Binge Eating Disorder: Surprisingly Common, Seriously Under-treated
"Binge eating disorder is more common than anorexia and bulimia combined, according to a national survey, but many physicians are unaware of the problem. The guidance and evidence discussed here highlight the key issues in recognizing and managing the disorder."
Though binge eating is not an officially recognized psychiatric disorder, it is more common than anorexia nervosa and bulimia; carries serious health risks; can be chronic; transcends racial, gender and socioeconomic boundaries; and frequently occurs along with other mental disorders.
Given these findings -- taken from the first nationally representative survey of eating disorders in the U.S. -- experts say physicians should routinely screen for binge eating disorder, especially among overweight and obese patients. Mental-health clinicians, in particular, are in a good position to recognize and treat the disorder, and the issues of low self-esteem and poor body image that often accompany it.
Most physicians, however, aren't aware of the problem, says James Hudson, MD, director of the Psychiatric Epidemiology Research Program at McLean Hospital and a professor of psychiatry at Harvard.
"Doctors have a reasonable degree of awareness about anorexia and bulimia, but they're not tuned into binge eating. It's just not as well known," says Hudson, lead author of "The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication". The study, published Feb. 1 in Biological Psychiatry, found that 2.8 percent of the general population has binge-eating disorder -- more than bulimia (1 percent prevalence) and anorexia (0.6 percent) combined.
Findings reveal 'major public health problem'
The study also found that:
* Binge eating disorder (BED) is strongly associated with severe obesity, which can lead to diabetes, heart disease, hypertension and stroke.
* Although eating disorders overall are about twice as common among women as men, 40 percent of binge eaters are men.
* 78.9 percent of those with binge eating disorder met the criteria for at least one other psychiatric disorder, and 48.9 percent met the criteria for three or more psychiatric disorders.
* No single class of mental disorders stood out as being consistently associated with BED. Among those with binge eating disorder, 31.9 percent also met the criteria for social phobia, 32.3 percent for major depressive disorder, 26.3 percent for post-traumatic stress disorder; 23.3 percent for any substance use disorder, and 65.1 percent for any anxiety disorder.
* 62.6 percent of those with BED reported at least some role impairment at home, work and/or in their social life.
* The average duration of BED was 8.1 years, compared with 8.3 for bulimia and 1.7 for anorexia.
* Less than half of those with binge eating disorder had sought treatment for it.
"Binge eating disorder represents a major public health problem," Hudson said. "It is imperative that health experts take notice of these findings."
While physicians are well aware of bulimia and anorexia, they tend to overlook binge eating, for reasons including its lack of obvious physical signs and its lack of official recognition. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) currently classifies BED as an "eating disorder not otherwise specified" and needing further study. Many researchers, however, believe there is now sufficient evidence to classify it as a separate disorder. A working group for the next (fifth) edition of the DSM, to be published in 2012, is being formed to discuss and will decide the question.
Detection is also hampered by physicians' reluctance to raise the issue of eating disorders, Hudson notes. "It makes the doctor uncomfortable; it makes the patient uncomfortable. I don't like to ask about it myself. But we need to be asking about it."
Questions to ask
Since binge eating is most common among the overweight and obese, those populations are the logical place to start screening. Since binge eating is most common among overweight and obese patients, those populations are the logical place to start screening. Binge eating is even more likely in overweight patients with low self-esteem and a poor body image.
Ruth Striegel-Moore, PhD -- professor and chair of psychology at Wesleyan University and past president of the Academy for Eating Disorders -- suggests starting the conversation with a simple question: "Do you feel you have any problems with your eating?"
If the patient says yes, the clinician should ask about these key signs of BED:
* Do you eat unusually large amounts of food at one sitting (equivalent to two full meals)?
* Do you eat this way even when you're not hungry?
* Do you eat until you're uncomfortably full?
* Do you feel you've lost control and can't stop eating?
* Do you feel ashamed or depressed afterwards?
* Has this happened two or more times a week for six months?
* Do you eat alone because you're embarrassed to eat around others?
Not a moral flaw
It's important to ask these questions in a neutral way, being sensitive to the shame and stigma surrounding eating disorders, Hudson emphasizes. "They need to convey that this is not a moral flaw, but a medical problem to be addressed."
But Cynthia Bulik, PhD, director of the eating disorders program at University of North Carolina, has found that many patients want to talk about their binge eating, and are relieved when a healthcare provider asks about it. "I can't tell you the number of e-mails I've gotten from people on the street who have seen me discussing this. They say, 'Thank you so much for talking about it. I'm cutting this out and taking it to my doctor.'"
While there's sometimes a grey area between binge eating and simply overeating, the key distinguishing factors for BED are a loss of control when eating, and feelings of distress after binges. Bingeing is often rooted in a patient's low self-esteem, poor body image, and the use of food to comfort oneself at times of stress.
Binge eating is also tied to all-or-nothing thinking, Bulik explains. "They think, well, I've already blown it by eating half this carton of ice cream; I might as well eat the rest of it."
Reassurance, referral, treatment goals
If the patient indicates a problem with binge eating, the clinician should reassure him or her that it's a treatable condition and that help is available. The patient should also be evaluated for other mental disorders including anxiety and depression.
"The biggest mistake doctors make is to trivialize the problem and say, 'Well, we all overeat sometimes,' and to tell the patient to just control their eating. It's more complex than that," explains Striegel-Moore.
The treatment goals for BED are stopping the binges, losing weight, treating any comorbid disorders, and correcting the self-defeating feelings, thoughts and behaviors that lead to binges.
Where to refer
To achieve these goals, many experts recommend a comprehensive eating disorders program. The programs take a multidisciplinary approach that typically includes nutrition counseling; a behavioral weight control plan with healthy meals spaced throughout the day; medication in some cases; and a strong foundation in cognitive behavioral therapy (CBT) -- considered the gold standard for treating the disorder. According to an April 2006 evidence report on eating disorders, commissioned by the Agency for Healthcare Research and Quality, CBT is effective in reducing the number of binge days or the number of binge episodes, though it does not lead to significant weight loss.
Eating disorders programs are offered by most academic medical centers and many hospitals. Or patients can work with a therapist who specializes in CBT and eating disorders; the Academy for Eating Disorders and the Association for Behavioral and Cognitive Therapies offer online searches to find a therapist.
Because binge eating disorder is not an official diagnosis, insurance coverage is often minimal or nonexistent, and patients without coverage often can't afford to pay for treatments out-of-pocket -- another reason some are urging official recognition for the disorder.
Self-help a viable approach
For patients without coverage, and those wary of traditional therapy yet motivated to work on the problem independently, self-help treatment may be a viable option. The approach uses books or other materials to guide patients through a program built on cognitive behavioral therapy. Like traditional CBT, the programs help patients develop a structured eating plan and correct the self-defeating thoughts and behaviors that lead to binges.
"Say your in-laws are coming this weekend, and you know it's a stressor for you. You make a plan for how you're going to handle that without bingeing," says Striegel-Moore.
According to studies in 1998 and 2001, self-help approaches were effective in reducing binges and improving patients' attitudes about eating.
Recommended self-help books include Overcoming Binge Eating and Getting Better Bite by Bite. And the newest frontier in self-help is computer-based programs. With a grant from the National Institute of Mental Health, for example, Bulik developed a program called Preventing Overweight with Exercise and Reasoning (POWER), which she describes as "therapy on a CD."
The program uses realistic vignettes, self-paced lessons and interactive quizzes to help patients understand why they binge and to help them make better eating choices. "Patients love it because it's so interactive," Bulik says. "Computer-based programs are the future of self-help."
While cognitive behavioral therapy is the most proven therapy for binge eating disorder, other approaches have shown promise, such as interpersonal therapy, which explores issues in the patient's relationships. A 2002 study which compared CBT with interpersonal therapy to treat 162 BED patients found recovery rates were equivalent in both groups.
And while some may believe a conventional diet program is the answer -- from Atkins to Jenny Craig to Weight Watchers -- the approach hasn't been well-tested for treating binge eating disorder. Some studies have found that BED patients lose as much weight as non-BED patients in traditional weight-control programs. But some experts advise against the approach.
"My experience is, by the time patients are talking to a doctor about this problem, they've already tried dieting programs and it didn't help," Hudson says. Furthermore, "some of these programs say, 'Our program can't fail -- it's you who failed.' So if the patient doesn't succeed, they feel worse than before."
The role of medications
Although there is no FDA-approved drug specifically for binge eating disorder, several medications have been found effective in clinical trials.
* Selective serotonin reuptake inhibitors (SSRIs) are most commonly used to treat BED. In randomized trials, they have been found more effective at reducing binge eating than in inducing weight loss.
* Some appetite suppressants have been shown to reduce binge eating and body weight in patients with BED.
* A small number of anti-convulsant medications have been tested in clinical trials for BED, and have been shown to decrease binges and reduce weight. The drugs often have troublesome side effects, however, including dizziness, fatigue and difficulty concentrating.
The question of whether and when to use medication ultimately depends on the patient's, and the doctor's, preference. Hudson recommends first trying CBT, and if the patient doesn't show sufficient improvement, medication can be tried, either alone or with therapy. Striegel-Moore recommends using medication primarily for patients with comorbid anxiety or depression, and using it to complement, not replace, therapy.
The AHRQ evidence report states that "combining medication and CBT may improve both binge eating and weight loss, although sufficient trials have not been done to determine which medications are best at producing weight loss."
No magic bullet
Unfortunately, successful treatment for binge eating disorder is neither quick nor easy, and relapses are common. Even the most effective treatments typically take 10-15 weeks to work. And, for reasons that aren't fully understood, the treatments that have helped patients stop bingeing have shown little success in helping them lose weight. This underscores the need for further study and better treatments -- and the importance of perseverance for those struggling to overcome binge eating.
"It's incredibly hard to lose weight long-term," Striegel-Moore says. "We live stressful lives, we're surrounded by cheap unhealthy food, and we don't exercise enough. For anyone to get control over binge eating -- or any eating disorder -- requires truly lasting behavioral change."
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