CASE
A 32-year old obese white female visited her primary care provider because she wanted “to lose weight.” She said that she had tried “everything on the market” with minimal and temporary success but that she always gained back any weight she had lost. When questioned, she admitted to trying fad diets, meal replacements, and OTC diet pills. The patient's medical history included “mild” depression, but she was otherwise healthy with no significant medical conditions. She denied any further symptoms, and her review of systems was noncontributory. Menses were regular with normal flow, although she described the bleeding as being “a bit heavier” some months. Medications included a serotonin reuptake inhibitor and an oral contraceptive. The patient also reported that her mother took “a pill for her mood,” but the patient was not sure of the specific diagnosis. The family history was positive for hypertension (both parents), type 2 diabetes, and obesity (mother and sister). The patient said she was happily married and worked full-time in banking and finance, which she described as “quite stressful” lately. She exercised regularly, with a walking regimen (30 minutes, 5 days per week) and light weight lifting (2-3 times per week).
The physical examination revealed an alert, well-developed, obese female with a body mass index (BMI) of 27 kg/m2. BP was elevated at 142/86 mm Hg. The remainder of the physical examination, including the thyroid examination, was unremarkable. The patient interacted well during the encounter but became tearful when discussing her failed attempts at weight loss. Laboratory test results, including those for thyroidstimulating hormone and fasting plasma glucose, were within normal limits. Triglycerides were elevated at 311 mg/dL; LDL cholesterol was only mildly elevated, and the HDL cholesterol was 70 mg/dL. A CBC was ordered because of the reported occasional heavy menses, but those results were also within normal limits.
The patient was referred for dietary guidance to a registered dietitian, who discovered in the course of the evaluation that the patient was secretly eating large quantities of food late at night after her family was asleep. She reported that she had engaged in this behavior at least twice weekly over the past year. She denied using any compensatory mechanisms such as purging or laxative use; she also admitted to having feelings of “worthlessness” and “self-loathing” after these binging episodes. The dietitian provided a thorough nutritional consultation and sent the patient back to her primary care clinician, who then referred the patient to a mental health provider to address her dysfunctional eating habits and history of depression. After a comprehensive evaluation, binge eating disorder (BED) was diagnosed. The patient received a multilevel treatment approach that included medical follow-up to address her hypertension, hyperlipidemia, and general health; and pharmacotherapy, psychotherapy (individual and group), and continued nutritional therapy for the BED.
DISCUSSION
BED differs from anorexia nervosa and bulimia nervosa, which are better-known eating disorders, and has different diagnostic criteria. An important distinction is that BED is the eating disorder most commonly found among obese patients. With the increased prevalence of obesity in the general population, clinicians should thus be able to screen patients properly for BED. Once the diagnosis has been made, appropriate management and follow-up can help many patients better control their disordered eating behaviors.
Diagnostic criteria BED falls into the category of Eating Disorders Not Otherwise Specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.1 By definition, BED involves recurrent episodes of binge eating without regular inappropriate compensatory behaviors such as purging, laxative use, or excessive exercise.2 The diagnostic criteria also require that the episodes of binge eating occur at least 2 days per week for a 6-month period. Finally, at least three of the following behaviors must occur during the binge episodes:
• The patient eats notably faster than usual.
• The patient eats to the point of feeling discomfort.
• Binging occurs when the patient is not physically hungry.
• The patient eats alone or in secret because of embarrassment about the amount of food consumed.
• Binging causes feelings of disgust, depression, or guilt afterward.2
Other criteria include significant distress during and/or after binging and that the behaviors exhibited do not meet diagnostic criteria for either anorexia nervosa or bulimia nervosa.1
Epidemiology and etiology BED has been most commonly identified in obese females of varying age; the epidemiology appears to be changing, however, with recent estimates indicating that 40% of BED cases now occur in boys and young men.3 An estimated 25% to 50% of patients undergoing bariatric surgery meet the diagnostic criteria for BED.2 The cause of BED remains unclear, but comorbid depressive and anxiety disorders are common, as is a family history of eating disorders. BED, like other types of eating disorders, seems to be the result of a combination of biological, psychological, genetic, environmental, and social factors.