EMNO DIET-MED-BED nutritional program for adults with obesity presenting binge eating

• Systematic administration at the start of the program, at 3 months, and at 6 months.
• Interpretation shared with the patient to reinforce involvement in the change process.

• Weight stabilization and prevention of major weight fluctuations (Grilo 2022).

• Reduction in self-stigmatization and dichotomous thoughts about eating.
• Improvement in body image, sense of personal efficacy, and self-esteem.
• Reduction in social isolation and improvement in the therapeutic relationship.
• Increase in frustration tolerance and emotional self-regulation abilities. (Duchesne 2007; Ricca 2000, Brelet 2021; Goodrick 1999)

• Reduction in mild to moderate anxiety and depressive symptoms (Duchesne 2007, Ricca 2000, Hilbert 2019)
• Improvement in sleep and circadian rhythms (Duchesne 2007, Tzischinsky 2000, Pendleton 2002, Levine 1996).

• Alteration of the homeostatic system of hunger and satiety: Patients suffering from binge eating disorder often show resistance to leptin signals and postprandial hyperactivation of ghrelin. This NPI promotes reconnection with bodily sensations through mindful eating exercises and regular structuring of food intake (Goodrick 1999).
• Low-grade inflammation and insulin resistance: Binge eating disorder is associated with an inflammatory state favored by cycles of restriction/rebound. Normalizing intake and reducing restrictive behavior contribute to the improvement of metabolic sensitivity (Succurro 2015, Pendleton 2002, Čížková 2020).

• Reduction of pathogenic cognitive restriction: The program deconstructs rigid dietary injunctions (mental dieting) and restores functional permissiveness, thus reducing the risk of compulsion through decompensation (Final Report Article 51 EMNO https://sante.gouv.fr/IMG/pdf/emno_rapport_evaluation_finale.pdf).
• Self-determination: This NPI promotes self-motivation through co-construction of goals, recognition of the patient's competence, and enhancement of their autonomy in decision-making (Duchesne 2007, Ricca 2000, Hilbert 2019).
• Social halo effect and internalized stigma: By restoring a caring and non-blaming discourse around food and body, the EMNO DIET-MED-BED program deconstructs self-devaluation and promotes social reintegration (Duchesne 2007, Ricca 2000, Hilbert 2019).

• Individuals aged 18 to 70 years with obesity (BMI ≥ 30 kg/m²) and a diagnosis of binge-eating disorder according to DSM-5 criteria.
• Patient expressing distress related to loss of control over eating, without purging compensatory behaviors (vomiting, laxatives, etc.).
• Person motivated by a non-prescriptive, educational, and progressive approach.
• Commitment to regular follow-up for 6 months in consultation.
• Person able to interact constructively with a healthcare professional (sufficient level of functional and digital literacy).

• Eating disorders such as anorexia nervosa, bulimia nervosa with vomiting, or atypical forms with major psychiatric instability.
• Severe, unstabilized psychiatric comorbidities (major depressive episode with melancholic symptoms, acute phase bipolar disorders, active schizophrenia).
• Individuals with cognitive or developmental disorders making it impossible to understand the program or voluntarily adhere to it (e.g., dementia, severe and unsupported autism spectrum disorder).
• Refusal to work on emotions, approach overly focused on rapid weight control, or exclusive pursuit of a "diet"-type effect.
• Individuals in situations of extreme social vulnerability without sufficient resources to allow regular follow-up (e.g., severe unsupported food insecurity).

• Analysis of the food diary prepared with the nurse.
• Qualitative evaluation of the relationship with food (awareness, automaticity, emotions).
• Collection of expressed representations, beliefs, and objectives.
• Co-construction of the therapeutic contract and identification of the first avenues for work.

• Mapping of risk situations: places, times, triggering emotions.
• Introduction of self-observation tools (hunger/satiety scale, emotional journal).
• Refocusing on the notion of food permission and breaking restrictive cycles.

• Learning mindful eating techniques.
• Distinction between physiological hunger and emotional hunger.
• Identification of pre-urge signals and formulation of alternative strategies.
• Integration of regular eating patterns and pleasure into meal planning.

• Work on high-risk social contexts (parties, shared meals, criticism).
• Anticipation of stress situations or emotional imbalance.
• Techniques for self-support and self-kindness after a possible episode.
• Review of implemented strategies and adjustment if necessary.

• Self-assessment by the patient (resources acquired, persistent obstacles).
• Discussion of tests, notably the EDE-Q.
• Development of a personalized maintenance plan.
• Guidance towards the next steps:

• Therapeutic food education focused on the mechanisms of hunger, satiety, and food pleasure.
• Deconstruction of dysfunctional beliefs (notions of “good”/“bad” foods, dichotomous view of the body or nutritional success).
• Identification and restructuring of thought automatisms related to food compulsion or post-meal guilt.

• Digital food diary used as a self-observation tool, not for judgment.
• Restoration of functional eating regularity, independent of weight.
• Supervised role-playing or simulated scenarios to prepare for risky situations.
• Monitoring of progress through self-measurement (EDE-Q scores).

• Mindful eating: focusing on internal sensations of hunger/satiety/pleasure during meals.
• Work on eating rhythm and chewing tempo to prevent impulsive intake.
• Indirect bodily reconnection through verbalization and guided visualization (not exposed in this protocol to direct bodily confrontation).

• Strong therapeutic alliance between patient and dietitian, based on the co-construction of the meaning of changes.
• Unconditionally caring attitude: weight neutrality, absence of judgment, support focused on the patient’s skills.
• Implicit motivational mobilization according to the principles of motivational interviewing (reflective listening, affirming reformulation, support for change).

• Interdisciplinary EMNO coordination between doctor, nurse, and dietitian.
• Structured and secure framework: frequency, duration, and sequence of sessions known in advance.
• Use of standardized and traceable tools (session sheets, EMNO platform, reproducible psychometric tests).

• EMNO Binge Eating Screening Sheet adapted from DSM-5 criteria to validate the indication.
• Standardized Dietary Summary Grid: used at each session to track the evolution of eating behaviors, associated emotions, and strategy adjustments.
• Internal technical sheets (risk situation management guide, reformulation templates, self-regulation tools).
• EMNO internal guide on non-purging eating disorders (printed or digital version).

• NUVEE: e-ETP system with obesity program
• MAELA - DOCTOLIB platform (professional and patient interface):

• Secure digital patient space: availability of validated complementary psychoeducational content.

• Food diary (paper or digital) with legend, observation areas, non-prescriptive markers.
• Target emotion tracking sheets (emotion/behavior/strategy diagram).
• Simplified mindful eating tools ("sensory pause" sheet, chewing markers, hunger-satiety scale).
• Personalized maintenance plan to be developed in session 5.

• Simple language documents to explain binge eating (2024 version “Understanding and Soothing Your Eating”).
• Possibility to use, if needed, the NUVEE platform on eating behavior disorders for patients (duration: 5 minutes, validated in therapeutic education).

• The intervention must be conducted by a qualified dietitian specifically trained in the management of eating disorders.
• Awareness of weight-related stigma and its counterproductive effects is essential.

• The EMNO structure commits to adhering to the 6-month protocol sequence, including the initial medical-nursing session, the 5 dietary sessions, and the medical reassessment at 6 months.
• The systematic use of the EMNO digital record is mandatory to track the program, session reports, and psychometric tests.
• The schedule of sessions must be set as soon as the patient is enrolled and validated with them.

• The protocol relies on effective coordination among the three participants: doctor, referring nurse, and dietitian.
• Formal exchanges are expected at mid-program for patients with atypical or complex progress.
• A quarterly multidisciplinary meeting is recommended in EMNO centers to standardize practices and discuss sensitive cases.

• The helping relationship is based on a non-stigmatizing attitude, focused on expressed needs, mobilizable skills, and the patient’s values.
• The objectives should never be exclusively weight-based, but should aim for behavior changes, a reduction in compulsive intake, and an improvement in the relationship with food.
• Implementation must integrate the acceptance of relapses as a possible element of the change process, and not as a failure.

Quality monitoring and supervision

• Professionals should have access to a space for supervision or peer exchanges at least once a year.
• EMNO structures are encouraged to monitor impact indicators: retention rate, EDE-Q test completion rate, rate of continuation or progression of the care pathway.
• Any local adaptation of the protocol must be documented and discussed with the EMNO quality team to ensure overall coherence.

• The intervention must be officially referenced within the EMNO intervention catalog.
• It is integrated into the center's quality system, with standardized planning, document archiving, and reporting procedures.
• A digital version of the procedure must be kept up to date in the shared document system.

• A continuing education plan for new professionals (dietitians, doctors, nurses) must be planned, with validation of acquired skills and accreditation criteria.
• Feedback from teams (quality committee, multidisciplinary meetings, supervision) must be systematically collected to improve content and adjust practices.
• Summary implementation sheets can be distributed internally to consolidate skills.

• This NPI is designed to be applied in different EMNO structures (fixed centers, mobile units, hospital collaboration programs) provided the minimum implementation conditions are respected.
• A “light” version (3 sessions instead of 6) can be considered in certain clinical situations or logistical contexts, after medical validation and according to defined criteria.
• An enhanced version (8 sessions instead of 6) can be deployed in centers with a unit specialized in severe eating behavior disorders.

• Activity and impact data must be reported annually to the EMNO quality management.
• Anonymized results can be used for scientific or institutional dissemination (communication, publications, efficiency indicators).
• Quality audits can be organized at regular intervals (at least once every two years) to ensure compliance with the standard protocol.

• A shared understanding of issues related to binge eating, beyond just the weight aspect, is an essential factor for sustainability.
• The EMNO culture values long-term support, individualized follow-up, and the acknowledgment of the suffering associated with eating behavior disorders.
• These principles must be regularly reiterated in team meetings and incorporated into the onboarding guides for new professionals.

• In cases of severe associated psychiatric disorders (major depression with inhibition, bipolar disorder in an acute phase, unstable psychosis), a psychiatric opinion is necessary before starting the protocol.
• Dietary follow-up should never replace psychotherapeutic or psychiatric care when it is indicated.
• Lack of adherence or rapid deterioration of the patient’s relational functioning should lead to a temporary interruption of the intervention and a multidisciplinary reassessment.

• If the diagnosis of binge eating disorder is uncertain or if there are elements of a mixed presentation (alternating with bulimia nervosa, intermittent purging behaviors, atypical forms), inclusion in the protocol must be subject to consultation.
• The intervention is not suitable for patients with anorexia nervosa or with extreme weight control behaviors (vomiting, pathological physical hyperactivity, laxative compulsions).

• Any normative or prescriptive dietary formulation (quantities, exclusions, injunctions) should be avoided, as it can reinforce cognitive restriction and pose a risk of binge eating rebound.
• The use of a food diary should be carried out in an exploratory, non-punitive manner. It is not a monitoring tool but a tool for understanding.

• A history of abuse, mistreatment, or an unstable family environment can influence the relationship with food.
• In these situations, it is necessary to remain vigilant regarding withdrawal reactions, dissociative episodes, or retreat behaviors, and to offer a psychotherapeutic referral in cases of blockage or persistent psychological distress.

• If the patient expects a diet prescription or rapid weight loss, it is necessary to explicitly restate the objectives and framework of the protocol.
• Preliminary work with the referring physician may be useful before starting the cycle with the dietitian.

• In cases of food insecurity, housing instability, or significant social disruptions, the intervention must be adjusted with partner social or medico-social services.
• The objective of food regularity or specific purchases should not worsen the economic situation or induce guilt-inducing pressure.

• The intervention is delivered exclusively by a State-certified dietitian, whose practice is governed by Article L4371-1 of the Public Health Code.
• The professional acts under their own responsibility, in compliance with the ethics of their profession and EMNO internal procedures.
• The protocol provides for a complementary role of the prescribing nutritionist physician and the coordinating nurse, each within the defined scope of their regulatory competencies.

• This intervention is an NPI, structured, codified, and reproducible, meeting the criteria defined by the Haute Autorité de Santé (2011) and the NPIS Registry.
• It does not constitute a standardized dietary prescription act, but a personalized therapeutic support protocol targeted at an identified behavioral disorder, binge eating.
• The intervention does not replace a medical diagnosis nor specialized psychotherapeutic care if such care is required.

• All exchanges, reports, and follow-ups are conducted via the secure information system EMNO, compliant with the GDPR (EU Regulation 2016/679).
• The collection and analysis of questionnaires are carried out with the patient's informed consent.
• In case of participation in analysis or research work, the data is anonymized in accordance with internal procedures approved by EMNO's governance committee.

• The intervention can be part of a patient therapeutic education program, declared to the Regional Health Agency and coordinated by EMNO, if the patient is included in this program (https://www.sante.fr/etp-obesite-surpoids-emno-dijon-valmy-espace-medical-nutrition-et-obesite#q=recherche/trouver/cartographie ETP/Dijon%2C%20C%C3%B4te-d%27Or).
• The protocol is compatible with the directions of Article 51 pathways, or city-hospital coordination experiments around obesity and eating disorders, subject to contractual adaptation and attachment to accredited structures (EMNO, GPSO, TIMEO, PACO specifications).

• Registered dietitian trained in eating disorders and at the NPI
• Registered nurse trained in eating disorders and at the NPI
• Registered physician trained in eating disorders and at the NPI

Prototype studies
Gauthier C et al. Espace médical nutrition et obésité, une meilleure prise en charge des patients atteints d’obésité [Medical space nutrition and obesity, a better management of patients with obesity]. Soins. 2022 Sep;67(868):52-54. French. https://dx.doi.org/10.1016/j.soin.2022.09.017
Poussier M et al. Le concept Emno, une approche novatrice en nutrition et médecine intégrative [The Emno concept, an innovative approach to nutrition and integrative medicine]. Soins. 2025 Jul-Aug;70(897):48-52. French.https://dx.doi.org/10.1016/j.soin.2025.05.018
Gardner MM et al. Practical implementation of an exercise-based falls prevention programme. Age Ageing. 2001 Jan;30(1):77-83. https://dx.doi.org/10.1093/ageing/30.1.77

Mechanistic studies
https://sante.gouv.fr/IMG/pdf/emno_rapport_evaluation_finale.pdf
Alizadehsaravi L et al. The underlying mechanisms of improved balance after one and ten sessions of balance training in older adults. Hum Mov Sci. 2022 Feb;81:102910. https://dx.doi.org/10.1016/j.humov.2021.102910

Interventional studies
https://sante.gouv.fr/IMG/pdf/emno_rapport_evaluation_finale.pdf
Campbell AJ et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ. 1997 Oct 25;315(7115):1065-9. https://dx.doi.org/10.1136/bmj.315.7115.1065
Robertson MC, et al. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. BMJ. 2001 Mar 24;322(7288):697-701. https://dx.doi.org/10.1136/bmj.322.7288.697

Risk assessment studies
Campbell AJ et al. Falls prevention over 2 years: a randomized controlled trial in women 80 years and older. Age Ageing. 1999a Oct;28(6):513-8. https://dx.doi.org/10.1093/ageing/28.6.513
Campbell AJ, et al. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc. 1999b Jul;47(7):850-3. https://dx.doi.org/10.1111/j.1532-5415.1999.tb03843.x

Implementation studies in France https://sante.gouv.fr/IMG/pdf/emno_rapport_evaluation_finale.pdf
Gauthier C, et al. Espace médical nutrition et obésité, une meilleure prise en charge des patients atteints d’obésité [Medical space nutrition and obesity, a better management of patients with obesity]. Soins. 2022 Sep;67(868):52-54. French. https://dx.doi.org/10.1016/j.soin.2022.09.017
Poussier M, et al. Le concept Emno, une approche novatrice en nutrition et médecine intégrative [The Emno concept, an innovative approach to nutrition and integrative medicine]. Soins. 2025 Jul-Aug;70(897):48-52. French. https://dx.doi.org/10.1016/j.soin.2025.05.018.
Zak M et al. Physiotherapy programmes aided by VR solutions applied to the seniors affected by functional capacity impairment: Randomised controlled trial. Int J Environ Res Public Health. 2022 May 15;19(10):6018. https://dx.doi.org/10.3390/ijerph19106018

Other publications
Erskine, et al. (2018). Epidemiology of binge eating disorder. Current Opinion in Psychiatry, 31(6), 462–470. https://doi.org/10.1097/yco.0000000000000449
Bulimia nervosa and binge eating disorder. British Journal of Clinical Psychology, 42(3), 257–269. https://doi.org/10.1348/01446650360703375
Carter, J. C., & Fairburn, C. G. (1998). Cognitive–behavioral self-help for binge eating disorder: A controlled effectiveness study. Journal of Consulting and Clinical Psychology, 66(4), 616–623. https://doi.org/10.1037/0022-006x.66.4.616
Duchesne, M. et al. (2007). The use of a manual-driven group cognitive behavior therapy in a Brazilian sample of obese individuals with binge-eating disorder. Revista Brasileira de Psiquiatria, 29(1), 23–25. https://doi.org/10.1590/s1516-44462006005000035
Grilo, C. M. et al. (2022). Naltrexone-Bupropion and Behavior Therapy, Alone and Combined, for Binge-Eating Disorder: Randomized Double-Blind Placebo-Controlled Trial. American Journal of Psychiatry, 179(12), 927–937. https://doi.org/10.1176/appi.ajp.20220267
Villarejo, C. et al. (2013). Loss of Control over Eating: A Description of the Eating Disorder/Obesity Spectrum in Women. European Eating Disorders Review, 22(1), 25–31. https://doi.org/10.1002/erv.2267
Grilo, C. M. (2017). Psychological and Behavioral Treatments for Binge-Eating Disorder. The Journal of Clinical Psychiatry, 78(Suppl 1), 20–24. https://doi.org/10.4088/jcp.sh16003su1c.04
V.Ricca et al. (2000). Cognitive-behavioural therapy for bulimia nervosa and binge eating disorder. A review.. Psychotherapy and psychosomatics. https://www.semanticscholar.org/paper/ca445c3b08c708109275b4b53cc34fa615a e5792
Ghaderi et al. (2003). Pure and guided self‐help for full and sub‐threshold bulimia nervosa and binge eating disorder. British Journal of Clinical Psychology, 42(3), 257–269. https://doi.org/10.1348/01446650360703375
Carter, J. C. et al. (1998). Cognitive–behavioral self-help for binge eating disorder: A controlled effectiveness study. Journal of Consulting and Clinical Psychology, 66(4), 616–623. https://doi.org/10.1037/0022-006x.66.4.616
Duchesne, M. et al. (2007). The use of a manual-driven group cognitive behavior therapy in a Brazilian sample of obese individuals with binge-eating disorder. Revista Brasileira de Psiquiatria, 29(1), 23–25. https://doi.org/10.1590/s1516-44462006005000035
Grilo, C. M. et al. (2022). Naltrexone-Bupropion and Behavior Therapy, Alone and Combined, for Binge-Eating Disorder: Randomized Double-Blind Placebo-Controlled Trial. American Journal of Psychiatry, 179(12), 927–937. https://doi.org/10.1176/appi.ajp.20220267
Hilbert, A. et al. (2019). Meta-analysis of the efficacy of psychological and medical treatments for binge-eating disorder. Journal of Consulting and Clinical Psychology, 87(1), 91–105. https://doi.org/10.1037/ccp0000358
Brelet, L et al. (2021). Stigmatization toward People with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder: A Scoping Review. Nutrients, 13(8), 2834. https://doi.org/10.3390/nu13082834
Tzischinsky, O et al. (2000). Sleep-wake cycles in women with binge eating disorder. International Journal of Eating Disorders, 27(1), 43–48. https://doi.org/10.1002/(sici)1098-108x(200001)27:1<43::aid-eat5>3.0.co;2-z
Pendleton, V. R. et al. (2002). Exercise augments the effects of cognitive‐behavioral therapy in the treatment of binge eating. International Journal of Eating Disorders, 31(2), 172–184. https://doi.org/10.1002/eat.10010
Levine, M. D. et al. (1996). Exercise in the treatment of binge eating disorder. International Journal of Eating Disorders, 19(2), 171–177. https://doi.org/10.1002/(sici)1098-108x(199603)19:2<171::aid-eat7>3.0.co;2-k
Goodrick, G. K. et al. (1999). Binge eating severity, self-concept, dieting self-efficacy and social support during treatment of binge eating disorder. International Journal of Eating Disorders, 26(3), 295–300. https://doi.org/10.1002/(sici)1098 108x(199911)26:3<295::aid-eat7>3.0.co;2-7
Succurro, E. et al. (2015). Obese Patients With a Binge Eating Disorder Have an Unfavorable Metabolic and Inflammatory Profile. Medicine, 94(52), e2098. https://doi.org/10.1097/md.0000000000002098
Čížková, T. et al. (2020). Exercise Training Reduces Inflammation of Adipose Tissue in the Elderly: Cross-Sectional and Randomized Interventional Trial. The Journal of Clinical Endocrinology & Metabolism, 105(12), e4510–e4526. https://doi.org/10.1210/clinem/dgaa630

International scientific and medical sources
Fairburn CG et al. “Cognitive behaviour therapy for eating disorders: a ‘transdiagnostic’ theory and treatment.” Behav Res Ther. 2003;41(5):509-528.
Wilson GT, Grilo CM, Vitousek K. “Psychological treatment of eating disorders.” Am Psychol. 2007;62(3):199–216.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Publishing; 2013.
Hilbert A. Binge Eating Disorder: Advances in Psychotherapy – Evidence-Based Practice. Hogrefe Publishing; 2019. Brownley KA et al. “Binge Eating Disorder in Adults: A Systematic Review and Meta analysis.” Ann Intern Med. 2016;165(6):409–420.

Guidelines and institutional recommandations
Haute Autorité de Santé (HAS). Troubles des conduites alimentaires : repérage et prise en charge chez l’adulte. Recommandation de bonne pratique, 2010.
National Institute for Health and Care Excellence (NICE). Eating Disorders: recognition and treatment. Clinical guideline [NG69], 2017.
ANAES. Évaluation des pratiques professionnelles : prise en charge des troubles des conduites alimentaires. Paris, 2003.
American Dietetic Association. Position of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236–1241.

Specifications for experiments article 51 obesity
EMNO : https://sante.gouv.fr/IMG/pdf/emno-raa_du_11.09.20 arrete_et_cdc_modifies.pdf
GPSO : https://sante.gouv.fr/IMG/pdf/gpso-joe_20241107_0264_0019.pdf
PACO : https://sante.gouv.fr/IMG/pdf/paco-raa_du_30.05.23 arrete_et_cdc_modifies.pdf
TIMEO : https://sante.gouv.fr/IMG/pdf/timeo-arrete_et_cdc_modifies.pdf
 

Tools and tests used in the protocol
Fairburn CG, Beglin SJ. “Assessment of eating disorders: Interview or self-report questionnaire?” Int J Eat Disord. 1994;16(4):363–370. [EDE-Q]
Karlsson J et al. “Psychometric properties and factor structure of the Three-Factor Eating Questionnaire (TFEQ) in obese men and women. Results from the Swedish Obese Subjects (SOS) study.” Int J Obes Relat Metab Disord. 2000;24(12):1715 1725.
De Lauzon B et al. “The Three-Factor Eating Questionnaire-R18 is able to distinguish among different eating patterns in a general population.” J Nutr.2004;134(9):2372 2380.