November 2012 Issue
Binge-Eating Disorder — Learning About This Condition Can Help RDs Counsel Patients More Effectively
By Christin L. Seher, MS, RD, LD
Vol. 14 No. 11 P. 34
Whenever Pat was upset, stressed, anxious, or depressed, she’d eat large quantities of food in one sitting in the hopes of calming her emotions. “On one occasion, I ate seven bowls of cereal for breakfast,” she recalls. “Another time I ate an entire loaf of bread while standing in front of my toaster. And there were times I’d invite a friend to an all-you-can-eat pizza buffet, and we’d each eat a whole pizza pie.”
When Pat visited her doctor for heart palpitations, she learned she was more than 150 lbs overweight and that she could possibly die if she didn’t lose the weight. It was this life-changing moment that prompted Pat to reach out for help.
Like many women, Pat was grappling with binge-eating disorder (BED), a condition characterized by episodes of compulsive overeating, an unhealthful pattern of behavior that’s growing in prevalence in the US population.
Overweight and obesity are serious public health concerns, with approximately 72% of adult women classified as at least overweight. Of those, 44% are obese or suffering from extreme obesity.1 There are many factors influencing a person’s weight, but as Pat’s story illustrates, emotional eating—when food is used as an outlet for coping with life’s stressors—is one way calories can quickly add up.
This article will explore the characteristics of BED, review diagnostic criteria for the disorder, discuss the physical and psychological health problems associated with it, and present ways in which dietitians can help facilitate recovery in an interdisciplinary healthcare team.
What Is Binge Eating?
Binge eating, also called compulsive overeating, affects approximately 5% of Americans at some point in their lives.2 Prospective research estimates that approximately 2% of men and 3.5% of women will be diagnosed with BED in their lifetimes.3
While experts debate on the exact parameters of a binge, the term generally refers to a discrete period of time during which an individual overeats to the point of being uncomfortably full without hunger or a metabolic need driving eating behavior.2 Accompanying the excessive caloric consumption that occurs during a binge are feelings of loss of control and psychological distress, such as guilt, disgust, embarrassment, or depression.2,4
Binge eating triggers reported in the literature include exposure to physical or psychological stressors, food deprivation or restriction (eg, dieting), patterns of emotional eating, and the restriction or abstinence from, and then reintroduction of, highly palatable foods.2 Unsurprisingly, individuals who binge most often do so on high-fat, high-carbohydrate foods.2
The clinical manifestation of frequent binge-eating behavior results in a diagnosis of BED. While not formally defined as a psychiatric disorder like anorexia nervosa and bulimia nervosa, BED is included as a provisional diagnosis in the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) under “eating disorders not otherwise specified” (EDNOS). However, experts are seriously considering including BED as a formal diagnosis in the fifth edition of the DSM that will be published in May 2013.2,3,5
The DSM-IV states that to qualify as a BED diagnosis, binge-eating episodes should occur at least twice per week for six months, noting that further study is necessary to determine a frequency threshold for binging behaviors should the diagnosis be included in the fifth edition of the DSM. This research has been done, and little evidence has been found to suggest that the DSM-IV requirement (two binge-eating episodes per week for at least six months) is accurate.2 Instead, a frequency of two binge episodes or binging days per month for at least three months is being proposed for the revised diagnostic criteria in the DSM-V.3 Besides the presence of binge eating, an individual must experience marked distress associated with these eating episodes to be diagnosed with BED.4
There’s disagreement on what degree of loss of control a person must experience or what constitutes marked distress during or after a binge. And there are varying opinions on how much food must be consumed or the time frame in which food must be eaten (eg, a discrete period of time vs. grazing) to qualify an eating episode as a binge.
As a result, there’s little agreement among the questionnaires used to assess BED risk in different patient populations and when risk should be evaluated over time.6 Yet screening for BED remains extremely important, as research indicates it’s common in the primary care setting, and individuals with the disorder often are overlooked because general practitioners aren’t familiar with the diagnostic criteria or skilled in its assessment.6
What’s important to keep in mind is that there are several distinctions between BED and other eating disorders. The first key difference between BED and bulimia nervosa, in which binge eating is a criteria for diagnosis, is that individuals with BED don’t engage in excessive exercise, purging, laxative abuse, and fasting to compensate for the large number of calories consumed.4 Secondly, the onset of BED typically occurs during adulthood rather than in adolescence when the risk of developing other eating disorders is at its greatest.3,5 Most people are diagnosed with BED between the ages of 46 and 55.7 Thirdly, it appears that BED occurs just as frequently in blacks as it does in whites, although prevalence rates for other ethnic minorities is unknown. This is atypical of other eating disorders, as both anorexia and bulimia are most commonly diagnosed in whites.5,7 Finally, when compared with both anorexia and bulimia, BED is more common.5
Another reason screening for BED is so important is because there’s a strong association between the disorder and the presence of other health problems. The striking coexistence of both physical and emotional disorders with BED has prompted many in the scientific community to label binge eating as a public health concern.2,8 BED is strongly associated with greater body weight, with studies indicating approximately 70% of individuals diagnosed with BED also are obese.9 Furthermore, while roughly 2% to 5% of the general population will meet the diagnostic criteria for BED at some point in their lives, 30% of obese individuals seeking weight-control treatment will be affected.9
There’s been some debate about whether individuals with BED can be differentiated from those who are simply obese. Recent research has led to the widespread consensus that while the two conditions are inextricably linked, a distinct subpopulation exhibiting binge-eating behaviors exists, warranting separate diagnosis and treatment.5
People who are diagnosed with BED are at greater risk of metabolic syndrome, heart disease, diabetes, hypertension, high cholesterol, and many other medical problems related to obesity.5,10 Results from a recent five-year longitudinal study concluded that the greater odds of developing risk factors for metabolic syndrome (eg, hypertension, dyslipidemia, impaired glucose tolerance) in individuals with BED is independent of the risk associated with obesity alone.10 The researchers hypothesized that genetics, mood disorders, or the rapid consumption of large numbers of calories in a short period and the resulting inflammatory or oxidative stress may have mediating effects in individuals with BED.10
Individuals with BED also are more likely to experience psychological complications such as mood or anxiety disorders or substance abuse.5 New estimates suggest that people in the general population have a fair chance of developing depression (17%) or anxiety disorders (29%) during their lifetime, but those who are obese have a lifetime prevalence of 32.8% for depression and 30.5% for anxiety.9 The prevalence of these psychological disorders in individuals with BED is even higher, with one study reporting that 54% of them exhibited signs of a mood disorder and 37% an anxiety disorder.11
While the exact mechanisms underlying BED comorbidities haven’t been determined, recent research suggests that the symptoms of depression and anxiety may lead to compulsive eating behaviors, indirectly resulting in a BED diagnosis.9 Several studies support this notion, with individuals reporting negative mood as a precursor to binge-eating episodes and compulsive eating as a way to regulate mood.12-15
Some researchers have concluded that compulsive overeating is akin to other addictive behaviors, such as substance abuse.2,8 Animal models support this connection, and research in humans has linked the consumption of certain foods with an addictionlike response in neurochemical indicators in the brain, such as dopamine release.2,8 These studies are prompting further investigation of the construct of food addiction.
For example, Yale University researchers have developed a validated scale in an attempt to define food addiction.8 Using this scale, the Yale research team found that 57% of individuals with BED in one sample also met the criteria to be classified as having a food addiction.8 Of the remaining 43% in the sample who didn’t meet this criteria, more than one-half met three or more criteria for a food addiction but didn’t report significant clinical or emotional impairment associated with their eating behaviors—a criterion necessary to meet most mental health disorder diagnoses in the DSM-IV.8 These findings led the authors to conclude a strong relationship between BED and food addiction exists, although the relationship isn’t causal. This same study also found a significant concordance between people with food addiction and the presence of a mood disorder (most frequently major depressive disorder), further illustrating the interconnection between binge eating and affective disorders.
BED in Primary Care Settings
Due to the coexistence of these and other health concerns, individuals with BED use the healthcare system at higher rates than their peers, yet many remain undiagnosed due to a lack of effective screening measures, especially in primary care settings.5,6 Self-reported measures are the most economical way to formally incorporate screening into the healthcare setting, but this often yields inconsistent or unreliable results. However, a team of researchers recently validated a self-reporting method for BED screening in the primary care setting, concluding that low-cost, easy-to-administer screening methods can accurately identify patients who need further evaluation.6
Screening, especially in overweight or obese populations, is critical in helping BED patients get the care they need so they can respond most effectively to treatment. Nutrition interventions geared toward reducing body weight will be unsuccessful if compulsive eating behaviors and their underlying emotional triggers aren’t taken into account. RDs are encouraged to ask targeted questions during the patient history and interview process to help discern whether further screening and follow-up for BED is warranted. Some of the questions dietitians can ask are, “Do you experience loss of control over your eating?” “Do you ever feel guilty, ashamed, or embarrassed about how much you eat?” “Do you eat for emotional reasons, such as when you’re bored, sad, or anxious?” and “Have you been diagnosed with a mood or anxiety disorder? If so, are you taking medication for it?” Asking patients about their diet and weight-loss history also can provide valuable insight into their risk of developing BED, as weight cycling (eg, yo-yo dieting) is common.16
Research suggests that patients who seek bariatric surgery are at higher risk of BED; therefore, when working with this population, it’s critical for potential surgical candidates to be screened.3 RDs can ensure this happens and inform the patient that surgery is contraindicated in people with unresolved BED because binging behavior will remain a problem after surgery.3 (To read more about bariatric surgery and earn 2 CPEUs, check out this month’s CPE Monthly article at http://CE.TodaysDietitian.com.)
Treatment and Management Strategies
Working with clients with BED is different from working with those who are overweight or obese without the disorder, especially given the frequency in which it occurs as a secondary diagnosis to a mood or anxiety disorder. Therefore, treatment of BED, like all eating disorders, is best achieved through the collaboration of an interdisciplinary team of medical, psychiatric, and other health professionals in which the underlying emotional symptoms and cognitive processes are addressed in addition to the eating behaviors. If an RD suspects a patient has BED, an immediate referral for additional evaluation by a team of trained eating disorder specialists is warranted.
The Academy of Nutrition and Dietetics specifies the role RDs should play in the treatment and recovery of BED patients. It involves performing certain tasks within the nutrition assessment, intervention, monitoring, and evaluation phases.3 In addition to educating patients about food, eating behavior, and body shape and weight and challenging false beliefs about nutrition, RDs must show individuals how to identify and control factors that trigger binge-eating episodes by helping them learn self-monitoring behavior and recognize eating patterns.16 Then RDs can help BED patients learn healthful coping mechanisms to replace emotional eating by identifying and avoiding stressful situations.16 It’s important to understand that nutrition therapy should aim to control or reduce binge-eating episodes first before addressing weight loss, considering that binge eating can be triggered by dietary restraint.3
A successful treatment approach for BED addresses both binge-eating behaviors and the underlying emotional dysfunction promoting them. Cognitive-behavioral therapy (CBT) remains one of the most frequently used therapies for people with eating disorders, during which misconceptions about food, eating behaviors, and how certain foods affect the body are addressed. Studies on the effectiveness of CBT in BED patients are promising, yielding remission rates of 40% to 60%. However, despite reductions in binge-eating behavior, weight loss doesn’t automatically follow. The best way to achieve weight loss appears to be total abstinence from binge-eating episodes.17
Interpersonal psychotherapy and dialectical therapy also have demonstrated some success with BED patients. In dialectical therapy, patients work with their treatment team to identify how their eating behaviors serve as a coping mechanism for dealing with underlying emotional struggles. During therapy, patients learn new coping skills and how to replace unhealthful eating behaviors with healthful ones.3 This treatment approach appears to be promising, although CBT remains the preferred form of therapy.17
Finally, pharmacotherapy is an often-used treatment option, specifically for BED patients who have a coexisting mood or anxiety disorder. Currently, the FDA has approved only the antidepressant Prozac for the treatment of bulimia nervosa, although it and other drugs may be prescribed to treat BED.7 RDs should be aware of any potential drug-nutrient interactions associated with pharmacotherapy that’s integrated with BED treatments.
To work with BED patients most effectively, dietitians should pursue advanced training. Specializing in this area will allow them to work with other medical and psychiatric professionals while counseling clients during their recovery. They’ll use evidence-based practices specific to the individual, type of eating disorder, and the client’s readiness to change. RDs interested in obtaining additional certification to work with eating disorder patients can explore programs that focus on CBT, dialectical therapy, or motivational interviewing skills.
— Christin L. Seher, MS, RD, LD, is a dietitian, instructor, and nutrition consultant in northeast Ohio.
Dietitians who would like to learn more about binge-eating disorder and other eating disorder topics and receive additional training to counsel patients more effectively should use the following resources:
• Academy of Nutrition and Dietetics: Sports, Cardiovascular, and Wellness Nutrition (SCAN); Behavioral Health & Nutrition; or Eating Disorders, Adolescents dietetic practice groups, which offer training opportunities and collaborative relationship building
• The ADA Pocket Guide to Eating Disorders by Jessica Setnick, MS, RD, CSSD
• Annual Renfrew Center Foundation Conference for Professionals, which offers seminars, webinars, and workshops on eating disorder topics (www.renfrewcenter.com)
• Beck Institute, which offers cognitive-behavioral therapy workshops and training (www.beckinstitute.org)
• International Association of Eating Disorders Professionals Foundation offers training, certification opportunities, and research (www.iaedp.com)
• Molly Kellogg, RD, LCSW, a Philadelphia-based psychotherapist, nutritionist, and life coach, who offers resources and workshops to improve your counseling skills (www.mollykellogg.com)
• MotivationalInterviewing.org, which provides materials intended to facilitate the dissemination, adoption, and implementation of motivational interviewing by certain healthcare professionals to improve treatment outcomes
• Ozier AD, Henry BW; 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
• Tholking MM, Mellowspring AC, Eberle SG, et al. American Dietetic Association: standards of practice and standards of professional performance for registered dietitians (competent, proficient, and expert) in disordered eating and eating disorders (DE and ED). J Am Diet Assoc. 2011;111(8):1242-1249.
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3. Ozier AD, Henry BW; 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.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
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7. Binge eating disorder. Weight-Control Information Network website. http://win.niddk.nih.gov/publications/binge.htm. Last modified August 20, 2012.
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15. Haedt-Matt A, Keel P. Revisiting the affect regulation model of binge eating: a meta-analysis of studies using ecological momentary assessment. Psychol Bull. 2011;137:660-681.
16. Escott-Stump S. Nutrition and Diagnosis-Related Care. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008.
17. Grilo CM, Masheb RM, Wilson GT, Gueorguieva R, White MA. Cognitive-behavioral therapy, behavioral weight loss, and sequential treatment for obese patients with binge-eating disorder: a randomized controlled trial. J Consult Clin Psychol. 2011;79(5):675-685.