One common condition among a subgroup of individuals within the obesity ¹ population is a type of disordered eating behavior called binge eating. Binge eating behavior consists of eating objectively large volumes of food within a discrete period of time and exists on a continuum from mild binge eating to the more severe, binge eating disorder (BED) (1). BED is a psychiatric disorder that is characterized by recurrent episodes of binge eating, in the absence of compensatory behaviors and accompanied by a sense of loss of control (2). BED typically manifests in elevated body weight, greater preoccupations with food, poor dietary restraint, body dissatisfaction, psychological distress, low self-esteem, guilt, and self-disgust over food consumption (3–6). Whilst the condition has only recently been recognized by the Diagnostic and Statistical Manual fifth edition (7) as its own defined category, BED represents the most common eating disorder (ED) with prevalence rates ranging from 0.2% to 6.6% of the worldwide population (8–10). Co-morbid emotional disorders and cognitive deficits have been proposed to underlie and maintain numerous BED symptoms and difficulties including regulating food intake, generating alternative behavioral patterns as well as following through with meal plans and treatment recommendations (11–14). Due to the nature of binge eating, such behavior contributes to the progressive escalation of Body Mass Index (BMI) over time. Between 30-50% of individuals with obesity who seek weight management treatment report clinically significant degrees of binge eating (15–17), for example, binge eating episodes that last a full day (18–20). Moreover, a large US study found that 42% of those with a lifetime BED had obesity when the study was performed (21). It has furthermore been shown that adults with BED and bulimia nervosa are more likely to have been categorized with severe obesity compared to individuals without ED (22). More, in a recent health survey from England, individuals with obesity were more likely to screen positive for a possible ED, compared with those in lower BMI categories (23).

BED is common among bariatric patients (24) and the prevalence of disordered eating and ED in bariatric surgery populations is well known (25–28). Further, weight regain in patients with ED has been shown in post-surgical bariatric patients (29, 30) with one study showing pre surgery disordered eating in 65% of patients with weight regain (29). As patients with bariatric surgery can be helped with restriction of meal and portions post-surgery, some phenotypes may develop various eating disordered behaviors, such as grazing, as a compensatory mechanism, resulting in a higher energy intake (31). The association between the disordered behavior grazing (i.e., eating small portions of food with and without loss of control) and post-surgical weight regain (32), suggest a need for assessment and treatment of disordered eating such as binge eating and grazing pre- and post-surgery. Thus, comprehensive pre- and post-surgery assessments and interventions for disordered eating such as binge eating, and grazing may optimize outcomes of both conservative obesity treatments and bariatric outcomes.

There is ample evidence to show that BED is associated with elevated rates of psychiatric co-morbidity and lower quality of life (8, 33). When compared with individuals with obesity but without binge-eating problems, individuals with BED report earlier onset of obesity, more frequent episodes of dieting, marked weight fluctuations, more severe obesity (34), elevated body weight, greater preoccupations with food, poor dietary restraint, body dissatisfaction, psychological distress, low self-esteem, as well as guilt and self-disgust over food consumption (3–6). They also report less self-esteem, more depressive symptoms, less eating restraint, greater overall psychological distress and a greater lifetime prevalence of psychiatric disorders than do obese individuals who do not binge eat (35). Several empirical studies indicate that obese individuals who binge eat have higher rates of Axis I and Axis II mental disorders than obese individuals who do not binge eat (21, 36).

Despite the notion that difficulties with poor body image and associated stressors such as weight stigma have been shown to be commonly experienced by individuals with BED (37) and obesity (38, 39), it is rarely addressed in treatment approaches for the condition. Wang, Jones (40) reinforced need for increased targeting of overvaluation of shape and weight as it was shown to be a core symptom in patients seeking treatment for BED. Although current treatment approaches for obesity and BED target overvaluation of weight and shape, few interventions acknowledge the intricate relationship between binge eating, weight stigma and overvaluation of weight and shape. There are few studies which have examined BED stigma (41), and the majority of obesity interventions are concentrated on weight loss, lacking consideration of weight stigma (42). Hence, the damaging consequences of weight stigma (43) are seldom addressed in the treatments of obesity or BED.

Existing treatments recognize the mechanisms between ED and attachment functioning (44), and the psychological constructs that may contribute to development and maintenance of binge eating behavior including environmental, social, biological, physiological, political, and familial stressors (45). The prevalence of attachment insecurity among individuals with ED is shown to be high (46–48). Individuals with BED have been reported to have an avoidant attachment style, thus, individuals who are insecurely attached, may be more overwhelmed when they experience distress (49) compared to those securely attached.

Individuals with BED have shown to benefit from cognitive-behavioral therapy (CBT) and pharmacological treatments such as second-generation antidepressants, lisdexamfetamine, and topiramate (50, 51). As individuals with BED often present for weight loss treatments rather than treatment for an ED (4, 52), the condition is associated with a persistent pattern of symptom remission and relapse (53). Currently, CBT has been established as a beneficial psychological modality to treat the condition (54, 55).

Even though BED symptoms have been demonstrated to reduce following CBT, research has shown that this treatment modality is only partially effective (56, 57). Consequently, many individuals remain symptomatic or experience symptom reoccurrence following the conclusion of CBT treatment (58, 59). Other non-invasive approaches include behavioral weight loss interventions, guided-self-help, and interpersonal psychotherapy (IPT). However, similarly with CBT treatment, each have been established to be only partially effective, produce unsustainable effects, and/or not address core ED symptoms (5, 54, 60).

The recommended treatment modality for patients suffering from both obesity and BED is CBT (52), but IPT has also been shown to be acceptable to patients with BED (61, 62). Small effects have been observed in improved behavioral symptoms at posttreatment in favor of CBT in comparison to IPT, but extant studies have lacked comparison of the treatment modalities at follow-up (63). Other integrated treatment for patients with obesity and BED has been developed and tested (64–66).

However, high rates of attrition from interventions are reported both in patients with ED (67–69) and patients with obesity seeking weight loss treatments (70, 71).

The complex nature of obesity (72–74) and co-morbid ED (75) suggest prevention and treatment may be improved by addressing multiple factors contributing to obesity rather than just targeting weight (76). Recent studies recommend assessment of psychological distress, interpersonal sensitivity, shape-weight concern, and internalized weight stigma in patients seeking treatment for obesity (77). As many patients seeking treatment for obesity also suffer from BED, it is likely that a large group of patients with BED and obesity are not detected in obesity treatment settings.

Together these results highlight clear clinical implications and a need for innovative directions in the treatment of obesity and comorbid BED.

This study aimed to describe the rationale, design and feasibility of an intervention for patients with obesity and comorbid BED in an outpatient setting in Norway. This pilot study was conducted to inform the design of a larger clinical trial and to provide direction as to whether a larger study on treatment of obesity and comorbid BED should be conducted (78). The main purpose of this pilot study was to investigate feasibility by tracking attendance, adverse events related to the intervention and patient attrition. Secondly, we aimed to assess symptom severity of ED behaviors and quality of childhood, alexithymia, overvaluation of weight and shape, body image perception and internalized shame in patients with obesity and comorbid BED at baseline. Third, we aimed to evaluate change in frequency of binge eating episodes and health related quality of life (HRQoL) from pre to post intervention.

Descriptive frequency analyses were conducted on the quantitative data with respects to adherence, ED pathology, quality of childhood, alexithymia, internalized shame, impairment due to ED, body dissatisfaction and HRQoL. We tested normality of data distribution using the Shapiro-Wilk test which indicated that the HRQoL data were not normally distributed. To test whether there were significant differences between binge eating episodes and HRQoL pre- and post-intervention, we thus used Wilcoxon signed rank test. We calculated the r effect size for Wilcoxon signed-rank tests (126) (small r ≥.10, medium r ≥.30, large r ≥.50) (127). We noted whether correlations reached a medium effect size (i.e., r ≤.3). All analyses were conducted in IBM SPSS (version 27).

The pilot study aimed to include 40 patients. We did not perform a power calculation due to the feasibility nature of the study. However, the sample size was based on guidelines suggesting sample sizes in feasability studies to be at least 30 patients to estimate a parameter (128). Further, we based our sample size on other BED treatment pilot studies varying from 7 to 41 participants (129–131). Lastly, Moore, Carter (78) suggested that at least 12 patients is recommended for both practical reasons and for providing preliminary data informing later design estimate average values and variability for a future larger clinical trial,

In this study, we described the rationale, design, and the feasibility of the People Need People (PnP) intervention for patients with obesity and comorbid BED in a Norwegian tertiary outpatient setting in Norway. This pilot study was an open label pilot from a naturalistic setting to evaluate feasability by tracking attendance and patient attrition of a study population that is representative of the population at large. Symptom severity of ED behaviors and psychological difficulties hypothesized to be associated with both BED and development of obesity was reported in addition to change in binge eating episodes and health related quality of life (HRQoL) following the intervention.

Consistent with other studies, our study showed significant overvaluation of weight and shape and eating-disorder psychopathology (132–134). In total, patients reported considerable ED psychopathology and impairment comparable to patients with ED treated in inpatient and outpatient specialized clinics in Norway (135). Patients with BED are often not given access to treatment as the diagnosis is not recognized as a distinct eating disorder diagnosis in the ICD-10 (136). Further, no or few treatment providers for obesity in Norway offer treatment for patients with obesity with comorbid BED. Given the high levels of symptom severity in our study, it is likely that a large number of patients with obesity also suffer from BED as reported from others (15–17), and thus likely to regain weight post-surgery (29, 30). This is of concern, as there are no treatment options available for patients with BED post bariatric surgery in Norway. As comorbid mental illness is associated with weight regain, postoperative complications, and adverse psychosocial outcomes in bariatric obesity populations (137), assessment and treatment of BED, including childhood trauma and underlying constructs such as shame and alexithymia, may be of relevance for selection of candidates and surgery outcomes.

Generally, drop out from ED treatment is high with dropout rates between 17–30% for binge eating disorder (BED) treatment (138). The low dropout rate in this study is optimistic compared to other interventions for obesity and comorbid BED (139–141). However, the intervention which was given in this study was short, requiring longer follow up time for a better understanding of attrition.

Alexithymia is often characterized by difficulties with emotion regulation (142). Patients with ED across diagnostic types report less emotional awareness (143) compared to individuals without ED. Difficulties with emotional regulation is consistently shown in populations with ED (144), which corresponds to our findings showing high levels of alexithymia. Research indicates that childhood trauma increases the risk for alexithymia, where both factors increase the risk for eating disorder behaviors (145). In addition to high levels of alexithymia in our study, a majority reported their childhood to be difficult or very difficult, which is in line with other studies (146). Several of the study participants described their family environment where feelings were unacceptable (e.g., children could not show negative emotions, or they would not cry or show pain/weakness) suggesting an increased risk for development of alexithymia and later binge eating behavior to regulate their emotions. Our results showing high levels of poor quality of childhood is previously shown in a systematic review by of Palmisano, Innamorati (147) indicating adverse life experiences as a risk factor for developing both obesity and BED. The fact that the large proportion of patients reported their childhood to be of poor quality is in line with the evidence linking adverse childhood experiences such as physical abuse and/or sexual abuse to obesity (148, 149) and BED (150), further supported from other studies with ED populations (84, 151, 152). Types of childhood trauma has not been associated with BMI or binge eating behavior (151), hence it may be important to consider any childhood experiences in childhood or adolescence in assessment of BED. For instance, countless episodes of bullying were reported by the participants, and suggested to have had an impact on their binge eating behavior.

The prevalence of BED in bariatric populations is uncertain and has been reported to range from 2% to 53% (153) due to large variety of methods assessing BED in bariatric populations. Research indicate that presence of post-operative binge eating is a negative predictor of weight loss outcomes (154). It may be central to assess both BED and underlying psychological constructs including the role of habit, behavioral clusters, emotion dysregulation, mood, health literacy, and executive function as interconnected drivers of BED and obesity relevant to the field of bariatric psychology (73). Patients in this study with a previous history of bariatric surgery displayed high levels of ED symptoms including grazing and binge eating behaviors similar to previous studies showing substantial patterns of disordered eating in bariatric surgery patients (153) often associated with adverse surgical outcomes, weight regain and low quality of life (155, 156). The overall reliability of the scale measuring grazing was 0,69, and highest in the sub-scale measuring compulsive eating (α =0,77), and lowest in the subscale measuring repetitive eating (α =0,52). Thus, it may be that the items in the sub scale “compulsive eating” is measuring the feeling of loss of control in relation to grazing.

The diagnostic criteria for BED does not require a patient to meet a criterion related to body image (157) such as criteria for anorexia nervosa and bulimia nervosa. Few studies have investigated body image disorder or the misperception of one’s own body in clinical patient samples with BED. Contrary to previous studies that demonstrated that individuals with obesity and BED perceive their body size as larger than their actual size (158), the majority of individuals in the current study perceived their body size accurately. They did however exhibit high levels of body disturbance and dissatisfaction, consistent with earlier findings (159). The extreme levels of poor body image among the patients in our study is consistent with finding from Dalle Grave, Calugi (140), and may suggest that symptoms involving overvaluation of shape and weight, or related constructs of body image such as perception of one’s body of body image, may be central for assessment and treatment of patients with BED (157) helping clinicians within both fields refine their procedures of assessment and treatment towards a more personalized treatment of obesity and BED. Our findings are further supported by studies using network analyses showing overvaluation of weight and shape to be central in patients seeking treatment for BED (40, 77). Further, our results may suggest that a large discrepancy between perceived and ideal body may be a significant barrier for recovery of BED and obesity. Patients with a history of bariatric surgery have shown to display poor body image at longer term follow-up as shown in a recent review by Jumbe, Hamlet (160). Hence, a deeper understanding of why patients develop poor body image pre and post-surgery may enable a better comprehension of psychological aspects of bariatric surgery and how body image is related to BED and obesity.

Given the significant presence of overvaluation of weight and shape in this patient population, it is possible that that experiences of shame may contribute to such challenges. The high levels of internalized shame found in this study may suggest that binge eating behavior is a way to cope with shame experiences, which is also found in other studies as a way to regulate emotional states (161). It may be that shame experiences for this patient population include extreme presence of overvaluation of weight and shape. Mean scores of internalized shame in our study was higher than reported in Norwegian non-clinical populations and clinical outpatient samples presenting with anxiety and depression (112). During the 10 week intervention, patients consistently described experiences of being shamed for their weight, which may have contributed to high levels of internalized shame. This is consistent with numerous other studies where weight stigma and being bullied due to weight or appearance have been reported (38, 162). A number of patients in our study reported a history of bullying because of their weight or appearance severely affecting their quality of childhood, with interweaving experiences of weight stigma, shame, poor body image and binge eating behavior through a life span.

Generally, the changes in binge eating episodes and HRQoL were positive and underline the potential of treatment targeting binge eating and grazing as a response to common stressors associated with obesity such as weight stigma, alexithymia, childhood trauma and internalized shame. The results indicate that the PnP program is feasible for patients with patients with obesity and comorbid BED, including patients with past bariatric surgery who do not meet the diagnostic criteria for BED. The intervention may influence a pathway for patients with obesity and comorbid BED before and after bariatric surgery in order to optimize treatment outcomes.

Further need of development of PnP to optimize it for individuals with high ED psychopathology became obvious during the pilot, and modifications to PnP has been implemented after the pilot study period. Several patients reported that 10 sessions were insufficient for being able to reduce BED symptoms and to incorporate knowledge and skills into their everyday life during the 10-week treatment period. Consequently, add-on therapy group interventions using principles from the 10 sessions were developed where the aim is to utilize information learned in the modules and practicing other ways to respond to stressors without binge eating. For example, body-oriented therapy sessions adapted to higher weight bodies were designed and piloted for patients who are in need of interventions targeting overvaluation of weight and shape. An additional pilot study has been approved to assess reduction of BED symptoms and increased HRQoL with lengthened treatment. This is in line with studies showing that lengthened treatment of binge eating disorders predict better outcomes (163).

In summary, the current study provides initial support for the feasability of a brief 10‐session psychoeducational group intervention for patients with obesity and comorbid BED. It appears that emphasis on creating a safe context to explore underlying mechanisms and responses to internal and external stressors such as weight stigma, shame and poor body image may have contributed to the feasability of the study and the high attendance.

If the benefits of PnP can be reproduced, the consequence can be that patients can be treated effectively and cost-effectively, opening access to treatment for this group of patients. The content of PnP may also be of relevance and clinical importance for other groups of patients with obesity and disordered eating patterns not meeting the criteria for BED. Longer and enhanced versions of PnP may increase health outcomes and HRQoL.

A phase 2 study is being planned to establish efficacy for patient outcomes using the PnP intervention using a multiple-arm study design (165). Acceptance and tolerance will be reported in other separate study with qualitative interviews.

The datasets presented in this article are not readily available because availability of data can be requested to the Data Access Committee (DAC) at the Health Trust of Nord-Trøndelag, Norway. Requests to access the datasets should be directed to postmottak@hnt.no.

The studies involving human participants were reviewed and approved by REC Central Møre og Romsdal, Sør-Trøndelag and Nord-Trøndelag. The patients/participants provided their written informed consent to participate in this study.

TE-N and KB conceived the study. TEN- oversaw overall direction and planning and took the lead in writing the manuscript. All authors provided critical feedback and helped shape the analysis and manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.