Stephanie is a 33 year old woman with obesity who follows with you for primary care. Her weight has steadily increased from 160 lbs to 200 lbs over the last 5 years. You and Stephanie have discussed her weight gain in the past and worked together to set goals for lifestyle changes. She set a goal to walk her dog every day for 1 hour (two 30-minute walks) and has been doing this for a year. She cut most sweets out of her diet and shifted to cooking meals at home. She continually expresses an interest in losing weight, but the positive lifestyle changes have had no impact on her weight gain.
You take a break from goal setting this visit and ask her more about her eating habits, with a specific focus on evaluating for binge eating disorder.
What is binge eating disorder?
Binge eating disorder (BED) is an eating disorder characterized by recurrent binge-eating episodes (at least weekly for several months). Binge eating episodes are characterized by:
1) eating larger amounts of food than is typical for most people in a limited period of time
2) a loss of control over eating
3) significant distress associated with binge eating, including feelings of guilt, shame or disgust
Unlike patients with bulimia nervosa, patients with BED do not use compensatory behaviors like purging or laxative use to prevent weight gain from binge eating episodes.
BED is the most prevalent eating disorder in the US and worldwide, with a lifetime prevalence of 2-3% in the general population (Crone 2023). BED is strongly associated with obesity and is more prevalent in women than men. Up to 30% of people with obesity who are seeking weight loss treatments have co-occurring BED (Giel 2022). 80% of patients with BED have at least 1 comorbid psychiatric disorder (Kornstein 2017). Patients with BED are more likely to binge eat during stressful periods. Obese patients with BED have more shape and weight concerns than obese patients without BED (Montano 2016).
When working with patients with obesity, clinicians often focus on the physical problems related to weight gain and miss the diagnosis of binge eating disorder (Kornstein 2017). Additionally, weight bias among providers impedes the diagnosis and treatment of BED; patients in larger bodies are half as likely as those at a normal weight or underweight to be diagnosed with an eating disorder (Nagata 2018).
Who should be screened for binge eating disorder?
No clear guidelines exist on who should be screened for BED. A 2022 report from the USPSTF could not identify eligible studies to answer the question: “Does screening for eating disorders in adolescents and adults improve health outcomes, including for specific subgroups of interest?” (Feltner 2022). Expert guidance recommends screening in patients with risk factors for BED, including obesity, weight gain or weight cycling, psychiatric or substance use disorders, or a family history of disordered eating (Kornstein 2016).
How do you screen for binge eating disorder?
The most widely used screening tool for eating disorders (SCOFF questionnaire) was developed in 1999 before BED was defined (Kutz 2019). A 2019 meta-analysis and systematic review determined that the SCOFF has robust evidence as a screening tool in patients who are at risk for anorexia nervosa or bulimia nervosa; however, the authors cautioned against its use as a screening tool for BED (Kutz 2019).
The interview questions below can help clinicians learn more about their patients’ eating behaviors.
| Screening questions for BED: How do you feel about your eating patterns? Do you ever eat an unusually large amount of food in a short period of time? – Can you tell me more about that? – Can you give an example of what you ate (type of food and how much)? A patient may consider eating 2 slices of pizza to be a “binge,” while we might consider this to be a normal meal. Eating an entire large pizza, on the other hand, would be more food than is typical for most people.Have you ever felt out of control when eating? If the patient describes a binge eating episode, continue with: How many times a day (or a week) do you binge currently? How do you feel during the binge? How do you feel after the binge? After binging, have you ever done anything to get rid of the food, such as making yourself throw up or using laxatives? Does anything happen before a binge that might be related to it? What time of day do you typically binge? Past History: Have you ever weighed much less than people thought you should weigh? (screening for anorexia) When was the last time you vomited, used laxatives, or over exercised after binging? (screening for bulimia) How much time do you spend thinking about food/weight? Have you ever been diagnosed with an eating disorder? Does anyone in your family have an eating disorder? What is it like to talk with me about this? |
Returning to Stephanie
You start by asking Stephanie broad questions about her relationship with food, using the screening questions above as a guide. Stephanie acknowledges that around 3 times per week, for the last 4 years, she has engaged in binge eating behavior, which she describes as eating 5 packages of macaroni and cheese in 20 minutes, to the point of feeling sick to her stomach. She feels out of control during the binge. Immediately after, she feels disgusted with herself and cancels any plans she has for the rest of the day. In general, she feels an overarching sense of shame and guilt around these episodes; she has not spoken about these events to anyone. When she is feeling anxious about work, she has more frequent binge eating episodes. She has never made herself vomit or used laxatives after binging. She has never restricted her eating or weighed less than expected for her age (she notes always being the tallest and biggest girl in her class). No one in her family has an eating disorder. She thinks about her size a lot, yo-yoing between embracing her shape and size and feeling ashamed by how she looks. She is grateful to you for the opportunity to name this painful experience and is eager to engage in treatment.
You focus the conversation on the DSM-5 criteria for BED and diagnose Stephanie with binge eating disorder. You elicit Stephanie’s thoughts on next steps. Rather than focus on medications for obesity or weight loss, you offer psychological and pharmacologic options for the treatment of BED.
Look for a future PsychSnap focused on treatments for binge eating disorder.
Key Points
1) A narrow focus on goal setting or weight loss medications for patients with obesity may miss an underlying binge eating disorder that requires specific treatment.
2) Consider screening patients who have a history of obesity, psychiatric or substance use disorders, or a family history of disordered eating for binge eating disorder.
3) The shame associated with binge eating may prevent patients from bringing up the topic with health care providers. A non-judgmental clinical interview, asked in the context of a supportive therapeutic relationship, can lead to the diagnosis of binge eating disorder.
References:
Crone, C., Fochtmann, L. J., Attia, E., Boland, R., Escobar, J., Fornari, V., Golden, N., Guarda, A., Jackson-Triche, M., Manzo, L., Mascolo, M., Pierce, K., Riddle, M., Seritan, A., Uniacke, B., Zucker, N., Yager, J., Craig, T. J., Hong, S.-H., & Medicus, J. (2023). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders. American Journal of Psychiatry, 180(2), 167–171. https://doi.org/10.1176/appi.ajp.23180001
Feltner, C., Peat, C., Reddy, S., Riley, S., Berkman, N., Middleton, J. C., Balio, C., Coker-Schwimmer, M., & Jonas, D. E. (2022). Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 327(11), 1068. https://doi.org/10.1001/jama.2022.1807
Giel, K. E., Bulik, C. M., Fernandez-Aranda, F., Hay, P., Keski-Rahkonen, A., Schag, K., Schmidt, U., & Zipfel, S. (2022). Binge eating disorder. Nature Reviews Disease Primers, 8(1), 16. https://doi.org/10.1038/s41572-022-00344-y
Kornstein, S. G. (2017). Epidemiology and Recognition of Binge-Eating Disorder in Psychiatry and Primary Care. The Journal of Clinical Psychiatry, 78(Suppl 1), 3–8. https://doi.org/10.4088/JCP.sh16003su1c.01
Kornstein, S. G., Kunovac, J. L., Herman, B. K., & Culpepper, L. (2016). Recognizing Binge-Eating Disorder in the Clinical Setting: A Review of the Literature. The Primary Care Companion For CNS Disorders. https://doi.org/10.4088/PCC.15r01905
Kutz, A. M., Marsh, A. G., Gunderson, C. G., Maguen, S., & Masheb, R. M. (2020). Eating Disorder Screening: A Systematic Review and Meta-analysis of Diagnostic Test Characteristics of the SCOFF. Journal of General Internal Medicine, 35(3), 885–893. https://doi.org/10.1007/s11606-019-05478-6
Montano, C. B., Rasgon, N. L., & Herman, B. K. (2016). Diagnosing binge eating disorder in a primary care setting. Postgraduate Medicine, 128(1), 115–123. https://doi.org/10.1080/00325481.2016.1115330
Nagata, J. M., Garber, A. K., Tabler, J. L., Murray, S. B., & Bibbins-Domingo, K. (2018). Prevalence and Correlates of Disordered Eating Behaviors Among Young Adults with Overweight or Obesity. Journal of General Internal Medicine, 33(8), 1337–1343. https://doi.org/10.1007/s11606-018-4465-z
Send a Comment