New Model Reduces Binge Eating, Obesity in Veterans

A new model to treat binge eating disorders and loss of control eating was associated with decreased BMI and caloric intake for veterans in a recent clinical trial published in JAMA Network Open.1

The Controlling Hunger and Regulating Eating (CHARGE; NCT03678766) randomized clinical trial compared active comparator cognitive behavioral therapy (CBT) with regulation of cues combined with behavioral weight loss in veterans aged 18 to 65 years with binge eating disorder (BED) or sub-threshold BED and had a body mass index (BMI) of 25 to 45. The trial was conducted from March 2019 to April 2023 at the University of California, San Diego. BED is the consumption of large amounts of food within a short period while experiencing loss of control (LOC) eating. It is also associated with overweight, obesity, and high-risk comorbidities.

A new model successfully helped veterans curb loss of control eating behaviors and see a significant reduction in weight loss. | Image Credit: AdobeStock_Yauhen.jpeg

The study aimed to address and suggest new solutions for the high rates of binge eating, overweight, and obesity amongst veterans. Symptoms of BED and obesity can be traced back to military habits, including cycles of eating quickly followed by periods of deprivation, thus increasing veterans’ risk of binge eating, BED, overweight, and obesity.

Full-syndrome BED, measured by the Eating Disorder Examination (EDE), is diagnosed when an individual has had at least 12 objective binge eating episodes (OBEs) over the past 3 months. Sub-threshold binge eating, while less intense, constitutes at least 3 OBEs, at least 6 subjective binge eating episodes (SBEs) or LOC episodes, at least 2 OBEs and 2 SBEs, or at least 1 OBE and 4 SBEs over the past 3 months. Of the randomized 129 veterans in the trial, 49% were White, 33% were Hispanic, 5% were Black, 5% were Asian, and 9% identified as more than 1 race, other, or unknown race. A total of 39 (30%) participants had 12 or more OBEs in the past 3 months at the beginning of the trial.

The Behavioral Susceptibility Theory provides evidence to support that there are genetic traits responsible for obesity, often amplified by the current ‘obesogenic’ environment—an increase in the availability of cheap, crave-inducing foods—highlighting 2 mechanisms: eating onset and offset.2 Eating onset is defined as food-driven responses induced by an individual’s sensitivity to environmental food cues like food ads and shelf placement in grocery stores. Eating offset is characterized by an individual’s sensitivity to internal fullness, often driven by satiety responses.

The clinical trial framed its model around the behavioral susceptibility theory and developed regulation of cues (ROC) to target both eating onset and onset responses. Researchers evaluated veterans randomized into the active comparator or CBT group and the ROC, ROC plus BWL, and BWL cohorts at mistreatment, post-treatment, and at a 6-month follow-up.1

ROC and BWL Groups Outperform CBT Group

Both groups received weekly 90-minute, in-person sessions and had the same goal to engage in at least 250 minutes of moderate- or vigorous-intensity physical activity a week. Cohort 1 of this trial was the only cohort to receive in-person treatment, while cohorts 2 through 5 received treatment remotely via telehealth due to the COVID-19 pandemic restrictions.

The ROC and BWL treatment incorporated psychoeducation, self-monitoring (hunger, food cravings, food, calories, and physical activity), experiential learning, and coping skills. This group's program focused on improving satiety responsiveness and decreasing food responsiveness and energy intake. Participants were also taught about the physiological development of responses to food cues, how appetitive traits can trigger overeating in today’s obesogenic environment, and how to use the skills provided to master a tolerance of food responsiveness. On the contrary, the CBT treatment operated in phases of education, focusing first on reducing the frequency of binge eating, then addressing problematic cognition related to behavior, and lastly learning about self-esteem, body image, and problem-solving.

The primary outcomes included feasibility, acceptability, and changes in binge eating, BMI, and energy intake. The ROC plus BWL groups exhibited a greater reduction in risk of binge eating than the CBT group at mid-treatment (difference in probability, −0.20; 95% credible interval [CrI], −0.30 to −0.11), post-treatment (difference in probability, −0.23; 95% CrI, −0.22 to −0.19), and at the 6-month follow-up (difference in probability, −0.21; 95% CrI, −0.21 to −0.18). However, participants in both groups did decrease their LOC episode by 45% for the ROC plus BWL group and by 64% for the CBT group.

The ROC plus BWL group also experienced greater weight loss than the CBT group at the mid-treatment (difference in BMI change, −0.68; 95% CrI, −1.23 to −0.12) and post-treatment (difference in BMI change, −0.71; 95% CrI, −1.40 to −0.01) assessments. The former group also reported a greater reduction in caloric intake than those in the CBT at post-treatment (difference, −280.16 [95% CrI, −446 to −113] kcal) and 6-month follow-up (difference, −300.00 [95% CrI, −465 to −133] kcal) assessments. The study authors also noted that the benefits of the ROC plus BWL treatment vs the CBT treatment were more significant for participants with BED compared with SBE.

“ROC+BWL was more effective at reducing binge eating frequency (as measured by the EDE) throughout the study, which is remarkable because meta-analyses show that CBT is effective at reducing binge eating in the short term but not the long term,” the study authors observed.

Researchers concluded that ROC plus BWL was more successful because it targeted both top-down and bottom-up changes in behavior and cognition by training appetitive cues as opposed to CBT, which only targets top-down changes and focuses more on decreasing overevaluation of weight and shape. While this is the first study with a model that is more effective at treating binge eating and LOC eating than CBT, one of the biggest limitations was the self-reported nature of the assessments. Furthermore, the trial only assessed weight using BMI and did not account for other metabolic indicators.

“Based on these results, ROC+BWL could provide an alternate model for the treatment of both binge eating and obesity in veterans, in particular for those with full syndrome BED. ROC+BWL targets both appetitive traits and reduction in energy intake, which could provide multiple distinct skills to manage urges to binge eat and overeat and provide a more durable treatment,” the study authors wrote.

References

1. Boutelle KN, Afari N, Obayashi S, etal., Regulation of cues vs cognitive behavioral therapy for binge eating and weight loss among veterans: a feasibility and randomized clinical trial. JAMA Netw Open. 2025;8(8): e2525064. doi:10.1001/jamanetworkopen.2025.25064

2. Llewellyn CH, Kininmonth AR, Herle M, et al. Behavioural susceptibility theory: the role of appetite in genetic susceptibility to obesity in early life. Philos Trans R Soc Lond B Biol Sci. 2023;378(1885):20220223. doi:10.1098/rstb.2022.0223