Regulation of Cues vs Cognitive Behavioral Therapy: Advancing Binge Eating Disorder Treatment for Veterans

Highlights

• The ROC+BWL intervention provided greater reductions in binge eating than CBT in veterans with obesity, particularly those with BED.
• ROC+BWL led to greater short-term weight loss than CBT, but these differences were not maintained at 6-month follow-up.
• Both interventions were feasible and well-accepted, with high retention rates.
• Addressing appetitive traits—food and satiety responsiveness—may augment traditional approaches for binge eating disorder (BED).

Study Background and Disease Burden

Binge Eating Disorder (BED) is the most prevalent eating disorder in the United States, with significant comorbidity, medical complications, and impaired quality of life. Veterans are at elevated risk for both obesity and BED due to unique stressors, trauma exposure, and environmental factors. Standard treatment relies on cognitive behavioral therapy (CBT), which targets maladaptive thoughts and behaviors driving the binge/diet cycle. However, a growing body of evidence highlights the role of appetitive traits—such as heightened food responsiveness (tendency to eat in response to environmental cues) and impaired satiety responsiveness (difficulty recognizing fullness)—in perpetuating binge eating and obesity, particularly in the context of an obesogenic environment. The Regulation of Cues (ROC) intervention, developed to address these appetitive processes, may offer a complementary or alternative pathway to improve outcomes for individuals struggling with BED and obesity.

Study Design

This single-site, randomized clinical trial was conducted at a university clinic from March 2019 to April 2023. Participants included veterans aged 18-65 years, with a BMI between 25 and 45, who met criteria for BED or subthreshold BED, and without other exclusionary conditions. Of 1853 veterans screened, 129 were randomized: 63 to ROC+BWL and 66 to CBT. The ROC+BWL intervention was tailored to reduce food responsiveness, enhance satiety responsiveness, and achieve energy reduction through behavioral weight loss strategies. In contrast, CBT focused on modifying dysfunctional cognitions and behaviors linked to the restraint-binge cycle. Both interventions were delivered over five months, with assessments at midtreatment (2.5 months), posttreatment (5 months), and at a 6-month follow-up (11 months total from baseline). Primary outcomes were feasibility (attendance, acceptability), change in binge eating (loss of control eating), and body weight (BMI change).

Key Findings

Feasibility and Acceptability
Both ROC+BWL and CBT achieved high retention: 95% of participants completed posttreatment assessments, and 89% completed the 6-month follow-up. Attendance rates and acceptability ratings were comparable between groups, confirming the feasibility and acceptability of both interventions in a veteran population.

Reduction in Binge Eating
ROC+BWL delivered greater reductions in the risk of binge eating compared to CBT at all time points:
– Midtreatment (2.5 months): Difference in probability of binge eating, -0.20 (95% credible interval [CrI], -0.30 to -0.11)
– Posttreatment (5 months): Difference, -0.23 (95% CrI, -0.22 to -0.19)
– Follow-up (11 months): Difference, -0.21 (95% CrI, -0.21 to -0.18)
These effects were more pronounced in veterans with full-syndrome BED than in those with subthreshold presentations, suggesting that appetitive trait-targeted interventions may be especially beneficial for those with more severe binge eating pathology.

Weight Loss Outcomes
ROC+BWL also resulted in greater reductions in BMI than CBT at midtreatment and posttreatment:
– Midtreatment: Difference in BMI change, -0.68 (95% CrI, -1.23 to -0.12)
– Posttreatment: Difference, -0.71 (95% CrI, -1.40 to -0.01)
However, these differences were not sustained at the 6-month follow-up—BMI differences were no longer statistically significant (difference, -0.22; 95% CrI, -0.98 to 0.54). This suggests that while ROC+BWL can produce greater short-term weight loss, maintaining these effects post-treatment remains a challenge.

Safety and Adverse Effects
No significant safety concerns or adverse events were reported in either group, consistent with the established safety profiles of behavioral interventions for BED and obesity.

Expert Commentary

The introduction of ROC+BWL represents an important innovation in the treatment landscape for BED, particularly in populations like veterans who may have higher exposure to environmental food cues and unique stressors. By directly targeting food and satiety responsiveness, ROC+BWL addresses mechanisms not typically prioritized in classic CBT protocols. The observed superiority of ROC+BWL in reducing binge eating—especially among those with full BED—reinforces the need for individualized, mechanistically-informed treatment approaches.

However, the attenuation of weight loss effects at follow-up underscores a persistent challenge in behavioral weight loss interventions: sustaining initial gains. Potential explanations include the difficulty of maintaining behavioral change in real-world environments and the need for ongoing support or booster sessions. The high retention and acceptability rates are notable strengths, supporting the scalability of both interventions within the Veterans Health Administration and similar systems.

Limitations include the single-site design, relatively small sample size, and inability to blind participants to treatment allocation. Additionally, the study population may not generalize to non-veteran or more diverse clinical settings. Future research should explore strategies to sustain weight loss, investigate cost-effectiveness, and determine which patient subgroups derive the most benefit from ROC+BWL.

Conclusion

This randomized clinical trial demonstrates that ROC+BWL is a feasible and effective intervention for reducing binge eating in veterans with BED and obesity, offering greater short-term benefits than standard CBT. While ROC+BWL also produced greater initial weight loss, these differences were not maintained long-term, highlighting an ongoing need for durable weight management strategies. The ROC+BWL paradigm may represent a valuable addition to the therapeutic armamentarium for BED, particularly among patients with prominent appetitive dysregulation. Further research is needed to optimize weight outcomes and evaluate broader applicability.

References

Boutelle KN, Afari N, Obayashi S, Eichen DM, Strong DR, Pasquale EK, Peterson CB. 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 Aug 1;8(8):e2525064. doi: 10.1001/jamanetworkopen.2025.25064. PMID: 40758351.

Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Publishing; 2013.