Binge Eating Into Obesity
Today’s Dietitian
By Victoria Shanta-Retelny, RD, LD
Vol. 6 No. 5 p. 34

The difference between a person’s public and private eating habits can be a nebulous zone filled with denial and shame. Consequently, confessions from a binge eater can be hard to ascertain. There seems to be a line drawn in the sand between self-disclosure and secrecy. Without having a PhD in psychology, it can be a daunting prospect to uncover binge eating disorder (BED). However, recent literature points to common behavioral markers, which dietetics practitioners can identify at the initial medical nutrition therapy (MNT) assessment. The inherent keys to unlocking the door to patient/client disclosure of BED behaviors lie in understanding binge eating behaviors and developing correct probing techniques during the visit.

What Is BED?
According to Binge Eating: Nature, Assessment, and Treatment (The Guilford Press, 1993), the clinical definition of BED has evolved over time. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association currently defines BED as eating in discrete period of time (ie, within any two-hour period) an amount of food that is definitely larger than most people would eat during a similar period of time in similar circumstances; and a sense of a lack of control over eating during this episode (ie, a feeling that one cannot stop eating or control what or how much is eaten).1 The major component, lack of control during periods of excessive eating, is what really drives this disordered eating pattern.

According to Julie Friedman, PhD, a health psychologist who specializes in treating patients with BED at Northwestern Memorial Wellness Institute in Chicago, “It is not the actual amount of food consumed but the loss of control when eating and the preoccupation with food that are hallmarks of BED; food becomes a mood regulator.” The literature supports this notion of quantity of food not being the cardinal characteristic of a binge,1 since several self-reported binges in overweight patients revealed binges of only 500 to 600 calories.2

Friedman emphasizes that “in order for binge eating to be classified as a disorder, it has to take place at least twice a week over a six-month time period.” So, an occasional binge of once per month would not fit the diagnostic bill for BED. Neither does continual snacking throughout the day constitute as a binge, as it needs to occur in “a discrete period of time.” This can be a challenge as RDs counsel overweight and obese patients who are grazing all day but not binge eating—at least according to the clinical definition. Thus, boundaries of individual binges need to be assessed and monitored over time to determine whether or not a patient has BED. Through a combination of MNT, cognitive behavioral therapy (CBT), and pharmacotherapy, a multidisciplinary healthcare team can effectively diagnose and treat multiple facets of this eating disorder.

Prevalence of BED in Obese Populations
It is no secret that BED occurs in obese individuals, but the prevalence was not fully recognized until the mid-1980s. There is a definite subgroup of obese people with significantly disordered eating characterized by binge eating and psychosocial impairment.3 Among patients seeking treatment for obesity, there appears to be a clinically significant binge problem. In an early 1980s study, findings revealed that 28.6% of obese patients who sought obesity treatment self-reported binge eating two or more times per week.3 Two similar studies revealed via patient interviews that 23% of those applying for behavioral weight-control programs have significant binge eating behaviors.4,5 Although the available data indicate that more than 20% of overweight individuals seeking obesity treatment report binge eating behaviors, the investigations did not use strictly defined criteria for BED, and those seeking treatment may not be representative of the general obese population.3

Additional studies are needed to determine the actual prevalence of binge eating in obese individuals in the community at large vs. those seeking obesity treatment. Weaknesses in epidemiological study designs over the last two decades have led to narrow findings, such as examining predominately middle-class Caucasians aged 30 to 45 and incorporating normal-weight individuals in investigations.3 Subsequently, more racially heterogeneous, multisocioeconomic, and age-stratified studies are needed to accurately determine BED prevalence rates.

Diagnostic Considerations for BED in Obesity
For many patients, “addressing bingeing and drawing attention to it are the first steps in diagnosis,” according to Julie Roth, MD, a physician who works with overweight and obese patients with BED at Northwestern Memorial Wellness Institute. “There’s a certain rate of spontaneous remission as the patient and internist work together to shed light on binge behaviors,” Roth explains. Patients who present with chronic weight cycling (ups and downs) should send up a red flag for further probing. Cross-sectional studies have consistently found a positive relationship between weight cycling and binge eating.6 The literature indicates that the greater the number of weight-loss efforts, the greater the severity of binge eating. Just which causes which is still unclear. Do weight loss and regain cause binge eating or vice versa? That is the burning question begging further investigation.

A primary indicator for binge behavior, reports Friedman, is when patients “vacillate between periods of excessive dietary restraint and dietary disinhibition— overeating in response to emotional or cognitive cues.” Friedman explains that “obese individuals are fighting a biological predisposition for obesity and can fall very easily into a public vs. private way of eating, which can lead to deprivation in public and bingeing in private.” Since bingeing becomes a robotic, automatic part of everyday life, it is important to ascertain whether patients are eating while doing other things, such as watching TV, working on the computer, or talking on the phone. It becomes a “stimulus—response equation, in which eating, particularly binge eating, becomes habitual, stress-induced, and/or an emotional panacea,” explains Friedman.

Among obese persons encountered in clinical settings, approximately 10% to 20% are likely to suffer from depression, negative body image, or impaired health-related quality of life, especially in those with BED.6 Thus, part of diagnosing binge eating is to be sensitive to the emotional state of patients and allow them to reveal their own stories of how weight has affected their lives.

Food records are often used as a therapeutic tool for binge eating. The International Journal of Eating Disorders (1992) reported a study in which 22 women (average body mass index = 33) who were seeking treatment for binge eating completed seven days’ worth of food logs. Binge behaviors were reported and reviewed. The food records yielded 225 self-described binge episodes that were analyzed for calorie and macronutrient intake and duration of episodes.2 The average calorie consumption per binge episode was 602; duration was 38.5 minutes per episode—and the average daily caloric intake on binge days was 2,357 calories compared with 1,528 calories for nonbinge days.2 The percentage of protein and fiber was higher on nonbinge days (no significant difference in carbohydrate and fat intake). The one inherent weakness in keeping food logs for binge eaters is the shame or denial associated with eating, which may affect perceptions and reports of eating behavior.

CBT for BED
As part of her CBT, Friedman teaches people to map out an “avoidance hierarchy” in which patients write down in order their most avoided foods to their least avoided foods. Patients are then taught how to incorporate “feared” foods back into their everyday life. By creating a trajectory of avoided foods, Friedman helps patients rid themselves of irrational thoughts associated with certain foods and take the word “forbidden” out of their vernacular.

Since true BED never fully goes away, healthcare providers must instill in patients the need to attend to this disorder at all times. A primary aspect of CBT is “relapse prevention.” Patients are prone to have binge eating relapses; thus, Friedman works with patients on controlling urges and identifying binge triggers. By tracking urges and labeling triggers (eg, hunger, stress, or dietary deprivation), patients can delay urges to binge and delay eating for 10 to 15 minutes by doing things incompatible with eating (eg, taking a shower, walking the dog, doing laundry).

What About Medications for BED?
Pharmacotherapy for the treatment of obesity has been studied as a treatment for BED. Roth notes, “Medications for BED are used as an adjunct therapy to the main line treatment—psychological.” Studies have looked at the use of antidepressants for the treatment of BED with mixed results. Appetite suppressants have been studied with some positive success. Roth points to a study published in Obesity Research on the effects of sibutramine (Meridia), a serotonin and norepinephrine reuptake inhibitor, on binge eating behavior in patients with BED. The sample size was small (N = 7). Subjects were fed in a human feeding lab over 10 weeks. Findings indicated significant evidence in the reduction of binge eating episodes; those taking sibutramine decreased their caloric intake and binge eating episodes substantially.7

Another medication that may be implicated in controlling BED is topiramate, an antiepileptic medication. A study in the May 2000 Journal of Clinical Psychiatry took 13 female psychiatric patients who met the DSM-IV criteria for BED, administered open label treatment with topirimate (100 to 1,400 milligrams per day), and observed their response. After beginning topiramate treatment, nine patients displayed a moderate or better response of BED symptoms, two patients had a moderate or marked response that subsequently diminished, and the last two had mild or no response.8 Although the results are promising, Roth points out that “the use of topiramate warrants future research.”

Obese Binge Eaters vs. Obese Nonbinge Eaters
Is there a distinct difference between obese binge eaters and obese nonbinge eaters? In 1980, the Journal of Counseling Psychology reported that obese binge eaters struggle to avoid binge episodes and perfect the standards for dieting.3 On the other hand, obese nonbinge eaters reported no problems with urge control or strict adherence to rigid dieting standards. As far as eating behaviors, when obese binge eaters vs. obese nonbinge eaters were observed, there was no real difference in calories consumed in the short term. But in the long term, binge eaters eat more calories when presented with an array of food items.3

Who Responds Better to Treatment?
There is some controversy about whether obese binge eaters or obese nonbinge eaters respond better to treatment. Binge eating has been negatively associated with treatment outcome in weight-control programs secondary to poorer weight losses. A history of repeated weight loss coupled with frequent binge eating has been associated with good short-term weight loss but poor maintenance in a behavioral program.3 When the treatment focuses on the disordered eating rather than weight loss, there are better outcomes. Short-term group cognitive-behavioral therapy has been proven effective in reducing binge eating in overweight patients,3 which indicates that the binge eating needs to be addressed separately from the weight issue.

As dietetics practitioners, there is a need to collaborate with different healthcare disciplines, especially when treating patients with BED. MNT is not only about giving these patients a meal plan. It is also about helping them assimilate to the medical and psychological realms. Start small by focusing on not skipping meals during the day, creating structured mealtimes, and keeping food logs for accountability. Follow-up appointments are a necessary component of care. Dietitians should communicate patient progress or noncompliance with the other disciplines involved at every step of the way.

— Victoria Shanta-Retelny, RD, LD, is a practicing dietitian at Northwestern Memorial Wellness Institute in Chicago, a freelance food and nutrition writer, and a culinary spokesperson.

References for this article are available upon request by e-mailing TDeditor@gvpub.com.

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