The main objective of this study was to evaluate the effectiveness of a multidisciplinary online intervention in patients with BED. Considering that most of the participants were women, we can say that, according to the literature, women are more likely to seek help for an eating disorder even though there are similar rates of BED by sex (3). In addition, it has been observed that in men there is less awareness of eating psychopathologies and greater reluctance to seek treatment for a disorder that they possibly consider "feminine"(5). Given this, it was important for patients to decide to seek treatment, as many of them were unaware of BED and how the disorder influenced their emotions and eating habits.
It is important to mention that there were men in this study and that they were the ones who presented the greatest emotional and eating psychopathology. Thus, their incorporation into more treatment programs is significant since, even though BED is commonly reported in men (2.5% in men vs. 3.0% in women), they are underrepresented in clinical treatment studies (13). In this sense, two community studies have found few differences in physical and psychosocial deterioration according to sex, in relation to binge eating symptoms (32,33). Therefore, it is necessary to continue implementing strategies to ensure that more men attend and remain throughout the treatment process. In our study, the two men were able to complete the treatment, observing good effectiveness and an improvement in their quality of life.
On the other hand, it is also necessary to point out that there was a dropout of 30% of the participants during the treatment. According to a review (34), the average online treatment dropout is 29%, so our study was within this mean. It has been shown that by measuring patient adherence (e.g., participation in the program, attention given to the time spent in a session, written exchange with the therapist, submission of assignments) it is possible to prevent dropouts in Internet-based programs for BED. Therefore, adherence should be monitored and encouraged during the program (35). Additionally, in future research it would be important to consider the potential dropout rate of the participants.
Patients at the beginning of treatment showed severe symptoms and subsequently a positive clinical change from 94–67%, which lasted until the second follow-up. This result is important because it indicates that a central aspect of BED decreased and is consistent with two studies which are considered to be effective, also conducted online. The first one being based on CBT significantly reduced binge eating episodes (36) and the second saw a reduction in the frequency of binge eating lasting throughout the follow-ups carried out (18). In both studies food records were also used and the alliance with the therapist was important for the patients to be motivated to continue treatment.
Regarding symptoms of depression and anxiety at the start of treatment, a moderate trend was observed. These findings are consistent with other studies that show that more than half of the patients with BED who complete online treatment suffer from symptoms of anxiety and depression. Above all, it has been observed that depression is a comorbidity that is recurrent in men with eating disorders (37). Both the symptomatology of anxiety and depression are aspects that have been pointed out in the literature as clinical symptoms in BED. In this sense, it was encouraging to observe that the significant decreases in these clinical variables were maintained throughout the follow-ups.
Regarding emotional intelligence, it was observed that there were improvements in the factors of clarity and emotional regulation only in women, while the emotional attention variable had no changes since both women and men showed adequate scores from the beginning. Some authors (38,39) have provided evidence that people with BED are less able to manage emotions or use more dysfunctional regulation strategies such as repressing emotions or using binge eating as a maladaptive emotional strategy in the face of stressful social situations. Also, in men it has been observed that there is difficulty recognizing emotions (4). Given the above, in our male patients there were limitations to emotional self-awareness from the beginning by not answering the instruments adequately, so it was not possible to quantitatively measure their progress.
Regarding body weight in the study participants, there was a reduction between 3 and 15 kilograms. It is important to note that the main objective of this treatment was not only the reduction of body weight, but moreover the resolution of eating problems for each patient.This aim had a clear impact on their body weight, due to the lower frequency of binge eating, this reduction finding appears promising. The decrease and maintenance of body weight as a point of effectiveness for BED treatments is a point that is being discussed, since an improvement in quality of life and associated psychological variables has been observed in some interventions, without a decrease in body weight. Recently, it has been examined that in multidisciplinary formats, that is, by combining the psychological, nutritional, and physical activity parts, there is a reduction in body weight and also greater efficacy in improving eating psychopathology (40,41).
Regarding food, it was initially observed that the participants consumed many grains, fried foods and sugars and there were no fruits or vegetables at home. After the intervention, the intake of fried foods and sugars decreased and there was an introduction of vegetables and fruits, some patients were even involved in the preparation of food at home. It is important that patients with BED learn to eat and be able to vary their diet, so the inclusion of the nutritionist in this study was essential. A review of the literature highlighted that a multidisciplinary intervention produced a greater impact in the treatment since it helps participants have a greater variety of meals and an improvement in binge eating symptoms compared to interventions that are only psychological or dietary (42). This multidisciplinary approach was used, which had a notable impact on the improvement in patients in their way of eating as well as in their relationship with food and their quality of life.
In relation to physical activity at the beginning of the treatment, the patients did not do any physical activity, at the end of the intervention we observed that they introduced it three to four times a week. In this regard, physical activity interventions have shown promise for improving physical health (43), eating symptoms, such as decreased binge eating, as well as improved mood (44). In our online treatment, it was observed that physical activity had an impact on both the diet and the emotional part and the well-being of each of the patients.
Finally, more evidence is needed to evaluate this type of online intervention in multidisciplinary formats, comparing them with face-to-face interventions. As well as to study their effects on participants and to evaluate the changes when performing the treatment virtually, adding technological applications and other components that could facilitate the intervention. In addition, it is necessary to guide health professionals so that these online programs are more effective and can be replicated both in the clinical field and in research.
The findings of the present study have some limitations. Regarding dropouts, more monitoring of the patients was needed throughout the treatment to assess the motivation for the intervention and to be able to prevent dropouts. On the other hand, the number of participants was small, resulting in limited power to generalize our results. Another limitation was that the findings in the emotional intelligence variable were not as efficient as expected, especially in men, since it was not possible to measure their progress throughout the treatment, so the evaluation of the changes was difficult. This is an area of improvement in future interventions given the important role that emotions play in BED. Another limitation was not being able to measure the patients anthropometrically and only having weight and BMI as reference, since these are measurements that may have restricted us from observing whether there was a greater impact on the participants, both in physical and nutritional health.
Among the strengths of the study, to the best of our knowledge, this is one of the first online multidisciplinary studies conducted with patients with BED in Mexico. This study takes a step forward in evaluating the efficacy of online multidisciplinary formats for patients with this psychopathology. In addition, the use of technology allowed a good adherence of the participants, helping in the performance of therapeutic tasks. Likewise, having a collaborative team allowed for the addressing of various problems of the disorder, deepening its treatment. Finally, the follow-up periods helped to obtain more information and evidence on the medium and long-term effects of the intervention.