Though binge eating is not an officially recognized 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 primary-care physicians should routinely screen for binge eating disorder, particularly among overweight and obese patients.
Physicians have a crucial role to play in detection, referral and follow-up of the disorder. 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 certainly see obesity as a problem, 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.
•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 DSM-V, to be published in 2012, will decide the question.
Detection is also hampered by physicians' reluctance to discuss eating disorders, Hudson notes. "It makes the doctor uncomfortable; it makes the patient uncomfortable. 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. "I would start by saying, 'Your BMI indicates that you're overweight. I'd like to discuss ways we can address that,'" advises Kelly Allison, PhD, assistant professor at the University of Pennsylvania School of Medicine and a co-director at the Center for Weight and Eating Disorders. " 'One problem that's often associated with gaining weight is binge eating. Have you had any problems with that?' "
Cynthia Bulik, PhD, director of the eating disorders program at University of North Carolina, says the ideal time to screen for binge eating, and other eating disorders, is when weighing the patient. "It's the perfect time to ask, and it can be done without losing time. While the patient is on the scale, the nurse can ask, 'How do you feel about your weight? Do you have any problems with eating?' "
If the patient says yes, the physician 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?
Not a moral flaw
It's important to ask these questions in a non-judgmental way, being sensitive to the shame and stigma surrounding eating disorders, Hudson emphasizes. "Doctors need to convey that this is not a moral flaw, but a medical problem to be addressed."
Bulik has found that many patients want to talk about their binge eating, and are relieved when a doctor asks about it. "I can't tell you the number of e-mails I've gotten from people who have seen me discussing this. They say, 'Thank you so much for talking about it.’”
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.
Reassurance, referral, treatment goals
If the patient indicates a problem with binge eating, the physician should reassure him or her that it's a treatable condition and that help is available. The patient should be screened 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 Ruth Striegel-Moore, PhD, professor and chair of psychology at Wesleyan University and past president of the Academy for Eating Disorders. The treatment goals for BED are stopping the binges, losing weight, and correcting the self-defeating feelings, thoughts and behaviors that trigger 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 be referred to a therapist specializing in eating disorders; the Academy for Eating Disorders and the Association for Behavioral and Cognitive Therapies offer online searches to find a therapist. In communities without such resources, the physician can create a treatment plan involving a nutritionist, and a therapist with experience in CBT.
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.