What is binge eating disorder

Binge eating disorder is characterized by recurrent binge eating episodes accompanied by a sense of loss of control over eating during the episode (called a binge). During binge eating, the person also feels a loss of control and is not able to stop eating. Unlike other eating disorders, as in bulimia nervosa or anorexia nervosa, people who have binge eating disorder do not throw up the food, starve themselves or exercise too much.

People with binge eating disorder are often overweight or obese. But not all people with binge eating disorder are overweight, and being overweight does not always mean you have binge eating disorder. Binge eating disorder is a serious health problem, but people with binge eating disorder can get better with treatment.

• It is possible to have more than one eating disorder in your lifetime. Regardless of what type of eating disorder you may have, you can get better with treatment.

Binge eating disorder is the most common type of eating disorder in the United States ¹ affecting 3.5% of females and 2% of males among adults ². Rates of binge eating disorder in children and adolescents are estimated to be 2.3% in adolescent females and 0.8% in adolescent males. Prevalence of subthreshold binge eating disorder is estimated to be 2.3% in female adolescents and 2.6% in male adolescents ³. Some studies suggest that among obese adolescents, about 1% meet criteria for binge eating disorder and 9% have objective binge episodes ⁴. A high percentage of adults and adolescents who present with binge eating disorder are moderately overweight or obese. Prevalence rates of binge eating disorder are higher among women enrolled in weight-control programs compared to those who are not.115

In binge eating disorder, these episodes are associated with at least 3 of the following:

1. Eating more rapidly,
2. Eating until uncomfortably full,
3. Eating when not hungry,
4. Eating alone because of embarrassment about the amount of food consumed, and
5. Feelings of disgust, depression, or guilt.

According to the Diagnostic and Statistical Manual of Mental Disorders-5, binge eating episodes need to occur, on average, at least once a week for 3 months, and must be associated with marked distress, to meet diagnostic severity levels. Binge eating disorder is distinguished from bulimia nervosa in part because the binge eating episodes are not associated with inappropriate compensatory behaviors. In addition, to meet criteria for binge eating disorder, binge eating episodes cannot occur exclusively during the course of anorexia nervosa or bulimia nervosa.

There are similar challenges in diagnosing binge eating disorder and bulimia nervosa in childhood and adolescence because of developmental differences between younger patients and adults ⁵. A sense of being out of control when eating is likely more important than eating an objectively large amount of food in younger patients ⁶, because younger patients often cannot gain access to food as easily as adults ⁷. For these reasons, a clinical concern about binge eating disorder in children and adolescents should consider using a lower threshold for the rate and duration of binge eating episodes. A suggested rate of once per month, over the previous 3-month period, was recommended by a consensus group of experts in child and adolescent eating disorders ⁵. In addition, as with anorexia nervosa and bulimia nervosa, children and adolescents are limited in their abstract thinking ability and self-expression. They may also minimize any discomfort or shame that they experience when binge eating. Thus, parental interviews and other collateral reports are often necessary for making a definitive diagnosis ⁵. Bulimia nervosa usually occurs in patients of normal weight or slightly overweight; binge eating disorder often occurs in overweight and obese individuals. In bulimia nervosa, binge eating is considered to be a response to restriction of food intake ⁸, whereas in binge eating disorder, binge eating occurs in the context of overall chaotic and unregulated eating patterns ⁹.

Binge eating disorder causes

Researchers are not sure exactly what causes binge eating disorder and other eating disorders. Researchers think that eating disorders might happen because of a combination of a person’s biology and life events. This combination includes having specific genes, a person’s biology, body image and self-esteem, social experiences, family health history, and sometimes other mental health illnesses.

Some studies suggest that restrictive dieting, pressure to be thin, body dissatisfaction, emotional eating, low self-esteem, and poor social support are risk factors for the onset of adolescent binge eating ¹⁰. Other studies suggest increased eating related to specific psychopathology, depressed mood, and increased anxiety are associated with the initiation of binge eating in adolescents ¹¹.

Studies suggest that people with binge eating disorder may use overeating as a way to deal with anger, sadness, boredom, anxiety, or stress ¹².

Researchers are studying how changing levels of brain chemicals may affect eating habits. Neuroimaging, or pictures of the brain, may lead to a better understanding of binge eating disorder ¹³.

Comparatively little is known about the specific risk factors for binge eating disorder in children and adolescents, as it is a relatively rare disorder in younger populations. Onset of binge eating typically begins in late adolescence or early adulthood, often after a period of significant dieting or weight loss.

Who is at risk for binge eating disorder ?

Binge eating disorder affects more than 3% of women in the United States. More than half of people with binge eating disorder are women ¹⁴.

Binge eating disorder affects women of all races and ethnicities. It is the most common eating disorder among Hispanic, Asian-American, and African-American women ¹⁵.

Some women may be more at risk for binge eating disorder.

• Women and girls who diet often are 12 times more likely to binge eat than women and girls who do not diet ¹⁶.
• Binge eating disorder affects more young and middle-aged women than older women. On average, women develop binge eating disorder in their early to mid-20s ¹⁷. But eating disorders are happening more often in older women. In one study, 13% of American women over 50 had signs of an eating disorder ¹⁸.

Binge eating disorder symptoms

It can be difficult to tell whether someone has binge eating disorder. Many women with binge eating disorder hide their behavior because they are embarrassed.

You may have binge eating disorder if, for at least once a week over the past three months, you have binged. Binge eating disorder means you have at least three of these symptoms while binging ¹⁹:

• Eating faster than normal
• Eating until uncomfortably full
• Eating large amounts of food when not hungry
• Eating alone because of embarrassment
• Feeling disgusted, depressed, or guilty afterward

People with binge eating disorder may also have other mental health problems, such as depression, anxiety, or substance abuse.

How does binge eating disorder affect your health ?

Many, but not all, people with binge eating disorder are overweight or obese. Obesity raises your risk for many serious health problems ²⁰:

• Type 2 diabetes
• Heart disease
• High blood pressure
• High cholesterol
• Gallbladder disease
• Certain types of cancer, including breast, endometrial (a type of uterine cancer), colorectal, kidney, esophageal, pancreatic, thyroid, and gallbladder cancer ²¹
• In women, problems with your menstrual cycle, including preventing ovulation, which can make it harder to get pregnant

People with binge eating disorder often have other serious mental health illnesses such as depression, anxiety, or substance abuse. These problems can seriously affect your everyday life and can be treated.

How does binge eating disorder affect your pregnancy ?

Binge eating disorder can cause problems getting pregnant and during pregnancy. Pregnancy can also trigger binge eating disorder.

Obesity raises the level of the hormone estrogen in your body. Higher levels of estrogen can stop you from ovulating, or releasing an egg from the ovary. This can make it more difficult to get pregnant. However, if you do not want to have children right now and have sex, you should use birth control.

Overweight or obesity may also cause problems during pregnancy. Overweight and obesity raises your risk for:

• Gestational hypertension (high blood pressure during pregnancy) and preeclampsia (high blood pressure and kidney problems during pregnancy). If not controlled, both problems can threaten the life of the mother and the baby.
• Gestational diabetes (diabetes that starts during pregnancy). If not controlled, gestational diabetes can cause you to have a large baby. This raises your risk for a C-section ²².

Pregnancy can raise the risk for binge eating disorder in women who are at higher risk for eating disorders. In one study, almost half of the women with binge eating disorder got the condition during pregnancy. The research suggests that binge eating during pregnancy may be caused by ²³:

• Worry over pregnancy weight gain. Women may binge because they feel a loss of control over their bodies because of the pregnancy weight.
• Greater stress during pregnancy
• Depression
• History of smoking and alcohol abuse
• Lack of social support

After pregnancy, postpartum depression and weight from pregnancy can trigger binge eating disorder in women with a history of binge eating. Women with binge eating disorder before pregnancy often gain more weight during pregnancy than women without an eating disorder. Researchers think that weight gain during pregnancy may cause some women who had binge eating disorder before pregnancy to binge eat during pregnancy ²⁴.

How is binge eating disorder diagnosed ?

Your doctor or nurse will ask you questions about your symptoms and medical history. It may be difficult to talk to a doctor or nurse about secret eating behaviors. But doctors and nurses want to help you be healthy. Being honest about your eating behaviors with a doctor or nurse is a good way to ask for help.

Your doctor may also do blood, urine, or other tests for other health problems, such as heart problems or gallbladder disease, that can be caused by binge eating disorder.

Binge eating disorder treatment

Your doctor may refer you to a team of doctors, nutritionists, and therapists who will work to help you get better.

Treatment for binge eating disorder is generally performed an outpatient basis. However, if the patient has severe comorbidities such as self-harm, suicidality, or substance misuse or the severity of the binge eating places the person at risk for significant physical illness, residential treatment should be considered ²⁵. The role of loneliness should not be underestimated, especially when treatment is ineffective ²⁶.

Treatment plans may include one or more of the following:

• Psychotherapy. Sometimes called “talk therapy,” psychotherapy is counseling to help you change any harmful thoughts or behaviors. This therapy may focus on the importance of talking about your feelings and how they affect what you do. For example, you might talk about how stress triggers a binge. You may work one-on-one with a therapist or in a group with others who have binge eating disorder.
• Nutritional counseling. A registered dietitian can help you eat in a healthier way.
• Medicine, such as appetite suppressants or antidepressants prescribed by a doctor. Antidepressants may help some people with binge eating disorder who also have anxiety or depression.

Most people do get better with treatment and are able to eat in healthy ways again ²⁷. Some may get better after the first treatment. Others get well but may relapse and need treatment again.

Behavior Modification

Cognitive behavior therapy (CBT) is a treatment of choice in binge-eating disorder, especially in the context of high levels of specific eating disorder psychopathology, such as overvaluation of body shape and weight. A randomized placebo-controlled trial found that cognitive behavior therapy (CBT) with placebo was superior to fluoxetine only, and adding fluoxetine to cognitive behavior therapy (CBT) did not enhance findings compared to adding placebo to cognitive behavior therapy (CBT) at 12-month follow-up after treatment completion ²⁸.

Family therapy should be considered when family dynamics figure prominently as triggers for binging and in children and younger adolescents. Family therapy can be very helpful, but has not been proven superior to other approaches for binge-eating disorder such as interpersonal psychotherapy or dialectical behavior therapy.

Family therapy can be effective to improve communication by decreasing negative emotional expressivity. Improved positive communication between family and friends of the person with binge eating disorder may play an important role in encouraging persistence with treatment ²⁹.

Interpersonal psychotherapy is a proven treatment for binge-eating disorder and focuses on identification of interpersonal conflict as triggers for binges ³⁰.

Guided self-help appears to be less effective than cognitive behavior therapy or dialectical behavior therapy for binge-eating disorder. Although this approach is popular because of its low cost and easy accessibility (eg, as with self-help groups such as Something Fishy), this approach should be viewed carefully, as not all online guided self-help resources are balanced and supportive ³¹.

Integrative response therapy, which has the mnemonic RESPONSES (Reflect, Exercise, Start distracting, Problem Solve, Open communication, get distaNce, Soothe, get cEntered, Social and/or pleasurable activities) appeared to be an effective group-based cognitive restructuring and emotion management technique. Integrative response therapy appeared to show significant reduction in numbers of binge days by providing a structured intervention that provides temporary relief from aversive emotions ³².

Behavioral weight loss: Self-monitoring strategies for behavioral weight loss typically include the following (1) A paper diary of diet, physical activity, weight, and obesity-related risk behaviors such as drinking sugary drinks to self-monitor weight maintenance and/or (2) electronic devices such as web-based dietary monitoring, mobile applications with food diaries, and activity trackers can be used with the potential to allow for more proximal reporting and immediate feedback ³³.

Dialectical behavior therapy can be helpful to reduce binge eating, as it helps to reduce sudden intense surges of emotion. Dialectical behavior therapy is a manual-based treatment developed by Dr. Marsha Linehan that helps the person identify interpersonal relationship situations that can trigger cognitions that cause dysphoric emotions, to use their own strengths in collaboration with the therapist to be able to self–soothe, and to accept dysphoric emotions without needing to engage in maladaptive behaviors ³⁴.

Embodied cognition therapy includes the idea that abnormal eating behaviors are both influenced by and influence how the brain encodes incoming perceptual data about the body such as the person’s perception of their own body image and internal states such as hunger and satiety ³⁵.

Virtual reality therapy uses technology to help to identify triggers for binge eating and is especially helpful in persons who do not integrate body image with a solid sense of self by reducing shame and improving body image. The idea of autobiographical awareness and memory as an external observation can be integrated in virtual reality ³⁶.

Mindfulness meditation is a Western form of meditation derived from a very old Buddhist practice called Vipassana or insight meditation, the skill of paying attention to one’s experiences with calm patient acceptance and compassion in a nonjudgmental manner. Mindfulness meditation can be practiced alone or with others; it involves the practice of being fully present in the moment with the breath to help with centering. Mindfulness meditation, when added to other interventions, appeared to be helpful ³⁷.

Yoga has appeared to provide lasting maintenance of stable body mass index (BMI) in some persons with binge-eating disorder ³⁸.

Bariatric surgery, although proven to help obese individuals with weight loss, may not be as effective in persons with binge-eating disorder unless they also receive an evidence-based intervention to ensure that the weight loss from the bariatric surgery is maintained ³⁹.

Binge eating disorder medication

Medication treatment should not be the first or only treatment for binge-eating disorder because of the efficacy of some non-pharmacologic approaches.

Fluoxetine (Prozac) is the only medication thus far approved by the US Food and Drug Administration for the treatment of binge eating disorder by decreasing the number of binging episodes; however, other medications such as sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), and escitalopram (Lexapro), as well as other selective serotonin/norepinephrine reuptake inhibitors (SNRIs) and antidepressants that are generally FDA approved for depression and obsessive compulsive disorder, can also be useful alternatives when fluoxetine is not tolerated or ineffective. Nonetheless, antidepressants are associated with weight gain in some cases, which can be a significant barrier to success ⁴⁰.

Lisdexamfetamine (Vyvanse) was approved by the FDA in January 2015 to treat moderate-to-severe binge eating disorder in adults. It is the first FDA-approved medication to treat this condition ⁴¹.

Antiepileptic medications that decrease obsessive and compulsive behavior, such as topiramate, zonisamide and lamotrigine, as well as other medications that decrease compulsive eating, such as exenatide and liraglutide, may be effective owing to their effect on the regulation of neuropeptide Y that may help to control weight. Antiobesity medications such as phentermine, lorcaserin, and orlistat are also options for controlling weight.

Older antiobesity medications such as sibutramine and d-fenfluramine have been removed from the worldwide market owing to cardiovascular safety concerns.

Acamprosate appeared to have a favorable side effect profile but may not be consistently effective for binge-eating disorder. Memantine also appeared ineffective. Some other medications that appear to be ineffective or that worsen binge-eating disorder include valproate, phenytoin, and oxcarbazepine ⁴².

So far, pilot studies of agomelatine, a medication that increases levels of melatonin, have shown that it may be especially useful in persons that also have night eating syndrome, which is characterized by reduced feeding during the day, evening hyperphagia accompanied by difficulty falling asleep (initial insomnia), and difficulties in sleep maintenance, including frequent nocturnal awakenings that are associated with episodes (while awake) of craving and compulsive ingestion of food and that can be associated with obesity ⁴³.

Forty-five stable adults (i.e, non-rapid cycling, absence of clinically significant hypomanic symptoms) with bipolar I/II disorder and comorbid attention deficit hyperactivity disorder (ADHD) were enrolled in a phase IV, 4-week, flexible-dose, open-label study of adjunctive LDX. All subjects were initiated at 30 mg/day of adjunctive LDX for the first week with flexible dosing (ie, 30-70 mg/day) between weeks 2 and 4. Of 45 subjects enrolled, 40 received adjunctive LDX (mean dose, 60 ± 10 mg/day).

A statistically significant decrease from baseline to endpoint was evident in weight, BMI, fasting total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol, but not triglycerides or blood glucose. Significant reductions were also observed in leptin, but not in ghrelin, adiponectin, or resistin levels ⁴⁴.

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