PAPER Binge eating disorder and obesity

(2001), 25, Suppl 1, S51 S55 ß 2001 Nature Publishing Group All rights reserved 0307 0565/01 $15.00 www.nature.com/ijo PAPER 1 * 1 Department of General Psychiatry, University Hospital of Psychiatry, Vienna, Austria Binge eating disorder (BED) was included in the DSM IV as a proposed diagnostic category for further study and as an example for an eating disorder not otherwise specified (EDNOS). BED is characterized by recurrent episodes of binge eating in the absence of regular compensatory behavior such as vomiting or laxative abuse. Related features include eating until uncomfortably full, eating when not physically hungry, eating alone and feelings of depression or guilt. BED is associated with increased psychopathology including depression and personality disorders. Although BED is not limited to obese individuals, it is most common in this group and those who seek help do so for treatment of overweight rather than for binge eating. In community samples, the prevalence of BED has been found to be 2 5%, in individuals who seek weight control treatment the prevalence is 30%. BED is more equal in gender ratio than bulimia nervosa. Eating disorder treatments such as cognitive behavior therapy (CBT) or interpersonal psychotherapy (IPT) improve binge eating with abstinence rates of about 50%. Antidepressants are also effective in reducing binge eating, though less so than psychotherapy. Standard weight loss treatments including bariatric surgery do not seem to exacerbate binge eating problems. Thus, both eating disorder and obesity treatments seem to be beneficial in BED. However, it is recommended today that treatment should first be directed at the disordered eating and associated psychopathology. (2001) 25, Suppl 1, S51 S55 Keywords: binge eating; binge eating disorder; comorbidity Diagnosis Although Albert Stunkard in 1955 1 identified binge eating as a distinct eating pattern in some obese individuals, this phenomenon received little systematic attention until a few years ago. Preliminary criteria for a disorder, termed binge eating disorder (BED) in DSM IV 2 has been delineated in an attempt to better define and study this problem. This newly conceptualized eating disorder has been given provisional status by being included in the Appendix of the DSM IV 2 for diagnostic categories meriting further study, and is also included as an example of eating disorders not otherwise specified (EDNOS). The diagnostic criteria currently recommended for BED are presented in Table 1. It is important to keep in mind that in clinical settings the great majority of persons with BED will have varying degrees of obesity, even though the diagnosis is not limited to overweight individuals. Prevalence The community surveys have estimated the current prevalence of binge eating disorder to be between 2 and 5%. 3,4 *Correspondence:, Department of General Psychiatry, Währinger Gürtel 18-20, A-1090 Vienna, Austria. E-mail: martina.dezwaan@akh-wien.ac.at BED is more equal in gender ratio 5 (65% female, 35% male) than bulimia nervosa (BN), for which only about 10% of persons affected are men. 5 BED is more common among overweight women seeking treatment than overweight women not seeking treatment. Approximately 30% of those participating in weight loss programs and 70% of individuals in Overeaters Anonymous display BED. 4 Interestingly, in a community survey only half of the BED subjects were obese (BMI > 27.5 kg=m 2 ) and only about 5% of the obese subjects met BED criteria. 3 Consequently, this problem behavior seems to be significantly less prevalent in obese subjects not currently in treatment (Table 2). Course Prolonged periods without binge eating seem to be rare, at least in the weight control samples investigated thus far. 4 In a community sample of young women with BED the diagnosis was less stable. After an observation period of 5 years just 10% still met the criteria for BED. 6 The binge episodes of overweight individuals seem to differ in important ways from the binge episodes described by patients with BN. BED subjects consume approximately half the calories of those with BN during binges and they

S52 Table 1 Proposed diagnostic criteria for binge eating disorder (A) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) Eating, in a discrete period of time (eg within any 2 h period), an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances. (2) A sense of lack of control during the episodes (eg a feeling that one cannot stop eating or control what or how much one is eating. (B) The binge eating episodes are associated with at least three of the following behavioral indicators of loss of control: (1) Eating much more rapidly than usual. (2) Eating until feeling uncomfortably full. (3) Eating large amounts of food when not feeling physically hungry. (4) Eating alone because of being embarrassed by how much one is eating. (5) Feeling disgusted with oneself, depressed or feeling very guilty after overeating. (C) Marked distress regarding binge eating. (D) The binge eating occurs, on average, at least 2 days a week for a 6 month period. a (E) The binge eating is not associated with the regular use of inappropriate compensatory behaviors (eg purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa. a Without purging behavior it is sometimes difficult to label binge eating episodes. Consequently, the diagnostic criteria for BED focus on days in which binge eating episodes occurred rather than on specific numbers of episodes. also binge less frequently. 5 In line with data on BN subjects, obese binge eaters appear to increase their intake of fat rather than carbohydrates. 7 There is no evidence that in obese patients binge eating is a result of dietary restraint. 8 10 About half of the patients with 11 13 BED start binge eating first in the absence of dieting. Consequently, disinhibition rather than dietary restraint seems to precipitate binge eating in many obese subjects. 5 Negative emotional states such as anger and frustration, depression and anxiety, a nonspecific feeling of tension 14 social situations, time of day, and the type of meal have been reported to trigger bingeing in BED. 15 Emotions following a binge are usually negative, with guilt, regret, disgust and selfloathing evident. 16 that binge eating obese have an earlier onset of obesity than nonbinge eating obese, start dieting at an earlier age, start worrying about their weight at an earlier age, report a higher prevalence of marked weight fluctuations in the past, and spend more time during adulthood trying to lose weight. 18,19 Metabolic characteristics Few studies have investigated physiological differences between obese individuals with and without BED. There is no evidence that obese subjects with BED are more prone to medical consequences of obesity than obese subjects without BED if one controls for weight. No significant differences were observed in blood pressure, resting metabolic rate (RMR), resting energy expenditure (REE), body fat distribution (waist=hip ratio), percentage body fat, and blood serum measures such as glucose, insulin levels, lipid levels, and thyroid hormones. 20 Others did not find an association between binge eating severity and glycemic control in obese patients with type 2 diabetes. 12 Psychopathology Most investigations found significantly higher levels of eating related and general psychiatric symptomatology in obese patients with binge eating than those without binge eating, 20 22 but significantly lower values compared with bulimic patients. 23 In most studies there appears to be a positive relationship between binge eating and depressive symptoms as well as a lifetime history of affective disorders in samples recruited for treatment trials but also, probably to a lesser degree, in non-treatment-seeking samples of obese BED women (Table 3). Regarding clinical implications, depressive symptomatology may render individuals more vulnerable to the development of binge eating but also to binge eating relapse after treatment. Treatment should, therefore, target the relation between binge eating and depression. Weight There seems to be a positive correlation between binge eating severity and the degree of obesity. 17 There is evidence Table 2 The prevalence of binge eating disorder Community samples 2 5% Percentage overweight 50% Percentage of those overweight 5% Gender distribution (f:m) 65:35 similar prevalence of BED among racial groups Participants in weight control programs 16 30% Overeaters Anonymous 70% Prior to bariatric surgery 33 47% Risk factors Fairburn et al 24 compared putative risk factors preceding the onset of BED in 52 women with BED, 104 without an eating disorder, 102 with other psychiatric disorders, and 102 with BN. BED appears to be associated with exposure to risk factors for psychiatric disorders (eg negative self-evaluation, parental depression, adverse childhood experiences including sexual and physical abuse and a range of parental problems, and pregnancy before onset) and with exposure to risk factors for obesity (eg childhood obesity, critical comments by family about shape, weight or eating). However, compared with BN the risk factors for BED are weaker. Even vulnerability to obesity seems to be more pronounced in BN.

Table 3 Lifetime prevalence rates of axis I disorders using structured clinical interviews in obese binge eaters (studies comparing obese binge eaters with obese nonbinge eaters) S53 Authors Any Axis I diagnosis Affective disorder Substance use disorder Anxiety disorder Hudson et al 39 91.%* 21.% 17.% Marcus et al 40 60.%* 32.%* 12.% 20.% de Zwaan et al 15 72.% 55.% 46.% Yanovski et al 22 60.%* 51.%* 12.% 9.%* (major depression) (panic disorder) Brody et al 8 42.% 33.% 8.% Specker et al 21 72.%* 49.%* 28.% 12.% Mussell et al 41 70.%* 50.%* 23.%* 19.% Telch and Stice 42 59.%* 49.%* 15.% 12.% (major depression) (alcohol) (panic disorder) # Non-treatment-seeking sample. *Significantly higher values compared to nonbinge eating control groups. Adapted from Mussell et al 41 and de Zwaan. 43 Treatment Treatment should target eating behavior and associated psychopathology, weight and psychiatric symptomatology. Psychotherapy Cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT) are successful in reducing binge eating frequency in the short-term. 25 Patients are usually treated as outpatients in a group format. Subjects treated with CBT show reductions in the number of episodes of binge eating and abstinence rates from 48 to 98% and 28 to 79%, respectively. In contrast waiting list control groups exhibit reductions of binge eating and abstinence rates ranging from 9 to 22% and 0 to 9%, respectively. 26 However, many subjects resume binge eating after completion of treatment. Fichter et al 27 reported the results of a 6 y follow-up of 68 obese BED patients after intensive inpatient treatment. The disturbed eating behavior as well as general psychopathology improved significantly in obese binge eaters and remained stable during follow-up. At follow-up, the majority showed no major DSM-IV eating disorder, 5.9% still had BED, 7.4% had shifted to BN purging type, 7.4% were classified as EDNOS, and one patient had died. With regard to weight, reduction of binge eating through short-term psychotherapy results in only modest weight loss, if any. However, individuals who stop binge eating during CBT lose more weight than those who do not. BED subjects who stop binge eating during CBT are usually successful in maintaining their weight. This suggests that treating the eating disorder first and then treating the overweight is a logical approach to the management of the overweight binge eater. 28 Antidepressant medication Antidepressants are successful in reducing binge eating frequency in the short term, though less so than psychotherapy. However, withdrawal of drug treatment is frequently followed by immediate relapse. 29 In addition, attrition rates are generally higher for the medication trials (23 54% with a mean attrition rate of 31%) than for the psychotherapy trials of BED (16 35% with a mean attrition rate of 14%). 26 Medication does not add to the effectiveness of CBT in reducing binge eating. 30 However, AD medication may enhance weight loss beyond the effects of CBT. 31 Hudson et al 32,33 state that antidepressants should be considered as an option in all patients with BED and should be strongly considered in those who fail to respond to psychological treatments. The authors propose to start with an SSRI (eg fluvoxamine, fluoxetine) and, if necessary, to conduct sequential trials of antidepressants (eg desipramine, imipramine) to achieve a good result. Self-help Although psychotherapy has been found to be beneficial in reducing binge eating symptoms, this type of intervention is costly in the treatment of eating disorders and may be unnecessarily intensive for some individuals with BED. Self-help may facilitate the dissemination of treatment to a wider population of individuals who need it. There are now first results also in patients with BED using various modes of service delivery, eg group format with videotapes, 34 in-person on a one-to-one basis, 35,36 and even by telephone. 37 The results show a marked reduction in binge eating frequency as well as improvement in secondary outcome measures. Abstinence rates of 40 50% could be achieved after 8 12 weeks of working with a self-help manual or book. 36 This result could be maintained over a 6 month follow-up period. Weight loss treatments The clinical reality is that these patients want and seek treatment for weight loss. In weight reduction treatments

S54 the amount of weight lost does not differ between binge eating obese and nonbinge eating obese. There are studies showing greater attrition and faster weight regain in BED subjects than in non-bed subjects. However, most studies on the use of weight loss programs found that binge eating did not affect weight regain, adherence to the diet, or attrition. There is even evidence for lower attrition rates in binge eating subjects. Weight loss treatments including bariatric surgery do not exacerbate binge eating problems, but are associated with short-term reductions in binge eating. Thus, there is no reason to exclude obese BED patients from weight loss programs. 38 However, studies focusing on weight reduction are always confronted with the well-known problem of obesity being associated with high attrition rates and poor long-term maintenance of weight reduction. It is generally recommended today that in obese binge eaters treatment should first be directed at the disordered eating and associated psychopathology. Interventions directed at the psychopathology associated with BED could reduce the influence of emotional cues on binge eating. An approach to BED with obese patients would be first to bring the eating disorder under control, and only then to consider additional weight reduction methods to address the remaining obesity. References 1 Stunkard AJ, Grace WJ, Wolff HG. The night-eating syndrome: a pattern of food intake among certain obese patients. Am J Med 1955; 19: 78 86. 2 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. DSM-IV. APA: Washington, DC; 1994. 3 Spitzer RL, Devlin M, Walsh BT, Hasin D, Wing R, Marcus M, Stunkard A, Wadden T, Yanovski S, Agras S, Mitchell J, Nonas C. Binge eating disorder, a multisite field trial of the diagnostic criteria. 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