insurance and related decisions.
Key Questions
The authors from the RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) addressed 15 KQs in this review. Of these KQs, nine address efficacy and effectiveness of treatment (benefits and harms overall and benefits for various patient subgroups)—three for BED, three for LOC eating among bariatric surgery patients, and three for LOC eating among children. The other six KQs deal with course of illness, overall and for various subgroups, for BED or LOC eating. For this review, we use the term effectiveness to include efficacy.
- KQ 1.
What is the evidence for the effectiveness of treatments or combinations of treatments for binge-eating disorder?
- KQ 2.
What is the evidence for harms associated with treatments for binge-eating disorder?
- KQ 3.
Does the effectiveness of treatments for binge-eating disorder differ by age, sex, race, ethnicity, initial body mass index, duration of illness, or coexisting conditions?
- KQ 4.
What is the course of illness of binge-eating disorder?
- KQ 5.
Does the course of illness of binge-eating disorder differ by age, sex, race, ethnicity, sexual orientation, body mass index, duration of illness, or coexisting conditions?
- KQ 6.
What is the evidence for the effectiveness of treatments or combinations of treatments for loss-of-control eating among bariatric surgery patients?
- KQ 7.
What is the evidence for harms associated with treatments for loss-of-control eating among bariatric surgery patients?
- KQ 8.
Does the effectiveness of treatments for loss-of-control eating among bariatric surgery patients differ by age, sex, race, ethnicity, initial body mass index, duration of illness, or coexisting conditions?
- KQ 9.
What is the course of illness of loss-of-control eating among bariatric surgery patients?
- KQ 10.
Does the course of illness of loss-of-control eating among bariatric surgery patients differ by age, sex, race, ethnicity, sexual orientation, initial body mass index, duration of illness, or coexisting conditions?
- KQ 11.
What is the evidence for the effectiveness of treatments or combinations of treatments for loss-of-control eating among children?
- KQ 12.
What is the evidence for harms associated with treatments for loss-of-control eating among children?
- KQ 13.
Does the effectiveness of treatments for loss-of-control eating among children differ by age, sex, race, ethnicity, initial body mass index, duration of illness, or coexisting conditions?
- KQ 14.
What is the course of illness of loss-of-control eating among children?
- KQ 15.
Does the course of illness of loss-of-control eating among children differ by age, sex, race, ethnicity, initial body mass index, duration of illness, or coexisting conditions?
Analytic Frameworks
The relationships among the patient populations, interventions, comparators, outcomes, and timing of outcomes assessment (PICOTs) are depicted for each of the treatment KQs in Figure 1 and for each of the course of illness KQs in Figure 2. The populations of interest are displayed in the far left boxes; these boxes project through the central box displaying the interventions of interest (Figure 1 only) to the box on the far right that displays the final health outcomes either directly or through the intermediate outcomes.
Figure 1
Analytic framework for BED and LOC eating: Effectiveness and harms of interventions. BMI = body mass index; GERD = gastroesophageal reflux disease; KQ = Key Question
Figure 2
Analytic framework for BED and LOC eating: Course of illness (outcomes of the disorders). BMI = body mass index; GERD = gastroesophageal reflux disease; KQ = Key Question
Organization of This Report
In the following five chapters we first describe our methods and then present our results in three chapters (Overview and Efficacy and Effectiveness of Interventions To Manage Patients With Binge-Eating Disorder; LOC Eating; and Course of Illness). In the final chapter (Discussion), we give our synthesis of the evidence base and discuss our findings; we examine the limitations of the evidence base and this review, clarify gaps in the knowledge base, and offer recommendations for future research. References follow the final chapter.
The main report has several appendices, as follows: A, search strategies; B, criteria to exclude at the full text stage; C, excluded studies; D, risk-of-bias tables; E, detailed evidence tables; F, strength of evidence tables and G, a list of abbreviations.
- Introduction - Management and Outcomes of Binge-Eating DisorderIntroduction - Management and Outcomes of Binge-Eating Disorder
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