What began your interest in researching eating disorders, and in particular, binge eating and its impact on the workplace?
a. Binge eating holds great interest in part because of its relationship to the obesity epidemic. Among the obese, patients with binge eating typically generate the highest medical costs, experience the most psychological distress, and have the poor outcomes in weight management programs. In our sample, over 27% of those with Class III obesity reported binge eating. Imagine the implications if one out of four participants in weight management services is binge eating. Binge eaters will not succeed at weight management unless they get their eating behavior under control. In fact, dieting or restrictive eating can become a trigger for binges. Consequently, we won’t be addressing the obesity epidemic effectively unless we provide the right help for binge eaters.
b. Eleven years ago, I received a grant from the National Institute of Mental Health to develop the first version of our digital health coaching program for binge eating. Since then, the program has evolved to become more clinically sophisticated and more closely tailored to the individual needs of each participant.
c. Several years ago, we began to include screening questions for binge eating in our online health risk assessment (HRA). We are not aware of another HRA that routinely does this. Since our HRA also includes a measure of productivity impairment (a combined estimate of absenteeism and presenteeism), we then had an opportunity to look at the impact of binge eating not only on health, but also on workplace performance.
How did you define “binge eating” in your study? Did it also include employees who engaged in binge and purge behavior, such as bulimia?
a. Binge eating is defined as: Eating a larger amount of food than normal during a short period of time, accompanied by a lack of control over eating during the binge episode (i.e. the feeling that one cannot stop eating). It is the sense of loss of control that differentiates episodes of binge eating from ordinary overeating. So for example, for the average person, Thanksgiving dinner might be associated with overeating, but wouldn’t necessarily qualify as binge eating.
b. Because we do not screen for purging behaviors in our HRA, we are not in a position to make an educated estimate of the prevalence of those behaviors within an employee population.
In your study, you found a positive correlation between binge eating and loss of work productivity. To what factors do you attribute this correlation?
a. Binge eating is more than simply a behavioral problem. Binge eating is associated with greater psychological distress, as measured by increased frequency and intensity of negative emotions, and greater occurrence of negative thoughts and beliefs (e.g., poor body image, or obsessive worries about one’s weight). It’s not surprising then that it is also associated with diminished capacity to discharge one’s day-to-day responsibilities. In our study, we were also able to show that binge eating had an independent association with productivity impairment over and above the impact of stress and depression on performance.
Your study found that in a company of 1,000 employees, the estimated annual productivity loss due to binge eating is $107,965. Besides the financial loss to a company, why is it important to study the impact of binge eating on work productivity?
a. As noted above, there is a striking relationship between binge eating and obesity. Persistent episodes of binge eating ultimately lead to weight gain and obesity. However, it is important to bear in mind that at given point in time, there will be individuals whose binge eating has not yet resulted in obesity. While binge eating will inevitably result in weight gain, screening for the problem among all employees may result in identifying people whose eating behaviors have not yet resulted in high weight gain — if these people can receive help, they may avoid gaining weight and developing all the health problems that accompany obesity.
b. In general, eating disorders are typically not identified or treated. Not all healthcare organizations are cognizant of the strong association between binge eating and obesity. Consequently, routine medical examinations, and even weight management services may not include screening for binge eating. Moreover, people who binge eat typically feel ashamed of their behavior, which makes it hard for them to volunteer information about their problems. This may be even more of an issue among men, due to a perception that eating disorders are “female” disorders. There is research suggesting that some people are more likely to report potentially stigmatizing behaviors (e.g., unsafe sexual practices, substance abuse) to computer based assessment rather than face-to-face assessment with a health care provider. Providing confidential screening in the form of an HRA may make it easier for some individuals to disclose eating problems. Workplace screening may enable identification of binge eating and other behavioral health problems long before they ever come to the attention of the health care system.
c. Our experiences support the notion that alternate modes of screening, especially in the workplace, may help reach a group of individuals who otherwise might not come forward for help. To date, over 30,000 people have used our online digital health coaching program for binge eating: The vast majority of these participants were recruited because their HRA results suggested risk of binge eating. 18% of them have been healthy weight, and 24% have been overweight. The majority of participants are not yet binge eating daily. These data indicate that the program has been able to reach people before their difficulties had become more severe or resulted in significant weight gain. Moreover, around 30% if the participants (over 9,000 people) have been male, which is noteworthy when one considers that many eating disorder studies have difficulties enrolling sufficient numbers of men. Lastly, over 85% of the participants reported they that they were receiving no other services for their eating problems. Again, these data suggest that we have been able to reach a group of people whose eating difficulties might not have been identified or addressed in any other way.
In your study, you measured work productivity with the Work Productivity and Activity Impairment (WPAI) questionnaire. How does a company go about accessing this scale? Who can administer the scale?
Anyone who is considering use of the Work Productivity and Activity Impairment (WPAI) questionnaire should contact Reilly Associates, who are the authors of the scale (http://www.reillyassociates.net/WPAI_General.html). They will be able to provide information and guidelines on the appropriate use of the scale and interpretation of results.
In your estimate, how many employees who engage in binge eating may also have a purging component (such as in bulimia)?
Because we do not screen for purging behaviors in our HRA, we are not in a position to make an educated estimate of the prevalence of those behaviors within an employee population.
Would you say there is a difference in work productivity amongst employees with binge eating disorders such as bulimia, and employees with restrictive eating disorders such as anorexia?
We don’t have comparable data on bulimia or anorexia, so I cannot comment on this. Both bulimia and anorexia are very serious behavioral health problems, and may present immediate risks to health. Anyone with these difficulties should receive evaluation and treatment from a qualified healthcare professional.
What role does a company have in helping employees with eating disorders?
a. Screening and treatment for binge eating disorder need to be part of all workplace health promotion programs and every effort we make to contain the obesity epidemic. That means that all employer based health risk appraisals and weight management programs should be asking participants about binge eating behaviors and either providing them with or referring them to the appropriate services for the problem. As described in Question 4 above, our experiences indicate that this will result in identifying and triaging substantial numbers of people whose difficulties might otherwise go unnoticed or unacknowledged.
b. When employers provide confidential, alternative forms of self-help or self-management (e.g., digital health coaching) for people who might be reluctant to acknowledge their symptoms or come forward for treatment, they may be able to reach a group of people whose eating difficulties might not have been identified or addressed in any other way. As described in Question 4 above, our experiences support this recommendation.
Considering the litigious nature of society, what is the best way a business owner can address an employee’s possible binge eating?
Employers need to obtain appropriate legal consultation to ensure that they are complying with statutes and best practices designed to protect the privacy and safety of individuals, including the rules and regulations designed to safeguard Personal Health Information.
What treatments are available for issues with binge eating?
a. Much more research needs to be done on all treatments for binge eating, as there are a relatively small number of outcome studies. Many of the studies have small sample sizes, and importantly for this discussion, may exclude men, often because they cannot recruit enough male participants.
b. However, cognitive-behavioral therapy (CBT), offered both individually and in groups, is the treatment with the strongest research support to date. CBT focuses on helping patients develop stable eating habits, and identify triggers for binge episodes. Patients in CBT learn techniques for resisting the urge to binge and develop more adaptive strategies for coping with negative emotions and other triggers for binge eating. Lastly, they learn to challenge and change negative thoughts and beliefs that play a role in disordered eating.
c. The use of medications, such as antidepressants, has yielded mixed results in the research. Initial results on the use of appetite suppressants are promising, but more research needs to be done to confirm the effectiveness of these medications.
d. Other forms of psychotherapy, such as dialectical behavior therapy and interpersonal psychotherapy, have also shown positive results, but the research on them has been limited.
e. Likewise, combination treatments (e.g., CBT plus medication) have also shown promise in limited research.
f. Lastly, research is beginning to show that self-help CBT approaches, such as Web-based digital health coaching, can be helpful for binge eating. Results of our digital health coaching program have been very positive — we are in the midst of a randomized clinical trial to further test its effectiveness.
What are three things that employers should know about binge eating?
a. This is a common problem, but a treatable one.
b. Screening and treatment for binge eating disorder need to be part of all workplace health promotion programs and every effort we make to contain the obesity epidemic. That means that all employer based health risk appraisals and weight management programs should be asking participants about binge eating behaviors and either providing them with or referring them to the appropriate services for the problem. As described in Question 4 above, our experiences indicate that this will result in identifying and triaging substantial numbers of people whose difficulties might otherwise go unnoticed or unacknowledged.
c. We need to provide alternative forms of self-help or self-management (e.g., digital health coaching) for people who might be reluctant to acknowledge their symptoms or come forward for treatment. As described in Question 4 above, our experiences indicated that by doing so, employers may be able to reach a group of people whose eating difficulties might not have been identified or addressed in any other way.
Bedrosian, R.C., Striegel, R.H., Wang,C., Schwartz, S. (2012). Association of binge eating with work productivity impairment, adjusted for other health risk factors. Journal of Occupational & Environmental Medicine 54(4), p. 385-393.
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