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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.
Psychiatric Times Poll
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 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:
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.