Valdez‑Aguilar et al. Journal of Eating Disorders Journal of Eating Disorders (2023) 11:86 https://doi.org/10.1186/s40337-023-00809-9 RESEARCH Open Access Online multidisciplinary treatment of binge eating disorder in people with high weight: a case series study Mariana Valdez‑Aguilar1* , Rosalia Vazquez‑Arevalo1, Xóchitl López‑Aguilar1 , Ana Olivia Ruíz Martínez2, Magda Rosinska3   and Juan Manuel Mancilla‑Díaz1 Abstract Background Binge eating disorder (BED) is the most frequent eating behavior among the general population (Guerdjikova in Med Clin 103:669–680, 2019). Many studies on interventions and BED treatments have been carried out in the United States and Europe, few have been reported in Latin American populations. People with this disorder not only have physical consequences of it but also social and psychological ones, therefore a multidisciplinary treat‑ ment approach is a good option to treat this condition. Objective To evaluate the feasibility of a multidisciplinary online intervention (i.e., psychological, nutritional, and physical activity) in patients with BED. Method The design was a case series study of two clinical treatment groups, with pre-test and post-test psycho‑ metric measures along with two follow-ups (at 2 and 6 months). Fifteen people diagnosed with BED (2 men and 13 women), with a mean age of 34.93 years (SD=11.91) and a mean initial BMI of 42, participated in this study. The treat‑ ment was carried out over the span of 28 sessions, each one being two hours per week consisting of 1 hour of group therapy and 1 hour of individual therapy. There were four evaluations: pre, post and two follow-ups. Results Five patients did not complete the treatment (30%). The comparisons were made through the non-para‑ metric Friedman test, finding a statistically significant decrease in binge eating symptoms (x2=15.57; p=.001), anxiety symptoms (x2=15.96; p=.001) and depression (x2=15.03; p=.002). There was an improvement in clarity (x2=11.60; p=.010) and emotional regulation (x2=7.75; p=.050), only in women. The patients reduced their body weight, and improved their eating and exercise habits by introducing fruits and vegetables and including 20-30 minutes of physi‑ cal activity into their daily routine. Regarding the Objective Clinical Change Index, in terms of the objective clinical change, a positive change was observed in all the variables addressed. Conclusions The data presented allowed us to conclude that the online multidisciplinary intervention was effective in the treatment of BED. Trial registration Retrospectively registered *Correspondence: Mariana Valdez‑Aguilar psicmarianav@gmail.com Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 2 of 11 Plain English summary Binge eating disorder (BED) is the most frequent eating disorder, however, it is underdiagnosed and undertreated, therefore it is currently considered a serious health problem. There are various psychological treatments for BED, but most of them focus on eating, not including the role played by emotions in this disorder. The importance of a mul‑ tidisciplinary form of treatment (i.e., psychological, nutritional, and physical activity) has been observed in previous studies, emphasizing the importance of the psychological aspect which can improve treatment outcome. Hence the objective of this study was to evaluate the effectiveness of an online multidisciplinary intervention in patients with binge eating disorder. The treatment consisted of 28 two-hour sessions in which contents of psychoeducation, moti‑ vation, improvement of eating habits, emotional regulation, and modification of lifestyle in general were addressed. Assessment instruments were applied before and after treatment as well as at two follow-ups. Statistically, improve‑ ment was observed in all areas, in addition, these improvements were maintained in the follow-up evaluations at two and six months. The findings of this study are significant given that it is one of the first case series studies carried out in Mexico in this population. Therefore, it is important to continue research on this topic while also being able to provide a timely diagnosis and treatment for these patients. Keywords Feeding and eating disorders, Binge-eating disorder, Psychological intervention, Obesity Background and goals; food intake planning, and modification of cog- Binge eating disorder (BED) is characterized by the con- nitive distortions related to food and weight [9]. sumption of large amounts of food, greater than those Some studies [15–17] have observed that implement- that would be normally eaten, in short intervals of time ing a multidisciplinary intervention has greater benefits and accompanied by a sense of loss of control. It differs in both the short and long term [2, 16]. These programs from Bulimia Nervosa (BN), since there are no compen- have four main components: 1) psychological therapy, 2) satory behaviors (e.g., vomiting, purging, excessive exer- nutritional recommendations, 3) physical activity, and 4) cise, use of diuretics and/or laxatives) [1]. In 1994, BED medical monitoring [17]. In the psychological compo- was proposed for research in the fourth version of the nent, patients are motivated to adhere to treatment with Diagnostic and Statistical Manual of Mental Disorders strategies such as self-monitoring during meals, setting [2] and since May 2013, it is officially recognized by the realistic and achievable goals, reflecting on the origin of American Psychiatric Association [3] as an eating disor- binge eating and the disorder, as well as being provided der such as Anorexia Nervosa (AN) and BN. BED is the with alternative strategies and behaviors. The nutritional most common eating disorder [4] with a prevalence in part of this therapy is generally designed to educate the community samples between 2 and 6% [5, 6] and in clini- individual about healthy eating habits and restructure the cal samples, between 30 and 54% [7]. consumption, purchase, and organization of food. The The causes of BED are complex. Binge eating episodes physical component consists of simple daily exercises are related to negative feelings such as guilt and shame, such as walking or dancing which may produce weight and mood changes such as depression and anxiety [4, loss and enhance muscle mass. Finally, the medical com- 8], as well as difficulties in emotional regulation and an ponent aids in monitoring medical conditions and/or association with stressful life events [9]. Given this, more comorbidities associated with BED [18]. attention is needed regarding the mental health of indi- On the other hand, due to the COVID-19 pandemic, viduals with BED and further research regarding its treat- a large part of mental health treatments, including eat- ment [10]. ing disorder programs, have migrated to digital health Psychological therapy is the first-choice interven- platforms. tion for BED. There are various psychotherapies such as Previous research [19, 20] has reviewed the potential Cognitive Behavioral Therapy (CBT, [11]) Interpersonal of online interventions for eating disorders. They found Therapy (IPT, [12]), Dialectical Behavioral Therapy (DBT, that these interventions have a high efficacy, and appear [13]) and Cognitive Affective Integrative Therapy [14] to be an improvement when compared to other programs that have a similar efficacy [14]. However, CBT is the (e.g., in reducing BED psychopathology and binge eating most widely used form of intervention, as it has proven frequency), especially in individuals with fewer comor- to be an effective treatment for people with this disorder. bidities. Given this reasoning, it is necessary to con- CBT consists of psychoeducation; analyzing problems tinue evaluating the contributions of online treatments, Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 3 of 11 especially in patients with BED. Therefore, the objective participants presented with polycystic ovary syndrome of this study was to evaluate the feasibility of a multidis- (see Table 1). ciplinary intervention (i.e., psychological, nutritional, and physical activity) online in patients with BED. Inclusion and exclusion criteria The inclusion criteria were that: 1) participants were Methods adults (18 years or older), they volunteered to participate Ethical considerations in the study and adhere to the proposed schedules, 2) Approval of the study was granted in August 2020 by they acknowledged that they had problems with eating, the UNAM Psychology Postgraduate Ethics Commit- 2) the diagnostic interview resulted in a BED diagnosis tee [reference number 0165] in Mexico City, Mexico. All according to the diagnostic criteria of the DSM-5. the participants signed an informed consent document The exclusion criteria were that they: 1) did not sign the which stated the objective of the study, the participation informed consent document, 2) were already participat- requirements and adherence in this study. In addition, in ing in another psychological, medical and/or nutritional accordance with the ethical principles of Helsinki, they treatment program and 3) had a psychiatric comorbid- were assured that the information provided was confi- ity (e.g., schizophrenia, bipolar disorder and/or risk of dential and voluntary. suicide) or medical (e.g., uncontrolled hypertension and heart and/or liver disease) that prevented them from par- Research design ticipating in this study. An uncontrolled case series design was used to exam- The elimination criteria were: 1) failure to attend more ine the evidence for an online multidisciplinary inter- than two sessions and 2) failure to complete the evalua- vention. The treatment of this intervention combined tion follow-ups. both group and individual sessions. Outcomes were reported at assessment, prior to treatment, upon com- Dropout during treatment pletion of treatment along with two follow-ups (2 and 6 Of the initial 15 participants, 5 women abandoned treat- months) [21]. ment, representing 30% of the sample size. Two of the First, a pilot study was carried out regarding this inter- five people reported physical obstacles, 1 had to return to vention. Then, some adjustments were made to the inter- work in person and the other changed her place of resi- vention and participants were recruited via the social dence. Regarding the other three, 2 people were asked to communication page of UNAM FES Iztacala. Those leave due to a lack of compliance to the treatment frame- interested in this type of treatment had to be people who work and 1 required psychiatric treatment. were concerned with their way of eating. Initially, 150 people responded to the announcement via email. First, Diagnostic assessment they were asked to answer two screening instruments: 1) Clinical assessments took place before and after the Binge Eating Scale and [22] 2) Weight and Eating Patterns intervention and at 2 and 6 months follow up. Group Questionnaire [23]. The participants who exceeded the evaluation feedback forms were completed online at the cut-off point for both instruments were asked to answer final group session. the rest of the psychological battery, which was sent to them by email through google forms. Then, a diagnostic 1. Sociodemographic data questionnaire Created for interview based in the DSM-5 [24] was scheduled, which this research study, it consists of 8 questions regard- was then carried out through the online platform Zoom, ing participant sociodemographic data. with the psychologists in charge of the project conduct- 2. Daily self-registration A self-registration document ing the interview. was developed to have data about daily food con- sumption, number of binge episodes, associated Participants emotions, as well as physical activity performed each Fifteen adults participated (2 men and 13 women), with a day. mean age of 34.93 years (SD=11.91), with an initial mean 3. Interview for the Diagnosis of Eating Disorders (IDED; weight of 112 kilograms (kg) and a mean body mass index [25]) It is a semi-structured interview consisting of 18 (BMI) of 41.73, which is categorized as Obesity Class II. questions. Its purpose is to determine the differential The participants reported 4 or more episodes of bingeing diagnosis between AN, BN, and BED, with questions per week. In regard to their socioeconomic & educational related to patient history, symptoms, and general status, 73% completed university studies, 60% were single evaluation items. The duration of this interview is up and 34% had a history of addiction (e.g., alcohol or smok- to 45 min. The Spanish version [24] of this interview ing). Lastly, regarding medical comorbidities, 26% of the was used for this study. Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 4 of 11 Table 1 Sociodemographic variables Participants (N = 15) Frequency %; (SD) Sex Male 2 (13.3%) Female 13 (86.7%) Age 34.93 (11.91) Range = 19–55 years Weight 112 (31.86) Body Mass Index (BMI) 42.01 (9.36) Obesity Class 1 5 (33.3%) Obesity Class 2 2 (13.3%) Obesity Class 3 8 (53.3%) Binge eating episodes per week 4 (2.3) Education High School Diploma 2 (13.3%) Bachelor’s Degree 11 (73.3%) Master’s degree or higher 2 (13.3%) Occupation Student 5 (33.3%) Employed 6 (40%) Housewife 2 (13.3%) Unemployed 2 (13.3%) Marital status Single 9 (60%) Married 2 (13.3%) Divorced 4 (26.7%) Addiction Alcoholism 4 (26%) Tobacco 1 (6%) None 10 (66%) Comorbidities Hypothyroidism 2 (13.3%) Hyperthyroidism 1 (6%) Polycystic ovary syndrome 4 (26%) Pre-diabetes 1 (6%) None 7 (46%) SD Standard deviation 4. Binge Eating Scale (BES [26]) This scale is used to during the binge, its duration, and feelings of guilt detect the presence of BED as well as the intensity of regarding food, diet, and weight. It was validated in binge eating, from moderate to severe [4]. This scale Mexico and showed good reliability and validity [23]. was validated for Mexico [22] and had a recent con- 6. Trait Meta-Mood Scale-24 (TMMS-24) There is a firmatory analysis by Valdez-Aguilar [22]. This scale Spanish version [28]. It assesses meta-knowledge has 16 items, consisting of 2 dimensions, cognitive of emotional states. It consists of 24 items on a Lik- and behavioral manifestations. It was found that ert-type scale and is organized into three factors: 1. Cohen’s alpha showed good internal consistency in Attention 2. Clarity or Comprehension and 3. Regu- the Mexican validation (α = 0.88 for cognitive mani- lation of emotions. festation and α = 0.87 for behavior manifestation). 7. Beck Anxiety Inventory (BAI [29]) It contains 21 5. Questionnaire on Eating and Weight Patterns questions that evaluate anxiety symptoms and their (QEWP-R [27]) It is used to identify individuals with severity. The Mexican version of the BAI [30] pre- recurrent binge eating episodes with a feeling of loss sents a high internal consistency of 0.84 and 0.83, of control and guilt, in the absence of inappropri- in students and adults respectively. The qualifica- ate compensatory behaviors typical of BN, accord- tion norms in the Mexican population are from 0 to ing to the DSM-5. The questionnaire consists of 13 5 points signifying minimum anxiety; from 6 to 15, items, which are about the amount of food consumed mild anxiety; from 16 to 30 points, moderate anxiety; Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 5 of 11 and from 31 to 63, severe anxiety. The criterion to session lasted two hours. The first hour consisted of group consider anxiety as clinically relevant is to obtain 16 work and the second consisted of an individual session. or more points. The sessions always began with a review of the daily self- 8. Beck Depression Inventory (BDI [31]) It contains 21 records by a nutritionist, then feedback was given about items that evaluate symptoms of depression and its the nutritional goals set at the beginning of the treatment severity, for the Mexican population it was trans- and the planning of meals and portions was reviewed. lated, adapted, and validated showing good proper- After this nutritional feedback, which usually lasted about ties The higher the score, the greater the severity of 20 minutes, the topic to be reviewed during the session depressive symptoms [32]. A score greater than 10 was presented. The topic was presented in a psychoedu- reveals the presence of depression. This instrument cational format while generating a group reflection on it, has adequate concurrent validity (r = 0.70) and high this portion lasted 30 minutes. Then there was a 10-min- internal consistency (α = 0.87). ute period where the participants performed simple exer- cises to encourage physical activity. Pilot study Individual sessions Before carrying out the main study, a pilot test was car- The second hour of the session consisted of a one-on- ried out with 4 participants (3 women and 1 man) to one session with a therapist lasting 45-60 minutes. In this evaluate each session, the topics, content, form of appli- part the participants discussed the topics from the pre- cation and make the pertinent changes and adjustments. vious hour along with emotional and life events related The pilot study consisted of 24 face-to-face sessions. In to BED or binge eating. Individual sessions were used to this study, the sessions were carried out individually. problem solve idiosyncratic concerns that arose as the Some topics were addressed in conjunction with a nutri- treatment progressed that were not fully addressed in the tionist and a sports doctor. The nutritionist participated group session. in the first module of the intervention, that is, the first two sessions, and in the last module in order to reinforce Treatment fidelity some concepts; teaching the participants to regulate their All therapists had been trained and were experienced diet, create healthy menus and plan their meals, in addi- in delivering the multidisciplinary treatment. The entire tion, at each session the participants were weighed and team met regularly to assure adherence to the original measured. The sports doctor gave them a session on the format for both the group and individual intervention as physical consequences of obesity, as well as the benefits well as to share ongoing practice and supervisory reflec- of physical activity in daily life. tions and knowledge. Therapeutic intervention Data analysis The multidisciplinary intervention was completed in Given the small number of participants and due to the three phases: 1) Motivation for treatment and psychoe- standardization of treatment, it was decided to analyze ducation about BED. 2) Work on different clinical topics the two groups as one. Nonparametric tests were used, and 3) Relapse prevention. Two treatment groups were the Wilcoxon rank sum test was used to compare before formed according to the level of severity of the disorder, and after differences within the group. And to observe considering the number of binge eating episodes and the the changes in the measures of the pre-test, post-test and history of crucial life events. All treatment sessions were follow-ups, the Friedman test was used. In addition, an conducted via Zoom. From the initial session they were objective clinical change analysis was performed to assess asked to start recording their daily meals and binge eat- changes at the individual level. All data was analyzed ing in the self-report document. In this way, 10 patients through SPSS version 27. completed the 28 sessions of the multidisciplinary inter- vention and the follow- ups. Table 2 shows the phases Results and themes of the entire multidisciplinary treatment. Binge eating symptomatology Five psychologists, 2 nutritionists and a sports physician Table 3 shows the results of the psychological vari- participated in this intervention. The entire team partici- ables from the pre-assessment to the second follow-up. pated in the sessions according to their area of expertise Regarding eating symptoms, statistically significant dif- ferences were found, both in the total score of the BES Format of the intervention (x2=15.57; p=.001), and in the QEWP-5 (x2=13.58; The treatment was carried out over 28 sessions for seven p=.004), observing a significant decrease in binge eating months with a frequency of 1 weekly meeting. Each and, in the symptoms, associated with the disorder. Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 6 of 11 Table 2 Multidisciplinary treatment sessions Treatment phases Session Objectives Motivation for treatment 1. Motivation and Psychoeducation Give psychoeducation about the disorder and an overview of the treatment is disclosed 2. Taking responsibility for my emotions Introduce emotions and how to manage them in different situations 3. Healthy Eating Eat in a planned and structured way to avoid the restriction-binge cycle 4. Planning my diet Restructure the purchase and organization of food 5. Who am I? Understand the importance of knowing themselves Work on different clinical topics 6. Physical activity Know the importance of physical activity in daily life 7. Freeing myself from my past Work with emotions and situations from the past 8. Self-esteem Work with self-esteem and make the participant realize their strengths 9. Strengths and weaknesses Work with self-esteem and make the participant realize their strengths and weaknesses 10. Body image (Part 1) Work with the positive aspects of the participants and beauty standards 11. Body image (Part 2) Work on reconciling with themselves and accepting their own body 12. Physical activity Monitor physical activity and exercises performed at home 13. Petitions and conflict resolution Solve problems and conflicts assertively 14. Who am I and where am I going? Review the tools that have been used throughout the treatment 15. Emotional regulation Know and use emotional regulation strategies 16. Being a man and being a woman Analyze the role of being a man and being a woman today 17. Evaluating my body weight Review weight charts for each participant throughout the treatment 18. Griefs Make known what a grief is and its process 19. Loss and grief Work on the experience of loss and its elaboration 20. Goodbyes Explain the process of mourning and their individual work 21. Emotional wounds Know emotional wounds and their difference from emotional trauma (Part 1) 22. Emotional wounds Know emotional wounds and their difference from emotional trauma (Part 2) 23. Resilience Analyze what resilience is and its application in different life situations 24. Maternity and paternity Explain the relationship of parents with children through motherhood and fatherhood Relapse prevention 25. Relapse prevention Explain what a fall and relapse is and ways to deal with them 26. A new lifestyle Develop a life plan with the tools reviewed in the treatment 27. Preparing for my future Carry out a closure plan and follow-up of what was reviewed in the treat‑ ment 28. New beginnings Finalize treatment Symptoms of anxiety and depression (X=7.37, SD=12.08), this was maintained throughout the For anxiety symptomatology, significant differences were follow-ups. found from the pre- evaluation to the second follow-up (x2=15.96.96; p=.001), based on the total scores meas- ured through the BAI questionnaire. It was observed that Emotional intelligence at the beginning the participants presented an average Regarding the emotional intelligence results, which score (X= 31.75, SD=10.20) that indicated moderate anx- were measured through the TMMS-24, statistically iety and at the end of the treatment (X=11.75, SD=12.25) significant differences were found from the pre-evalu- they showed no symptoms, which was maintained in ation to the second follow-up in the factors of clarity the follow-ups. Regarding the depression symptomatol- (x2=11.60; p=.010) and emotional regulation (x2 =7.75; ogy which was measured with the BDI total score, sta- p=.050) only in women. Thus, female participants tistically significant differences were present (x2=15.03; improved their understanding and emotional regula- p=.002). At the beginning, participants presented moder- tion, while no changes were observed in men via their ate depressive symptoms (X= 24.12, SD=8.95) and at the TMMS-24 scores. However, this did not correspond end they did not present with any depressive symptoms to what was observed during the sessions, where they Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 7 of 11 Table 3 Comparisons of the means of all the participants through the Friedman test between the baseline and the follow-ups in the clinical variables of the multidisciplinary treatment N = 10 Scales Gender Pre Post 1st follow-up 2nd follow-up X P BES 32.13 7.55 9.12 (6.91) 9.12 (4.79) 15.57 .001* (4.22) (9.33) QEWP-R 8.38 (1.92) 3.50 4.75 (2.76) 4.37 (3.02) 13.58 .004* (2.32) BAI 31.75 (10.20) 11.75 (12.25) 15.12 (10.56) 12.62 (5.75) 15.96 .001* BDI 24.12 (8.95) 7.37 (12.08) 9.00 (7.81) 5.37 (3.29) 15.03 .002* TMMS-24 Atention Female 28.00 (7.97) 25.14 (6.14) 25.75 (6.04) 26.87 (6.92) 2.72 .430 Male 29.00 (1.41) 26.00 (5.65) 27.00 (5.65) 27.31 (6.08) 1.31 .360 Clarity Female 21.57 (7.45) 29.75 (7.22) 26.75 (6.20) 29.25 (7.00) 11.60 .010* Male 23.50 (0.70) 21.50 (2.12) 29.50 (7.77) 29.75 (6.00) 4.10 .444 Regulation Female 22.00 (5.44) 30.72 (6.75) 27.37 (6.86) 26.75 (5.80) 7.75 .050* Male 28.00 (7.07) 28.50 (6.36) 24.00 (7.07) 24.75 (5.14) 0.28 .860 BES Binge eating scale, QEWPR Questionnaire on eating and weight patterns revised, BAI Beck Anxiety Inventory, BDI Beck Depression Inventory, TMMS-24 Trait meta- mood scale-24. Only the TMMS-24 is presented by sex because it is measured in both categories Bold value indicated the difference is significant at 0.05 level * p < 0.05 presented with a lack of emotional expression. This lack Physical activity did not translate in the self-assessment of their emo- At the beginning of the intervention, two of the par- tions, therefore their scores did not change throughout ticipants performed exercise or some other recreational the treatment (see Table 3). Therefore, although they activity sporadically. Three of the participants had a mentioned an improvement at the end of the interven- childhood history of doing some exercise aimed at los- tion, this was not reflected in the instrument, as their ing weight. After treatment, all participants were able to scores were already adequate from the beginning. adhere to physical activity in their daily routine, perform- ing it on average two to seven times a week with low to Body weight, diet, and physical activity medium intensity activities. During the follow-ups, it was Body weight observed that the frequency of the activity decreased, Regarding body weight, a reduction was observed from as the patients reported doing it between two and three the pre-evaluation to the second follow-up, this ranged times a week. Among the activities they began to perform between 3 and 15kg, with women having the greatest were walking, yoga, cycling and cardio. Some patients decrease. Additionally, in the first follow-up, most of the reported that the physical activity had an impact on their participants maintained the same weight as at the end of emotions, mentioning feelings of increased motivation to treatment, however, there were those who continued to carry out their daily activities. lose weight, observing a reduction of up to an additional In the case of males, it should be noted that perform- 4kg. At the second follow-up, all participants maintained ing physical activities was more difficult, even though their weight loss. one of them had a history of playing sports in childhood. However, it was possible for them to increase their activ- Eating habits ity from two to three times a week. In females, dance was At the beginning of treatment, little consumption of noted to be a motivator for them to be physically active, fruits and vegetables was observed, especially at break- doing it at home with videos and YouTube routines, fast, in addition, the consumption of sugars, cereals and supervised by the sports physician. tubers was high, this was observed especially at night, consisting of 4 to 6 times a week. After the intervention, Objective clinical change index of the participants a decrease was observed, from 2 to 3 times per week, To find out the differences at the individual level after in terms of the consumption of sugars. In addition, an the multidisciplinary intervention ended, each case was increase in the consumption of vegetables and fruits was analyzed obtaining the Objective Clinical Change Index constant, meaning there was a daily consumption. (OCC). A significant clinical change is considered when Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 8 of 11 it is greater than 20%; it is necessary to consider that, for BED. Therefore, adherence should be monitored and depending on the direction of the data, it may indicate encouraged during the program [37]. Additionally, in clinical deterioration or improvement [33]. future research it would be important to consider the All the participants obtained a positive change greater potential dropout rate of the participants. than 65% in binge eating symptoms, in terms of anxiety Patients at the beginning of treatment showed severe symptoms there were also changes between 40 and 90% symptoms and subsequently a positive clinical change in the participants. In the same vein, depression symp- from 94 to 67%, which lasted until the second follow-up. toms decreased from 88 to 72%. Regarding emotional This result is important because it indicates that a central intelligence, there were positive changes in six patients aspect of BED decreased and is consistent with two stud- in the attention factor between 27 and 44%. Likewise, in ies which are considered to be effective, that were also emotional clarity, changes were observed in eight par- conducted online. The first one being CBT based, which ticipants between 47 and 100%. And lastly in emotional significantly reduced binge eating episodes [38] and the regulation there were positive changes in eight patients second saw a reduction in the frequency of binge eating between 21 and 100%. lasting throughout the follow-ups carried out [20]. In both studies food records were also used and the thera- Discussion peutic relationship, between the patient and therapist, The main objective of this study was to evaluate the feasi- was important for the patients to be motivated to con- bility of a multidisciplinary online intervention in a group tinue treatment. of clinical case series patients with BED. Considering that Regarding symptoms of depression and anxiety at the most of the participants were women, we can say that, start of treatment, a moderate trend was observed. These according to the literature, women are more likely to seek findings are consistent with other studies that show that help for an eating disorder even though there are similar more than half of the patients with BED who complete rates of BED by sex [5]. In addition, it has been observed online treatment suffer from symptoms of anxiety and that in men there is less awareness of eating psycho- depression. Above all, it has been observed that depres- pathologies and greater reluctance to seek treatment for a sion is a comorbidity that is recurrent in men with eating disorder that they possibly consider "feminine"[7]. Given disorders [39]. Both the symptomatology of anxiety and this, it was important for patients to decide to seek treat- depression are aspects that have been pointed out in the ment, as many of them were unaware of BED and how literature as clinical symptoms in BED. In this sense, it the disorder influenced their emotions and eating habits. was encouraging to observe that the significant decreases It is important to mention that there were men in this in these clinical variables were maintained throughout study and that they were the ones who presented the the follow-ups. greatest emotional and eating psychopathology. Thus, Regarding emotional intelligence, it was observed that their incorporation into more treatment programs is sig- there were improvements in the factors of clarity and nificant since, even though BED is commonly reported in emotional regulation only in women, while the emotional men (2.5 % in men vs. 3.0% in women), they are under- attention variable had no changes since both women and represented in clinical treatment studies [15]. In this men showed adequate scores from the beginning. Some sense, two community studies have found few differences authors [40, 41] have provided evidence that people with in physical and psychosocial deterioration according to BED are less able to manage emotions or use more dys- sex, in relation to binge eating symptoms [34, 35]. There- functional regulation strategies such as repressing emo- fore, it is necessary to continue implementing strategies tions or using binge eating as a maladaptive emotional to ensure that more men attend and remain throughout strategy in the face of stressful social situations. Also, in the treatment process. In our study, the two men were men it has been observed that there is difficulty recogniz- able to complete the treatment, observing good effective- ing emotions [6]. Given the above information, our male ness and an improvement in their quality of life. patients exhibited limitations in emotional self- aware- On the other hand, it is also necessary to point out ness from the beginning by not answering the instru- that there was a dropout of 30% of the participants dur- ments adequately, so it was not possible to quantitatively ing treatment. According to a review [36], the average measure their progress. online treatment dropout is 29%, so our study was within Regarding body weight in the study participants, there this mean. It has been shown that by measuring patient was a reduction between 3 and 15 kilograms. It is impor- adherence (e.g., participation in the program, attention tant to note that the main objective of this treatment was given to the time spent in a session, written exchange not only the reduction of body weight, but moreover the with the therapist, submission of assignments) it is pos- resolution of eating problems for each patient. This pri- sible to prevent dropouts in Internet-based programs mary aim had a clear impact on their body weight, due Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 9 of 11 to the lower frequency of binge eating, which appears intervention and to be able to prevent dropouts. On promising. The decrease and maintenance of body weight the other hand, the number of participants was small, as a point of effectiveness for BED treatments is a point resulting in limited power to generalize our results. of discussion, since an improvement in quality of life and Another limitation was that the findings in the emo- associated psychological variables has been observed in tional intelligence variable were not as efficient as some interventions, without a decrease in body weight. expected, especially in men, since it was not possible to Recently, it has been examined that in multidisciplinary measure their progress throughout treatment, so evalu- formats, that is, by combining the psychological, nutri- ating changes was difficult. This is an area of improve- tional, and physical activity parts, there is a reduction in ment in future interventions given the important role body weight and also a greater efficacy in improving eat- that emotions play in BED. Another limitation was not ing psychopathology [42, 43]. being able to measure the patients anthropometrically Regarding food, it was initially observed that the par- and only having weight and BMI as reference, since ticipants consumed many grains, fried foods and sugars these are measurements that may have restricted us and there were no fruits or vegetables at home. After from observing whether there was a greater impact the intervention, the intake of fried foods and sugars on the participants, both in physical and nutritional decreased and there was an introduction of vegeta- health. bles and fruits, some patients were even involved in the Among the strengths of the study, to the best of our preparation of food at home. It is important that patients knowledge, this is one of the first online multidisciplinary with BED learn to eat and be able to vary their diet, so the studies conducted with patients with BED in Mexico. inclusion of the nutritionist in this study was essential. A This study takes a step forward in evaluating the effi- review of the literature highlighted that a multidiscipli- cacy of online multidisciplinary formats for patients with nary intervention produced a greater impact in the treat- this psychopathology. In addition, the use of technology ment since it helps participants have a greater variety of allowed the participants to have a good adherence to the meals and an improvement in binge eating symptoms treatment, helping in the performance of therapeutic compared to interventions that are only psychologi- tasks. Likewise, working in a collaborative team allowed cal or dietary [44]. This multidisciplinary approach was for possibility to address various problems of the disorder used, which had a notable impact on the improvement in and deepen its treatment. Finally, the follow-up periods patients in their way of eating as well as in their relation- helped to obtain more information and evidence on the ship with food and their quality of life. medium and long-term effects of the intervention. In relation to physical activity at the beginning of the treatment, the patients did not engae in any physical activity, at the end of the intervention we observed that Conclusions they introduced it three to four times a week. In this This multidisciplinary treatment proved to be feasible regard, physical activity interventions have shown prom- and effective on the proposed clinical objectives: binge ise for improving physical health [45], eating symptoms, eating symptoms, anxiety and depression symptoms, such as decreased binge eating, as well as improved improvement in emotional intelligence, eating habits, mood [46]. In our online treatment, it was observed that body weight and physical activity. The findings of the physical activity had an impact on both the diet and the intervention are significant since it is one of the first emotional aspect of the well-being of each patient. online BED case series carried out in Mexico, so it is Finally, more evidence is needed to evaluate this type important to disseminate and monitor it. Future research of online intervention in multidisciplinary formats, com- is needed to confirm the effectiveness and mechanisms of paring them with face-to-face interventions. As well as change of this multidisciplinary treatment. to study their effects on participants and to evaluate the changes when performing the treatment virtually, adding Abbreviations technological applications and other components that AN Anorexia nervosa could facilitate the intervention. In addition, it is neces- APA American Psychiatric Association sary to guide health professionals so that these online BAI Beck Anxiety Inventory BDI Beck Depression Inventory programs are more effective and can be replicated both BED Binge eating disorder in the clinical field and in research. BES Binge eating scale The findings of the present study have some limita- BMI Body mass index BN Bulimia nervosa tions. Regarding dropouts, more monitoring of the CBT Cognitive behavioral therapy patients was needed throughout the treatment to COVID-19 Coronavirus disease 2019 assess the motivation for their participation in the DBT Dialectical behavioral therapy Valdez‑Aguilar et al. Journal of Eating Disorders (2023) 11:86 Page 10 of 11 DSM Diagnostic and statistical manual of mental disorders 9. Brown KL, LaRose JG, Mezuk B. The relationship between body mass IDED Interview for the diagnosis of eating disorders index, binge eating disorder and suicidality. BMC Psychiatry. 2018;1:196. 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