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European Eating Disorders ReviewEur. Eat. Disorders Rev. 11, 397–404 (2003)Published online 25 May 2003 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.498

Paper

Size Really Doesn’t Matter

Bethan Lawrence1,2, Mari Campbell1, Marc Neiderman1 andLucy Serpell*1,21Eating Disorders Service, Huntercombe Manor Hospital, HuntercombeLane South, Taplow, Maidenhead, Berkshire, SL6 0PQ, UK2Department of Psychiatry, St George’s Hospital Medical School,University of London, Cranmer Terrace, London SW17 0RE, UK

Objective: The judgement of what constitutes a large amount of food is onepart of determining a binge and is therefore crucial for the diagnosis of BN. Thisstudy aimed to determine whether eating disorder professionals agree on whatconstitutes a large amount of food and the criterion they use to make the decision.Method: 147 eating disorder professionals completed a short questionnaire,that involved rating five food vignettes according to whether they believed themto consist of a large amount of food.Results: There was general consensus among eating disorder professionals asto what constituted a large amount of food. The results also suggested that manyparticipants based their judgement on how dissimilar the vignette was to anormal meal.Discussion: The finding that the judgement of whether an amount of food islarge can be made with high reliability but low validity should be the subject offurther research due to its importance in the diagnosis of bulimia nervosa.Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association.

Keywords: binge; bulimia nervosa; diagnosis; DSM; ICD

INTRODUCTION

The presence of binge eating is an essential criterion for diagnosingbulimia nervosa (BN) in the DSM-IV (American Psychological Associa-tion; APA, 1994). However, little research has been conducted into the

European Eating Disorders ReviewCopyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 11(5), 397–404 (2003)

*Correspondence to: Lucy Serpell, Early Onset Eating Disorders Team, Department of Psychiatry,St. Georges Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.E-mail: [email protected]

way in which the judgement of a binge is made. Beglin and Fairburn(1992) found that, when deciding whether an episode is a binge, youngwomen without eating disorders placed a greater emphasis on the lossof control than on the quantity eaten. Johnson and colleagues (2000)found that loss of control, but also quantity of food and time taken to eatit influenced whether an episode was rated as a binge by womenwithout eating disorders.

According to the DSM-IV (American Psychiatric Association, 1994),two criteria are needed to diagnose a the presence of binge: (1) ‘eating ina discrete period of time an amount of food that is definitely larger thanmost individuals would eat under similar circumstances’, and (2) ‘asense of lack of control over eating during the episode’. However, thereis considerable debate about whether these criteria are the mostappropriate ones and over how they should be applied. The ICD-10Classification of Mental and Behavioural Disorders: Clinical Descriptions andDiagnostic Guidelines (ICD-10; World Health Organization, 1992) doesnot use the term ‘binge’ in its diagnosis. However, for a diagnosis ofbulimia, the patient must experience ‘periods of overeating in whichlarge amounts of food are consumed in short periods of time’.

Assessment tools such as the Eating Disorders Examination (EDE;Cooper & Fairburn, 1987), used to aid DSM-IV diagnosis, requireclinicians to judge whether or not the patient is engaging in binge eating.Definitions have been given to make this task easier. For example, adiscrete period of time has been defined as being ‘within any 2-hperiod’. However, no criteria are given for the judgement of ‘a largeamount of food’.

Clinicians describe a great deal of variability in the amount patientsconsume during a binge (Crowther & Sherwood, 1997). Researchsuggests that although the term ‘binge’ suggests a large amount of food,in terms of calorific value, the actual eating episodes may or may notinvolve the ingestion of a large amount of food (Rosen, Leitenberg, Fisher,& Khazam, 1986; Rossiter & Agras, 1990). Studies investigating calorificintake during a binge episode vary considerably from less than 600calories up to 5000 calories (Kissileff, Walsh, Kral, & Cassidy, 1986; Rosenet al., 1986; Rossiter & Agras, 1990; Woell, Fichter, Pirke, & Wolfram,1989). Hence some authors have suggested a distinction between‘subjective’ bulimic episodes (where loss of control is experienced butthe amount of food is not objectively large) and ‘objective’ bulimicepisodes (where loss of control is experienced and the amount of food isobjectively large). Such authors suggest that only objective bulimicepisodes should be relevant for the diagnosis of bulimia nervosa.

Little research has been conducted looking at whether a binge is likelyto follow the form and content of a normal meal, i.e. how ‘meal-like’ it is.

B. Lawrence et al. Eur. Eat. Disorders Rev. 11, 397–404 (2003)

Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 398

However, it has been suggested that binges tend to consist of snackfoods and desserts (Rosen et al., 1986; Woell et al., 1989), hence a bingemay not be ‘meal-like’.

The aims of this study were to investigate whether eating disorderprofessionals agree on what constitutes a large amount of food and whatcriteria they use to judge whether an amount of food is large or not andhence whether it might be classified as a binge.

METHOD

Participants

One hundred and forty-seven eating disorders professionals attendingthe ‘Eating Disorders 2001’ conference in London completed the bingesurvey. The respondents consisted of psychiatrists, psychologists,nurses and other professionals, many of whom are likely to be involvedin the assessment and treatment of individuals with eating disorders.

Measures

Binge survey (see Appendix 1)

A survey was developed by the authors describing five food vignettes.The vignettes were chosen to illustrate a range of possible foods whichmight be consumed during a meal or binge. Written instructions weregiven asking participants to rate whether they considered each of thefood vignettes to be a large amount of food. Possible responses were‘yes’, ‘no’ and ‘unsure’.

Procedure

The Survey was distributed to 500 delegates attending the conference.Responses were anonymous and respondents returned the survey to abox in the registration hall.

RESULTS

Calorific value and weight was calculated for each vignette from foodpackages and the internet (www.cyberdiet.com). (N.B. This informationwas not made available to respondents). For the judgement of ‘meal-likeness’, 10 eating disorder professionals were asked to rate, on a scale

Eur. Eat. Disorders Rev. 11, 397–404 (2003) Size Really Doesn’t Matter


of 1 to 5, each vignette according to how similar to a meal they con-sidered it to be. A mean score was then calculated for each (see Table 1).

Table 1 shows the percentage of respondents who judged eachvignette as a large amount of food, not a large amount of food and thosewho were unsure. The percentage of respondents who judged eachvignette to consist of a large amount of food ranged from 8.2 to 98.6 percent. However, agreement (on whether or not a vignette was large) wasgenerally high, in that most participants responded in the samedirection, agreeing that a particular vignette either was, or was not alarge amount of food.

The vignettes were ranked according to the percentage of respon-dents who judged each to be a ‘large amount of food’, with ‘1’ being thevignette for which the fewest participants considered it a large amountof food (vignette 3) and ‘5’ that which the most participants consideredlarge (vignette 2). Next, the vignettes were ranked according to possiblecriteria participants might use to judge whether the amount of food waslarge or not, such as calorific value, weight and ‘meal-likeness’. Thevignettes were ranked according to the application of each criterion,then the ordering of the vignettes was examined to determine whetherthe application of the criterion led to a similar ranking to that thedetermined by participants’ responses. The criterion that resulted in themost similar ranking of the food vignettes to the consensus amongparticipants was assumed to be the factor most likely to be used todetermine a ‘large amount of food’.

Table 1 shows that using either calorific value or weight as thedetermining factor did not accurately rank the food vignettes, andtherefore it is unlikely that either of these factors were used by mostparticipants when completing the survey.

In fact, using ‘meal-likeness’ as the determining factor led to the mostsimilar ranking of vignettes to the consensus of the participants. Thissuggests that in this instance, ‘meal-likeness’ may have been the factormost commonly used to rank whether a food vignette was a ‘largeamount of food’ or not.

DISCUSSION

Overall, this study shows that there is high consensus among eatingdisorder professionals on what constitutes a large amount of food. Thissuggests that the judgement of ‘large-ness’, which is required for thediagnosis of BN, can be made with high inter-rater reliability. However,the results suggest that the criterion used by eating disordersprofessionals to quantify a ‘large amount of food’ was not size in terms



Tab

le1.

Results

Foodvignette

Ran

kCalorific

Weight

‘Mea

l-liken

ess’

Binge

Notbinge

Unsu

revalue(kcal)

(g)

large

large

Bo

wl

sou

p,

chic

ken

leg

,fo

ur

116

4217

761

8.16

287

.74.

081

po

tato

es,

po

rtio

no

fca

rro

ts,

(3)

(2)

(1)

pea

s,ca

bb

age,

slic

eo

fch

eese

cak

eF

ou

rh

eap

edb

ow

lsm

ues

li,

fou

rsl

ices

210

2244

32.

980

.96.

1212

.93

toas

tan

dja

m(1

)(1

)(2

)0

Sal

ad—

on

ew

ho

lele

ttu

ce,

122

1140

3885

3.2

80.9

6.89

12.2

tom

ato

es,

two

cucu

mb

ers;

fru

it(2

)(5

)(3

)sa

lad

—fo

ur

app

les,

fou

ro

ran

ges

,fo

ur

pea

rsT

hre

ep

ack

ets

cho

cola

teb

iscu

its

437

8775

05

87.7

4.76

87.

485

(5)

(3)

(5)

Six

pac

ket

scr

isp

s,si

xS

nic

ker

s,si

x5

3124

618

4.5

98.6

1.43

60

can

so

fco

ke

(4)

(2)

(4)

*Ran

kis

reco

rded

inp

aren

thes

es.



of weight or calorie content, but meal-likeness. Specifically, the more thefood vignette resembled a meal, the less likely it was to be classified as a‘large amount of food’. This suggests that the judgement of ‘large-ness’may be reliable but not valid.

There are several possible explanations for this finding. One is that theeffect was entirely spurious, due to a large variance in responses.However, this does not seem to be supported by the findings, as theparticipants were generally in agreement in their ratings of whatconstituted ‘a large amount of food’.

Another possible explanation is that participants may have thoughtthey were required to rate whether they judged the vignettes to be ‘abinge’ and not ‘a large amount of food’. If this was the case, it stillsuggests that eating disorders professionals classify a binge with regardto how meal-like was the food consumed, rather than according to theactual amount of food.

Although the findings are at odds with the definition of a binge in theDSM-IV, there is evidence to support the idea that binge episodes maynot be meal-like, being more likely to contain desserts or snacks(Hadigan, Kissileff, & Walsh, 1989; Rosen et al., 1986), tending to includea lower percentage of fruit and vegetables than non-binge episodes(Hadigan et al., 1989; Rosen et al., 1986) and being less likely to followthe normal pattern of a meal (Hadigan et al., 1989). When bingeing,people also tend to avoid food that involves extended preparation, e.g.boiling or roasting (Woell et al., 1989). In the survey the vignettes thatwere the most meal-like would also have taken the most time to prepareand therefore may not be likely to be eaten in a binge. This may havediscouraged the respondents from classifying these vignettes as a ‘largeamount of food’.

This was a small exploratory study and as such has several limitationswhich could be addressed in future research. One weakness was thatusing these particular vignettes, it was not possible to clearly distinguishwhich of the possible variables of weight, calorific context or meal-likeness were responsible for respondents’ choices, or which combina-tions of these were most commonly used. A revised version of thesurvey could match pairs of vignettes so that they are similar in weightbut widely different in the other variables, and so on for each variable,so that the effect of each variable on the judgement could be examinedindependently.

It is also possible that variables not measured in the current studywere responsible for judgements made by respondents. For example,macronutrient composition such as fat or sugar content may affect theclassification made. Further research could compare these elements indifferent vignettes.



Factors such as age, appetite and experience with eating disorderswere not measured in this study. Future research could examine howeach factor affects an individual’s classification.

From a clinical perspective, it is a concern that the criteria we use toclassify a large amount of food (and thus a binge) may not be those webelieve we use. However, on a positive note, it does seem thatprofessionals have high levels of agreement on what constitutes a largeamount of food. Overall, it appears that for eating disorder profes-sionals, size really doesn’t matter!

ACKNOWLEDGEMENTS

We would like to thank Professor Glenn Waller for his advice on theanalysis of the results and Professor Bryan Lask for his comments on anearlier draft.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual formental disorders (4th ed.). Washington, DC: APA.

Beglin, S., & Fairburn, C. (1992). What is meant by the term ‘binge’? AmericanJournal of Psychiatry, 149, 123–124.

Cooper, Z., & Fairburn, C. (1987). The Eating Disorder Examination: Asemistructured interview for the assessment of the specific psycho-pathology of eating disorders. International Journal of Eating Disorders, 6,1–8.

Crowther, J., & Sherwood, N. (1997). Assessment. In D. M. Garner, & P. E.Garfinkel (Eds.), Handbook of treatment for eating disorders (pp. 34– 49).Guilford Press: New York.

Hadigan, C., Kissileff, H., & Walsh, B. (1989). Patterns of food selection duringmeals in women with bulimia. American Journal of Clinical Nutrition, 50,759–766.

Johnson, W., Boutelle, K., Torgrud, L., Davig, J., & Turner, S. (2000). What is aBinge? The influence of amount duration, and loss of control criteria onjudgments of binge eating. International Journal of Eating Disorders, 27,471–479.

Kissileff, H., Walsh, B., Kral, J., & Cassidy, S. (1986). Laboratory studies ofeating behaviour in women with bulimia. Physiology and Behavior, 38,563–570.

Rosen, J., Leitenberg, H., Fisher, C., & Khazam, C. (1986). Binge-eating episodesin bulimia nervosa: The amount and type of food consumed.International Journal of Eating Disorders, 5, 225–267.



Rossiter, E., & Agras, W. (1990). An empirical test of the DSM-III-R definition ofbinge. International Journal of Eating Disorders, 9, 513–518.

Woell, C., Fichter, M., Pirke, K., & Wolfram, G., (1989). Eating behaviour ofpatients with bulimia nervosa. International Journal of Eating Disorders,8, 557–568.

World Health Organisation. (1992). The ICD-10 classification of mental andbehavioural Disorder. Geneva: World Health Organisation.

APPENDIX 1: ‘WHAT IS A BINGE?’

The Early Onset Eating Disorder Research Teams at St George’s Hospital Medical Schooland Huntercombe Manor Hospital are carrying out a brief survey and would very muchappreciate your professional opinions.

The issue of how to define an ‘objective bulimic episode’ (binge) has been puzzling usfor some time. We are trying to ascertain what people consider to be a ‘large amount offood’. We have therefore developed this quick survey. Please indicate by ticking therelevant box whether you believe the following amount of food can be classified as a‘large amount of food’.

Yes No Unsure

1. 3� 250 g/8 oz packets of chocolate biscuits & & &2. 6� 27 g/1 oz packets of crisps/potato chips, & & &

6� 65 g/2.5 oz Snickers bars6� 330 ml/11 oz cans of soft drink

3. Bowl of soup, chicken leg, four potatoes, portion & & &of carrots, peas, cabbage, slice of cheesecake

4. Four heaped bowls of muesli, four slices of toast & & &and jam

5. A salad consisting of one whole lettuce, & & &12 tomatoes, two cucumbers, and a fruit saladconsisting of four apples, four oranges, four pears

Thank you very much for taking time to complete this survey

Please return this form to the box situated in the Poster area, or to any one of theconference assistants (identifiable by a blue sash), or post to Bethan Lawrence, ResearchAssistant, Early Onset Eating Disorders Research Team, Department of Psychiatry, StGeorge’s Hospital Medical School, Cranmer Terrace, Tooting, London, SW17 0RE, UK,or fax to 020 87255514.

