Diet books fly off the shelves at this time of year as many people make New Year’s resolutions to lose weight or eat healthier. For individuals with binge eating disorder (BED), the books and apps and weight loss often signal the start of another cycle of yo-yo dieting, weight loss followed by regaining the weight — and often a few more pounds.
Even though it is the most common eating disorder, BED often proves more challenging for a clinician, nutritionist or family member to recognize than other eating disorders such as anorexia nervosa or bulimia. Many individuals with BED appear to eat normally. They may be normal weight or overweight. They do not lose weight quickly or spend inordinate amounts of time in the bathroom. But they still need treatment and the sooner they receive it, the better their long term outcomes.
Binge-eating disorder was first recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) published in 2013.1 As a result, it has gained more recognition in the medical and wellness communities, but even greater awareness will help us reach — and treat — more people. And there are a lot of people out there who need treatment. BED affects about 5% of the U.S. population, which is 318.9 million people
Characterized by recurrent episodes of eating, within a 2-hour period, significantly more food than most people would eat in a similar period under similar circumstances and a sense of lack of control over eating during the episode, BED often creates acute distress associated with these binge-eating episodes. The episodes occur at least once a week for a minimum of three months on average and are not counterbalanced by dangerous compensatory behaviors seen in anorexia nervosa or bulimia, such as excessive exercise, purging, extreme calorie restriction or laxative use.
Individuals with BED also exhibit at least three of the following:
• Eating much more quickly than usual
• Eating past the point where they feel comfortably full
• Eating a lot when they do not feel hungry
• Eating alone out of embarrassment for the amount consumed
• Feeling guilty, disgusted or depressed by their eating
Clinicians can screen for BED by asking straightforward questions such as, “Have you ever experienced a sense of loss of control while eating?” or “Have you ever felt compelled to eat even when you were not hungry?” Individuals who have commonly comorbid conditions such as anxiety, depression or substance abuse and those who are overweight or obese should particularly be screened for BED.2
Family members or friends may notice the disappearance of large amounts of food or find empty packaging for an unusual quantity of food. They may note that an individual stops eating with others or appears to hoard food or develops unusual eating patterns or food rituals.
Binge-eating disorder occurs two to four times more often in overweight individuals than in normal-weight individuals and as many as 25% of obese individuals meet the criteria. Women develop BED about 50% more often than men.
By taking action early in the development of binge-eating disorder, clinical teams can help individuals avoid the worst of its side effects and stop a patient’s suffering sooner. Because there are no compensatory behaviors with BED, unlike bulimia, for instance, patients with the disorder quickly gain weight and head toward obesity. The consumption of large numbers of calories put them on a downward spiral that makes returning to normal weight and healthy eating increasingly difficult. Early intervention can help patients adjust before the habits and physiological changes fully take hold.
Even after years of binge eating, patients can still return to a healthy weight, but their bodies have sustained irreversible changes. When the person loses weight, the fat cells do not suddenly disappear. They remain in the body and can quickly and easily fill up again.
Those fat cells drive the yo-yo dynamic that so many people, particularly those with BED, experience when they diet successfully. If someone goes from 300 to 150 pounds, she has less mass but the same number of fat cells. To keep the weight off, she will have to focus on a daily basis on eating and exercising in ways that will keep the size of the fat cells down.
Changes in brain chemistry complicate that battle. The history of binge eating alters the signaling in the brain to desire food bingeing. Certain stressors or triggers may make the person more vulnerable too. The combination of triggers and chemical changes essentially hijack the prefrontal cortex so that she is driven to consume more calories and fill up the fat cells again, quicker than ever. In those moments, the patient is not actively making decisions; it becomes very difficult to stop the cascade. Each cycle makes it harder to lose weight and keep it off.
The focus in treatment is symptom abatement, meaning a reduction in bingeing with the goal of eliminating bingeing altogether. Identifying emotional triggers, recognizing past events that could lead to future behaviors and working on incorporating healthier coping skills are all some of the things one can expect in treatment. Body acceptance and shame reduction are also a focus.
Getting individuals with BED into treatment before they develop obesity or before they experience multiple cycles of weight loss and regaining can help them avoid years of frustration, the physical consequences of crash diets and the health risks associated with obesity. While weight is not the main focus in treatment (it is viewed as a symptom of the pathology), getting help before the weight rises to a less manageable level is important. With the right support team, they can live binge free and learn the tools and education that will help them adopt healthy eating habits and keep the weight off.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th Edition. Washington, DC: APA Press; 2013
2. Sonneville KR, Horton NJ, Micali N, Crosby RD, Swanson SA, Solmi F, et al. Longitudinal associations between binge eating and overeating and adverse outcomes among adolescents and young adults: does loss of control matter?. JAMA Pediatr. 2013 Feb. 167(2):149-55.