Binge-Eating, Disordered and Not

We all binge on food we love from time to time. But there is binging and then there is binge-eating disorder (BED), an abnormal pattern of eating in which a person eats not only more rapidly than usual, but more than usual — and without being able to stop.

An analysis of studies on binge-eating disorder published recently found that binge-eating is more common than had previously been thought and helps distinguish binge-eating from overeating.

Binge-Eating Disorder (BED) was first included in the Diagnostic and Statistical Manual of Mental Disorders, DSM 5, in 2013.

Not everyone who binge-eats has a true binge-eating disorder. The diagnosis requires specific features, as well as the presence of physical, psychological or social consequences to the behavior. Its symptoms include:

Eating a large amount of food in a short period of time — say two hours — that is far larger than what most people would eat in a similar period of time under similar circumstances.

A sense of lack of control over eating during the episode; feeling that one cannot stop eating or control what or how much one is eating.

Not everyone who binge-eats has a true binge-eating disorder. The diagnosis requires specific features.

Eating much more rapidly than normal.

Eating until feeling uncomfortably full.

Eating large amounts of food when not feeling physically hungry.

Eating alone because of feeling embarrassed by how much one is eating.

Feeling disgusted with oneself, depressed or very guilty afterward.

The criteria for binge-eating disorder also require that:

The binge-eating occurs, on average, at least once a week for three months.

The binge-eating is not associated with compensatory behavior (such as purging/or starving) as in bulimia nervosa.

Binge-eating is the most common eating disorder, with about 3% of adults in the U.S. experiencing BED at some point in their lives. It is related to depression and anxiety. Individuals with BED are prone to diabetes, metabolic syndrome, chronic pain and obesity.

As mentioned above, binge-eating disorder is different from two other eating disorders, anorexia nervosa and bulimia, in which a person also binge-eats but then purges themselves — through vomiting or the use of diuretics — of the excess food they ate.

People who binge-eat are often overweight. Patients who are obese and hoping to undergo bariatric surgery may not be acceptable surgical candidates or have poorer outcomes post operatively because their BED behaviors may impair their ability to comply with post surgical eating guidelines.

The University of North Carolina, Chapel Hill undertook an analysis of 34 studies that focused on the effectiveness of currently available therapies to see which treatments for binge-eating seemed to work best.

Because it has both behavioral and emotional elements, treatment of binge-eating disorders has included cognitive behavioral therapy and medications used individually or in combination.

People who binge-eat are often overweight. Those who are obese and hoping to undergo bariatric surgery may not be acceptable surgical candidates.

There is currently only one drug specifically approved by the FDA for treatment of BED — lisdexamfetamine (brand name: Vyvanse®). Others medications are used off-label, however, to treat the disorder or to ease related symptoms. The UNC meta-analysis included reviews of cognitive behavior therapy, lisdexamfetamine, second generation antipsychotics (fluvoxamine) and anticonvulsants (topiramate).

Most of the studies reviewed in the analysis reflected treatments provided in the U.S. The patients in the various studies were primarily overweight or obese white women, 36 to 47 years old.

The researchers found that there are several effective treatments available for binge-eating disorder and that, in many cases, troubling side effects of treatments are minimal to moderate.

Cognitive behavioral therapy (CBT), when led by a therapist, helped reduce binge-eating and improved eating-related emotional issues such as susceptibility to hunger, developing better mental control over eating habits, and helping patients deal with overall concerns about their eating, shape and weight.

Lisdexamfetamine was found to be helpful in reducing BED as well as eating-related obsessions and compulsions. It also resulted in greater weight loss than placebo. Some studies showed it also caused a reduced triglyceride level when compared to placebo. Its side effects included insomnia, other types of sleep disturbances, gastrointestinal upset and general sympathetic nervous system arousal which can include increasing heart rate and blood pressure.

It also has the strong potential to decrease appetite and this side effect must be carefully monitored, as it can be harmful to patients in treatment who may cycle between binging and food restriction.

Second-generation antipsychotics, such as fluvoxamine, were also helpful in reducing binge-eating and in improving the depression associated with BED. Side effects included sympathetic nervous system arousal, GI upset and sleep disturbance.

In some studies, topiramate, an anticonvulsant, decreased eating related obsessions and compulsions. When compared to placebo, topiramate resulted in greater weight reduction. Its side effects included sympathetic nervous system arousal.

Many patients have limited access to providers trained in binge-eating-focused cognitive-behavioral therapy. This is concerning because self-help CBT (without the in-person guidance of a trained therapist) does not appear to be definitively effective in treatment of this condition.

The researchers conclude that therapist-led cognitive behavioral therapy, lisdexamfetamine and second-generation antipsychotics are effective treatments that reduce the frequency of binge-eating and help patients abstain from binge-eating.

The statistical evidence was not as strong for topiramate and other forms of cognitive behavioral therapy (such as partially therapist-led or structured self-help). The incidence of side effects was about doubled for patients treated with lisdexamfetamine, topiramate or fluvoxamine compared to those receiving placebo, and episodes of sympathetic nervous system arousal occurred four times more frequently with lisdexamfetamine.

Clinical guidelines encourage a combination of CBT and medication, but the authors note that many patients have limited access to providers trained in binge-eating-focused cognitive-behavioral therapy. This is concerning because self-help CBT (without the in-person guidance of a trained therapist) does not appear to be definitively effective in the treatment of this condition.

People who believe they or a family member have binge-eating disorder should undergo a comprehensive evaluation by both a medical and a psychiatric provider. Other physical and emotional causes of abnormal eating patterns should be investigated and addressed. These might include depression, anxiety or endocrine problems. Appropriate evaluation of physical (diabetes, metabolic syndrome, hypertension, etc.) and emotional consequences (anxiety, depression) of poor eating and overweight should be identified and treated. Treatment should be individualized and closely monitored to insure a sustained remission.

The meta-analysis is published in Annals of Internal Medicine. Its results may be limited by the homogeneous nature of the subjects in the various studies — overweight white women, aged 20 to 40. Additional studies will be needed to determine the most effective treatments for other populations with BED.