A food binge is characterized by episodes of rapid and excessive food consumption not necessarily due to hunger. Individuals who binge will typically eat until they are uncomfortably full and will not engage in compensatory behaviors such as purging, use of laxatives and/or enemas, or exercising. Until recently, binge eating disorder (BED) fell under the diagnostic classification of eating disorders not otherwise specified. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association [APA], 2013), BED was recognized as a separate diagnosis. Since then, BED has received increased recognition by clinicians and researchers. However, comparatively little about this debilitating disorder has been published in the nursing literature.
The purpose of the current article is to provide an overview of BED including assessment, diagnosis, and treatment implications. A literature search was conducted using the key words “binge eating disorder,” “treatment,” “risk,” and “nursing.” Databases searched included PubMed, Medline, and CINAHL with an initial return of more than 3,300 articles. A significant number of articles on anorexia nervosa and bulimia nervosa were excluded. Articles specific to risk factors, assessment and diagnosis, and treatment modalities for BED were reviewed for the current study.
BED is the most prevalent eating disorder in the United States, believed to affect an estimated 2.8 million adults (Masheb, White, & Grilo, 2013). A systematic review of 49 English language articles published between 2009 and 2013 revealed a 1% to 2% lifetime prevalence rate of BED in the general population and a 12-month prevalence rate of 0.1% to 1% (Agh et al., 2015). Recently, Cossrow et al. (2016) conducted an internet survey of a representative sample of adults (N = 22,397) who participated in the 2013 National Health and Wellness Survey. Of these participants, 344 individuals (242 women and 102 men) met DSM-5 criteria for BED. Prevalence estimates at 3 months, 12 months, and lifetime were 1.19%, 1.64%, and 2.03% respectively.
In an international study, Kessler et al. (2013) surveyed a community sample of adults (N = 24,124) across 14 countries including Colombia, Brazil, Mexico, Romania, Belgium, France, Germany, Italy, the Netherlands, New Zealand, Northern Ireland, Portugal, Spain, and the United States. Country-specific estimates were consistently higher for BED compared to bulimia nervosa. A lifetime prevalence of 1.4% was found in this sample, with age of onset ranging from late teens to early twenties.
Few risk factors are specific to BED. In an early study, Fairburn et al. (1998) used a community-based, case-control design to compare 52 women with BED to 102 women with major depression, anxiety disorder, and bipolar disorder, and 104 women with no known psychiatric disorders. Compared to healthy controls, women with BED endorsed significantly more parental depression, negative self-evaluation, marked conduct problems, deliberate self-harm, greater exposure to parental criticism and lack of affection, sexual and physical abuse, and repeated comments from family members about weight, shape, and eating. However, when compared to women with other psychiatric problems, only childhood obesity and negative comments from family members about weight, shape, and eating emerged. The authors concluded that based on the findings from their study, BED may be associated with two broad classes of risk factors: those that increase the risk for psychiatric disorders, such as major depression, bipolar disorder, and anxiety disorder; and those that increase the risk for obesity (Fairburn et al., 1998).
Striegel-Moore et al. (2005) replicated and extended the Fairburn et al. (1998) study using a sample of women who self-identified as Black American and White American individuals (N = 501). As in the Fairburn et al. (1998) study, participants were divided into three groups (i.e., BED, healthy controls, and other psychiatric disorder controls) and matched on ethnicity, age, and education. No significant effects for ethnicity were found among groups. However, childhood obesity and familial eating problems were found to be specific risk factors for BED.
Other studies evaluated risk factors in adolescents using prospective data from the Western Australian Pregnancy Cohort Study (Allen, Byrne, Forbes, & Oddy, 2009; Allen, Byrne, Oddy, Schmidt, & Crosby, 2014). Allen et al. (2009) followed males and females (N = 1,597) from birth through age 14 to assess prospective predictors of eating disorders relative to general control and psychiatric control groups. By age 14, approximately 6% of the sample met full or partial criteria for an eating disorder. Female gender and being perceived as overweight during childhood by one or both parents emerged as significant predictors of onset of eating disorders at age 14 compared to healthy controls and psychiatric controls. In the later study, Allen et al. (2014) assessed 1,383 individuals at ages 14, 17, and 20. As with the earlier study, female gender and parental perception of the child as overweight emerged as significant predictors of later onset eating disorders.
Individuals with BED are at a higher risk for concurrent psychiatric disorders. Swanson, Crow, LeGrange, Swendsen, and Merikangas (2011) found that 83.5% of adolescents meeting criteria for BED also met criteria for at least one other psychiatric disorder, with 37% endorsing more than three concurrent psychiatric disorders. Individuals with BED are more likely to have concurrent mood and anxiety disorders (Becker & Grilo, 2015; Cossrow et al., 2016; Swanson et al., 2011), attention deficit/hyperactivity disorder (Cossrow et al., 2016), and posttraumatic stress disorder (Mitchell & Wolf, 2016). Individuals with BED are more likely to use marijuana and other drugs and have a comorbid substance use disorder (SUD) (Becker & Grilo, 2015).
BED is strongly associated with obesity and associated medical comorbidities including: diabetes (Olguin et al., 2017; Wooldridge & Lemberg, 2016), hypertension and other cardiac problems (Kessler et al., 2013; Olguin et al., 2017; Wooldridge & Lemberg, 2016), dyslipidemias (Olguin et al., 0217; Wooldridge & Lemberg, 2016), sleep problems (Olguin et al., 2016), pain conditions (Kessler et al., 2013; Olguin et al., 2017), gallbladder disease (Wooldridge & Lemberg, 2016), osteoarthritis (Wooldridge & Lemberg, 2016), and ulcers, respiratory, and gastrointestinal problems (Wooldridge & Lemberg, 2016). In a systematic review of 49 articles, Agh et al. (2015) concluded that BED was associated with impaired health-related quality of life compared to individuals without BED, with annual direct health care costs ranging from $2,272 to $3,731 per patient with BED.
Despite the commonality of BED, the disorder is frequently overlooked by health care professionals. Associated comorbidities are often identified, but the underlying disordered eating is frequently not addressed. Cossrow et al. (2016) found that only 2% of 586 participants who met criteria for BED had ever been formally diagnosed. Similarly, Swanson et al. (2011) noted that a low proportion of adolescents had received treatment for BED.
BED occurs across gender, age, ethnicity, race, socioeconomic class, weight, and shape. Eating disorders such as BED are often thought to primarily afflict females. However, males account for as many as 36% of those with an eating disorder, with BED being the most common (Wooldridge & Lemberg, 2016). Males may not recognize their binge eating as a symptom of an eating disorder, and when they do, may be reluctant to seek treatment. Likewise, BED is often considered to be limited to the overweight and obese. It is important to note that not all overweight individuals have BED and, in some cases, individuals of average weight meet the criteria for BED. Thus, it is important to assess for BED regardless of gender, weight, and body shape (Wooldridge & Lemberg, 2016).
There is often a degree of shame and secrecy associated with food binging, highlighting the importance of assessing patients for eating problems even when they are not included in the presenting complaint. Ideally, questions about eating behaviors should be included in routine office visits. Eichen and Wilfley (2016) suggest that a good start is to ask questions related to eating patterns, appetite changes, feelings about shape, and whether the person is trying to lose weight. Questions should be asked in a matter-of-fact manner. Examples of initial questions include: “Do you eat large amounts of food at one sitting?”, “Do you eat until you are uncomfortably full?”, and “Do you feel a loss of control when you eat?” Affirmative answers to these questions are indicative of the need for a more detailed assessment (Eichen & Wilfley, 2016).
A number of instruments are available to assess for eating disorders. Although not diagnostic, they can alert clinicians to the possibility of an eating disorder and the need for further evaluation. The Eating Disorder Screen for Primary Care (Cotton, Ball, & Robinson, 2003) was developed specifically for primary care settings. The screen is a five-item dichotomous questionnaire that asks about satisfaction with eating patterns, eating in secrecy, self-appraisal, whether any family members have an eating disorder, and the presence of a prior or current eating disorder. Answering yes on two or more items is considered indicative of a possible eating disorder. This instrument has been tested with primary care patients and university students and found to be sensitive in screening for eating disorders (Cotton et al., 2003).
The Binge Eating Scale (BES; Gormally, Black, Daston, & Rardin, 1982) is a 16-item instrument that measures behavioral and emotional/cognitive symptoms associated with binge eating. Each item contains between three and four response options ranging in severity for the characteristic being measured. Total scores range from 0 to 32, with higher scores indicating greater severity. Respondents are classified as mild (≤17), moderate (18 to 26), and severe (≥27). In general, a score ≥17 is indicative of binge eating. The BES has demonstrated excellent performance (96.7%) on discriminating clinically significant cases of binge eating, showing a sensitivity of 81.8% and specificity of 97.8% (Duarte, Pinto-Goveia, & Ferreira, 2015).
A newer instrument, the Binge Eating Disorder Screener (BEDS-7), is a brief, self-report instrument with seven items based on DSM-5 diagnostic criteria, existing instruments, and input from three clinical experts. The tool comprises dichotomous and Likert-type items that assess loss of control, feelings of distress, the number of binges, and eating when not hungry. The BEDS-7 was developed as part of multi-site, prospective, non-interventional study of 97 adults. The seven items yielded 100% sensitivity and 38.7% specificity (Herman et al., 2016).
The Table lists the diagnostic criteria for BED. In addition to the listed criteria, the eating episodes must cause distress, occur at least once per week for a duration of at least 3 months, and are not accompanied by compensatory behavior(s). BED is classified as mild, moderate, severe, or extreme, depending on the number of binge episodes per week (APA, 2013).
DSM-5 Diagnostic Criteria for Binge Eating Disorder
There are challenges related to the current diagnosis. For example, not all presentations fit into the established criteria. Another challenge is the absence of any criteria related to concerns about shape and weight, which may indicate a more severe pathology (Eichen & Wilfley, 2016). An additional complication is the lack of a BED diagnosis in the 10th edition of the International Classification of Disease (ICD-10; American Medical Association, 2016), where such individuals fall under the category of “other eating disorders.”
A sound assessment will aid clinicians in ruling out differential diagnoses. As Eichen and Wilfley (2016) noted, patients cannot receive a diagnosis of more than one eating disorder. Thus, if binge eating and purging behaviors are present, a diagnosis of bulimia nervosa is more appropriate. If the patient severely restricts food intake in between binges, a diagnosis of atypical anorexia nervosa must be considered. Those who meet some, but not all, of the criteria for BED can receive a diagnosis of “other specified eating disorder” (OSED). These patients may include those who have not had binge episodes for at least 3 months and/or weekly (Eichen & Wilfley, 2016).
Physical conditions that may cause changes in eating patterns and weight should be ruled out, such as hypothyroidism, a dysfunction or tumor in the hypothalamus, or a nutritional deficiency. Psychiatric disorders may include mood disorders and anxiety disorders. Individuals may exhibit preoccupations with food and compulsions related to eating that may meet criteria for obsessive compulsive disorder.
The primary goal of BED treatment is to achieve abstinence from binge eating, with a secondary goal of sustainable weight loss (Amianto, Ottone, Abbate Daga, & Fassino, 2015). Choice of treatment should be based on factors such as availability, efficacy, financial feasibility, patient preference, body mass index (BMI), existing comorbidities, and any prior treatments and responses to treatment. Other treatment outcomes may include improved self-esteem, improved quality of life, and a reduction of symptoms related to associated comorbidities. Treatment modalities available to individuals with BED include nonpharmacological modalities, such as psychotherapy and behavioral weight loss programs, and medication.
Psychotherapies such as cognitive-behavioral therapy (CBT) and interpersonal therapy are common treatment modalities for BED. CBT is a well-established, evidence-based program for BED (Uniacke & Broft, 2016). Programs for individuals with BED based on CBT focus primarily on identifying and modifying dysfunctional eating patterns and associated attitudes, perceptions, and beliefs about eating, weight, body, and shape. These programs are delivered individually or in a group, online or face-to-face, or through guided self-help over a set period of time. Interpersonal therapy is psychodynamically based with a focus on the interpersonal aspects of BED and building interpersonal relationships (Peat, Brownley, Berkman, & Bulik, 2012). Interpersonal therapy is considered to be a particularly good choice for patients with low self-esteem and/or higher eating-related psychopathology (Wilson, Wilfley, Agras, & Bryson, 2010).
Although not considered to be psychotherapy, behavioral weight loss (BWL) programs are also common approaches. BWL programs vary considerably in content and format but are centered on making dietary and physical activity changes to achieve weight loss. These programs may or may not address binge eating.
Studies comparing CBT, interpersonal therapy, and BWL programs have found CBT and interpersonal therapy efficacious in decreasing binge eating episodes, whereas BWL programs are more effective in achieving a modest weight loss (Grilo, Masheb, Wilson, & Gueorguieva, 2011). Wilson et al. (2010) compared adult men and women (N = 205) who were randomly assigned to receive interpersonal therapy, CBT-guided self-help (CBTgsh), or BWL. Interpersonal therapy and CBTgsh were significantly more effective in reducing binge eating at 2-year follow up. In a randomized clinical trial, 125 obese adults with BED were assigned to receive CBT, BWL, or CBT + BWL (Grilo et al., 2011). At 12-month follow up, CBT produced significantly greater reductions in binge eating than BWL and combined CBT + BWL. However, BWL produced a significantly greater percentage reduction in BMI.
A recent nonpharmacological approach to treat BED is transcranial magnetic stimulation (TMS). Burgess et al. (2016) investigated the effects of transcranial direct current stimulation (tDCS) on food craving, food intake, binge eating desire, and binge eating frequency in 30 adults with BED or subthreshold BED (i.e., met all criteria except for binge frequency per week). In this study, participants received a 20-minute 2 milliampere session of tDCS targeting the dorsolateral prefrontal cortex (DLPFC) and a “sham” session. Participants were blind to whether they received a real session or sham session. The authors found that one 20-minute session of tDCS targeting the DLPFC significantly reduced in-lab food intake, in-lab food craving, and at-home desire to binge eat. Although additional research is necessary, TMS may be a noninvasive treatment option for BED with fewer side effects than most medications (Burgess et al., 2016).
Multiple neurotransmitter systems including the dopaminergic, serotonergic, cholinergic, noradrenergic, GABAergic, opioidergic, and glutamatergic systems are thought to be involved in the pathophysiology of BED (Kessler, Hutson, Herman, & Potenza, 2016). Dopamine, in particular, appears to play a key role in binge eating behavior (Kessler et al., 2016). However, drugs acting on other neurotransmitters, including serotonin, norepinephrine, glutamate, gamma-aminobutyric acid (GABA), and the opioid system, have been studied.
The stimulant lisdexamfetamine dimesylate (Vyvanse®) was approved by the U.S. Food and Drug Administration (FDA) in 2015 for adults with moderate to severe BED. This drug blocks reuptake of norepinephrine and dopamine and increases the amount of these neurotransmitters in the synapses (Stahl, 2014). To date, this is the only medication approved to treat BED. Lisdexamfetamine dimesylate is approved to reduce the number of binge eating days per week, but is not indicated for weight loss or obesity. The initial dose is 30 mg daily in the morning and can be titrated by 20 mg per day weekly to a target dose of 50 mg per day to 70 mg per day. Efficacy and safety studies have found lisdexamfetamine dimesylate to be superior to placebo in reducing binge eating days, with safety results consistent with the known safety profile of the drug (McElroy et al., 2016). Side effects include dry mouth, headache, and insomnia. In one safety and tolerability trial (N = 604 adults), there were two positive responses regarding suicidal ideation but no suicidal behaviors or completed suicides (Gasior et al., 2017).
Selective serotonin reuptake inhibitors (SSRIs) have also been used to treat BED, particularly fluoxetine, which is indicated for bulimia. These drugs increase serotonin, which at low levels may decrease inhibitory control over food and heighten the desire for sweet food (Fortuna, 2012). In a 6-week, double-blind, flexible-dose study, Arnold et al. (2002) found that compared to placebo, participants who received doses of fluoxetine ranging from 20 mg to 80 mg daily had a significantly greater reduction in frequency of binge eating, BMI, weight, and severity of illness. Sertraline, another SSRI, has also been found to be effective in reducing episodes of binge eating (Milano, Petrella, Sabatino, & Capasso, 2004). A randomized, double-blind study comparing fluoxetine and sertraline over a 6-month treatment period (N = 42) found both to be effective, with no significant differences between drugs on binge frequency, weight loss, and severity of psychopathology (Leombruni et al., 2008).
Bupropion, which acts on dopamine and norepinephrine (Stahl, 2014), has also been used to treat BED. In an 8-week randomized, double-blind, placebo-controlled trial with overweight and obese women (N = 61), White and Grilo (2013) noted that women who took 300 mg of bupropion lost a modest but significantly greater amount of weight compared to women who took the placebo. However, bupropion did not improve binge eating, food craving, associated eating disorder features or depression, and was not supported as a stand-alone treatment for BED. Bupropion carries a black box warning due to risk of seizures.
Topiramate is an anticonvulsant drug used for treatment of epilepsy, prophylaxis of migraines, and mood stabilization in bipolar disorders. Topiramate inhibits release of glutamate and potentiates activity of GABA (Stahl, 2014). Topiramate has well-documented efficacy in BED and obesity (Guerdjikova, Fitch, & McElroy, 2015) and has been found to significantly reduce binge eating and weight (Reas & Grilo, 2015).
An extended-release formula combining topiramate and the appetite suppressant phentermine (Qsymia®) is a newer medication approved as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management of obesity in adults. Guerdjikova et al. (2015) presented two patients with BED who were treated with this medication and experienced cessation of binge eating behaviors and clinically significant weight loss. Based on this finding, the authors supported the use of this medication, with concurrent supportive psychotherapy, as a viable treatment option for BED and obesity (Guerdjikova et al., 2015).
Findings from controlled trials provide support that some medications alone are effective in reducing binge eating and, in some cases, facilitating weight loss over the short term. However, there is a paucity of data regarding the long-term effects of medications (Reas & Grilo, 2015). Long-term studies using diverse populations are necessary to determine whether the medications are effective over the long term and to determine any adverse effects that may develop from long-term use.
Regardless of the setting, a nursing history may be the first place that BED is detected. Patients rarely present with BED as their primary complaint and may not disclose their disordered eating. However, how a patient answers one or two open-ended questions related to the amount of food eaten at a sitting and the feeling of loss of control over food intake may alert nurses to the possibility of BED and the need for a more in-depth assessment (Eichen & Wilfley, 2016). Asking the questions in a matter of fact manner, such as how one might ask about sleeping patterns, may help dispel the shame and secrecy that shrouds this disorder and prevents patients from openly discussing their eating patterns.
Once the presence of binge eating is detected, nurses can advocate that patients receive treatment designed to decrease binge episodes. This treatment may include referral to an eating disorders specialist, nutritionist, therapist, or medication evaluation. Depending on the setting, nurses may be more directly involved in helping patients recognize their eating patterns. For example, a nurse may suggest that patients use a self-monitoring technique such as recording everything eaten during the day, including the date, time, and place. This documenting can increase awareness of everything that is eaten in the course of a day (Cloak & Powers, 2006).
Individuals with BED may have difficulty expressing and experiencing emotions. In an exploratory nursing study comparing women with (n = 35) and without (n = 30) disordered eating, binge eating was significantly correlated with alexithymia (Wheeler, Greiner, & Boulton, 2005). Nurses can also suggest patients record what they were doing and how they were feeling immediately before and after a binge episode as another self-monitoring strategy (Cloak & Powers, 2006). This documentation may help identify events/thoughts/feelings that may trigger a binge as well as the impact of that binge on the patient and/or others. Relaxation exercises, biofeedback, guided imagery, and autogenic training are other strategies that may enhance self-awareness of bodily sensations (Wheeler et al., 2005).
Education is another area where nurses can take an active role. Patients may not recognize that their eating patterns are symptoms of an eating disorder. Rather, they may criticize themselves for having a lack of will power, further damaging their self-esteem. Information about BED including prevalence, symptoms, and available treatment options and resources in the area should be readily available and openly discussed. Educational interventions may serve as a useful starting point for more complex treatments (Amianto et al., 2015). For some, this may make the difference between obtaining treatment for a legitimate disorder versus continuing to suffer in silence.
In addition to a clinical interview, an assessment for BED should include a weight history and history of any weight loss attempts and outcomes. Vital signs should be taken, a weight obtained, BMI calculated (normal = 18.5 kg/m2 to 24.9 kg/m2) (American Heart Association, 2017), and waist circumference measured. Fasting lipids should be obtained for a BMI >27 kg/m2 (Cloak & Powers, 2006). Laboratory tests should include fasting glucose (normal value = <100 mg/dL), hemoglobin A1C (≤5.7%) (American Diabetes Association, 2017), and thyroid panel.
BED causes distress, impairment, psychiatric impairment, and medical morbidity. Although it is the most prevalent eating disorder, it is often undetected. Patients' function and overall quality of life can be improved when BED is diagnosed and treated via a thorough nursing assessment. Interventions may include pharmacological and nonpharmacological options. To date, CBT and interpersonal therapy have the most empirical support regarding efficacy in reducing binge eating. Lisdexamfetamine dimesylate is the only medication indicated for treating BED, although a variety of medications are used off-label. Long-term studies are needed that examine the efficacy of interventions over time using diverse participant samples.
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DSM-5 Diagnostic Criteria for Binge Eating Disorder
|a) Consumption, within a 2-hour period, of an amount of food larger than what most people would consume in a similar period of time and under similar circumstances, and a sense of a lack of control over what or how much one is eating during the episode.
The binge eating episodes are associated with at least three of the following:
Eating much more rapidly than usual.
Eating until feeling uncomfortably full.
Eating large amounts of food when not physically hungry.
Eating alone because of feeling embarrassed by how much one is eating.
Feeling disgusted, depressed, or very guilty post-binge.
|b) Marked distress regarding binge eating is present.|
|c) The binge occurs, on average, at least once per week for 3 months.|
|d) The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.|