ED: Everyone has ideas on what causes eating disorders. What about this disorder?
Primary care physicians should be aware that Binge Eating Disorder (BED) is common and is highly prevalent, especially in people seeking weight loss treatment. If BED goes unrecognised, it results in significant psychological distress and medical comorbidities.
Furthermore, if BED is untreated and these patients are referred for bariatric surgery, their outcomes are likely to be poor, so early detection and evidence-based treatments remain the preferred option.
Revision of the DSM-5 means that Binge Eating Disorder (BED) is now a fully-fledged diagnosis that parallels the other main eating disorders of Anorexia Nervosa (AN) and Bulimia Nervosa (BN). This seems appropriate, given that BED is more common that AN and BN combined. BED is thought to affect approximately 430,000 people in Australia which makes it the most prevalent eating disorder in adults. Unlike other eating disorders, it affects men and women in a more equal distribution and it has a later average age of onset in late adolescence to early 20s.
What does Binge Eating Disorder involve?
- Recurring episodes that take place at least once-a-week (on average) for 3 months.
- At least 5 of the following:
- Eating much faster than normal.
- Eating until uncomfortably full.
- Eating without physical hunger.
- Eating alone due to shame.
- Feeling disgust or guilt afterwards.
- Significant distress after binge eating.
- No compensatory behaviours; bingeing does not occur exclusively during anorexia nervosa or bulimia nervosa.
- Eating larger than normal amounts of food within short time periods with a perceived lack of control.
In terms of the neurobiology, BED is thought to be related to maladaptation of the corticostriatal circuitry regulating motivation and impulse control. This leads to altered reward sensitivity and food attentional biases and changes in neurotransmitters networks including the dopamine and opioid systems. This differs somewhat from other eating disorders in that it has some similarities to substance misuse disorders and this has implications for treatment.
While genetic studies show that BED tends to aggregate in families, the genetics are complex and likely to involve interactions with multiple environmental factors, incl:
- Trauma
- Poor distress tolerance and coping skills
- Mood disorders, including depression and anxiety
- Desire for weight loss and dietary restraint
Broaching BED with patients
Clinicians should screen patients presenting with weight issues seeking treatment for obesity, remembering that 25% of BED sufferers have a weight that falls within the normal range. It is a difficult subject for both patients and clinicians to talk about, with sufferers experiencing high levels of shame and embarrassment. Clinicians may also find it a difficult subject to raise, especially if this is not the presenting complaint. It is important to note though that BED is associated with multiple physical and mental health comorbidities, that patients suffer in silence, and that treatment is available.
Initiating a conversation about BED:
- Be sensitive to negative weight-based biases and terms
- Be sensitive to shame and embarrassment
- Ask about whether the patient feels concerned about eating behaviours or pattern
- Ask whether certain eating episodes “feel different” or if there are times when the “eating feels out of control” (e.g. you feel like “you can’t stop” or “you are driven”?)
- Ask if eating episodes occur when not hungry or already full.
Screening tools include the BED-7 and the Binge Eating Scale.
Therapy available
Once a diagnosis of BED is made, it is important to provide support and hope and most patients say they are relieved to learn this is a real illness and there are available treatments.
First-line therapy include psychological treatments such as Cognitive Behavioural Therapy, Interpersonal Therapy and Behavioural Weight Loss (BWL). Psychological targets include reducing the frequency and intensity of binge eating episodes, achieving sustainable weight loss and/preventing excessive weight gain and increased ability to cope with negative affect.
In terms of pharmacological treatment, Lysdexamphetamine (marketed as Vyvanse), is indicated for the treatment of moderate to severe BED (i.e. more than three episodes of bingeing a week), in conjunction with psychological treatment. Pooled analysis of three pivotal studies for Vyvanse showed that it had an effect size of 0.83-0.97 for a reduction in binge eating days/ week. It is generally well tolerated, with headache and dry mouth, insomnia and appetite suppression being the main side effects. However, the usual precautions for stimulant prescription would apply. Other pharmacological treatment options, include high dose Fluoxetine, Topiramate and anti-addiction drugs such as Naltrexone.
Key Messages
- Binge Eating Disorder (BED) results in poor outcomes for those undergoing bariatric surgery.
- BED affects men and women in a more equal distribution and has a later age of onset compared with other eating disorders.
- It is important for clinicians to initiate a conversation about BED, bearing in mind the patient may be shameful and embarrassed.
References available on request.
Questions? Contact the editor.
Author competing interests: nil relevant disclosures.
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