This document summarizes the development of a new "Eat, Think, Change" group for patients struggling with disordered eating and binge eating disorder (BED) within an existing weight management program. The group aims to address the mechanisms maintaining disordered eating behaviors before focusing on weight loss. Initial outcomes show reductions in binge eating frequency and increased awareness of eating behaviors among participants. The program aims to provide more effective support for this population and prevent cycles of unsuccessful weight loss attempts.

1. Disordered Eating Group
Nicole Allison
Specialist Dietitian
NHS Lothian Weight Management Service
Eat, Think, Change

2. Contents
• Causes of obesity
• Current weight management programme
• What are we missing?
• What is Binge Eating Disorder (BED)
• How could this be treated?
• What is Eat, Think, Change?- Ethos/aims/outcomes
• Starting to redress the balance

4. RisingBodyMassIndex
Number of Affected People
“Get Lighter in Lothian”
The Lothian Weight Management Service (Adults) 2017
Tier 1: Get Thinking
Tier 2: Get Moving with Counterweight
Tier 3
Tier 4
Bariatric Surgery
Patient information seminar
12 week ‘IPIC’ programme
Further 12 week 1:1 if required
Specialist Weight Management Team
Advanced Weight Management Group
1:1 consultations with specialist dietitian
Orlistat/Pilot Counterweight Plus
Tier 5
Community Dietetic Team and
Specialist Weight Management
Team
14 week core group programme
9 month maintenance group
programme
12 week Exercise group
programme
Eat.Think.Change
(disordered eating group)
Local Council and Leisure Trust Health
Coaches
12 week dietary (Counterweight) and
physical activity group programme
Follow up at 6, 9 and 12 months
General
population-
based advice
and services
e.g. websites,
apps,
community
initiatives

5. Current Weight Management Programme
As a Weight Management Service our aims are:
• Treatment of overweight and obesity by diet and lifestyle
interventions
• Where required/appropriate the treatment of obesity by
pharmacological therapy and bariatric surgery
• Prevention of weight regain following treatment
(SIGN, 2010)

6. Current Weight Management Programme
Structured weight management programme which includes:
• Physical Activity - reducing sedentary behaviour
• Dietary changes - Eatwell guide/portion sizes/food
choices
• Behavioural components - Mindful eating/food
diaries/SMART goals
(SIGN, 2010)

7. Current Weight Management Programme
However….
Q: How would this group environment feel if you could not relate to
the information provided or other group members?

8. Current Weight Management Programme
I’m not the same
as the people in
the group
No-one seems to be
in the same situation
as me
This is my 2nd time
through the weight
management programme
and I have failed both
times
I understand the
information but it’s
too difficult to make
changes

9. What are we missing?
Q: So, what is going wrong?
Q: What can we offer these people who are genuinely struggling?
Q: Is bariatric surgery the simple solution?

10. What are we missing?
• There is a population out there for whom this evidence based
tiered approach is not effective
• At initial assessment, we carry out an ‘Eating Behaviours
Questionnaire’ which includes the following 4 questions
– Are there times during the day when you could not have stopped eating, even
if you wanted to?
– Do you ever find yourself eating unusually large amounts of food in a short
period of time?
– Do you ever feel extremely guilty or depressed afterwards?
– Do you ever feel more determined to diet or to eat healthier after the eating
episode?
(SIGN, 2010)

11. What are we missing?
• From this information, it was apparent that Binge Eating Disorder
(BED) was prevalent within this population; data in line with
literature which estimated that 30% of patients within weight
management services are likely to have BED (SIGN 2010)
• In addition to the impact this eating behaviour was having on their
weight and their ability to lose weight it was also a source of great
distress – often impacting on day to day life.
• Work, relationships, mood and mental health all affected
detrimentally.
• However, the Lothian Eating Disorder Service does not currently
accept referrals for those with a BMI >40kg/m2
• A gap existed within the healthcare pathway

12. What is Binge Eating Disorder (BED)
Binge Eating Disorder Criteria (DSM 5, 2013)
BED is characterised by recurrent episodes* of binge eating that occur at
least once a week for 3 months
(*eating an unusually large amount of food in a discrete period of time,
having a sense of lack of control & causing marked distress)
Episodes are also associated with 3 of the following behaviours:
• Eating more rapidly
• Eating until uncomfortable full
• Eating large amounts of food when not physically hungry
• Eating alone due to embarrassment
• Feeling disgusted, depressed and guilty afterwards
(SIGN, 2010)

13. How could this be treated?
• A ‘gap’ or inequality had been identified… BED is more prevalent
that Anorexia Nervosa but help available did not reflect this.
(De Zwaan, 2001)
• The question at this time was ‘what support could we provide with
the very limited resources available?
– Initial pilot study identified patients referred to Weight Management Service
(WMS) with disordered eating or binge eating disorder
– BED affects approximately 30% of WMS patients (SIGN, 2010)
– In Lothian 58% of those assessed by psychology (30% of overall referred)
presented with significant disordered eating symptoms

14. What is Eat, Think, Change
• Group setting, co facilitated by Psychologist and Specialist WM
Dietitian
• Appropriate for patients with clinically significant disordered
eating/BED who meet Tier 3 criteria
• Patients are referred to the group by:
– Community Dietitians at initial Tier 3 assessment
– Patients identified at Tier 4 stage
– At point of triage
– All assessed by Psychologist

15. What is Eat, Think, Change (Aims)
• Main aim of the group is to provide an intervention which helps
individuals work towards stabilisation of eating behaviour in
preparation for the standard Tier 3 weight management
programme (which focuses on weight loss and lifestyle change)
• The group aims to address the main mechanisms maintaining the
patients disordered eating (or BED)
• The main outcomes for the group are:
– Reduction in binge frequency
– Reduction in binge duration

16. What is Eat, Think, Change
Areas Covered
-Education on:
-Balanced eating
-Binge Eating Disorder
-Obesity
-Diet/Binge cycle
-Impact of dieting
-Impact on weight
-Cognitive restructuring (Padesky)
- Self esteem (Fennel)
- Self Compassion (Gilbert)
- Anxiety/ Stress
- Depression and low mood
- Body image (Cash)
- Mindfulness (Kabat-Zinn)
- Sleep
- Applied relaxation
- Physical Activity
-Introducing self-monitoring
eating
- Identifying disorganised
eating/BED
- Identifying emotional eating

17. What is Eat, Think, Change (to patients)
“Before the group I felt hopeless and a failure – assuming something needed to
‘click’ in my head. I had no intentions for surgery. The size of the group was
perfect and there was time to discuss and feedback. The members were patient;
I was sceptical – could this fix me? I have learned I am not broken, I want to be
aware of the changes I need to make, of the habits I want to change. Reflection is
so helpful, I am bingeing less and less and gaining focus and control”
“I haven’t lost weight but I am very aware of what I am choosing and the effect it
will have. I know successful weight loss and sustained loss- is more to do with
my mind than my body”
(patient reflection at the end of E.T.C)

18. Eat, Think, Change - Outcomes
• Binge Frequency (From 2 groups)
• (EDEQ x in previous 28 days)
– 6 out of 10 patients reported no binge eating episodes in previous 28 days
post group
– ALL patients reported a reduction in binge frequency in previous 28 days post
group
– 73% (8 out of 11) patients reported a reduction in binge frequency in the 6
months post group
– 18% (2 out of 11) patients reported an increase in binge frequency in the 6
months post group

19. Starting to redress the balance…
• Further development and funding of this programme will provide a
more cost effective and efficient Weight Management Service.
– From a service point of view, prevents a cycle of patients completing the
same weight management programme with limited or no success. In the
past this has led to an increased risk of further weight related co-morbidities
and therefore further expense to NHS services
– From a ‘service user’ point of view, the appropriate intervention at the initial
stage of treatment could prevent increased feelings of failure and low self
esteem and ultimately prevent episodes of BED/disordered eating being
exacerbated

20. Starting to redress the balance…
• These personal feelings are damaging enough to an individuals
self esteem, confidence and ability to live their day to day lives
but are also frequently exacerbated by ongoing and incessant
feelings of judgement and shaming in a society that continues to
consider this as acceptable for the overweight/obese population
• How often do we see this judgement and fat shaming?
• Would we ever engage in this behaviour??...

21. Starting to redress the balance…

22. Thank you for listening…
…Any questions??

23. References
• Foresight Report. Tackling obesities: future choices—project report. The Stationery
Office, London; 2007http://www.foresight.gov.uk/Obesity/obesity_final/Index.html [Accessed 11 April 2017]
• Scottish Intercollegiate Guidelines Network (SIGN) (2010). Management of Obesity. A National Clinical Guideline
[online] Available at http://www.sign.ac.uk/guidelines/fulltext/115/index.html [Accessed 11 April 2017]
• De Zwaan, M (2001). Binge eating disorder and obesity. International Journal of Obesity and Related Metabolic
Disorders. Journal of the International Association for the Study of Obesity 25(1), p51-5