Clinical evaluation A multilevel approach is required to assess patients with suspected BED. A thorough medical history is essential to an appropriate differential diagnosis and is an important first step in the management of these patients. The dietary history should include weight fluctuations, dietary patterns (especially attempted weight loss measures), and exercise habits. Sensitive questioning can elicit information regarding inappropriate compensatory behaviors (purging, laxative use, food restriction, and excessive exercise), which may help to rule out anorexia or bulimia—although it is important to remember that patients with BED may occasionally adopt these behaviors. The clinician should consider diabetes, thyroid dysfunction, hypertension, dyslipidemia, and heart disease, as these conditions are more commonly found in the obese population. Instruments used to determine binging habits and their severity, such as the Binge Eating Scale and the Eating Attitudes Test, have been utilized successfully in various clinical settings.4,5
The physical examination should include height, weight, BMI, and vital signs. The appropriateness of weight for the patient's height and gender should also be evaluated. Additionally, a thorough head-to-toe evaluation must be performed to look for signs associated with other eating disorders, such as dental erosion, lanugo, amenorrhea, and Russell's sign. Most patients with BED will present only with obesity (ranging from mild to severe), along with disease states that may accompany obesity such as dyslipidemia, hypertension, or diabetes. More commonly reported associated symptoms include esophageal reflux, bloating, and fatigue.6 Laboratory evaluation and other diagnostic testing should be targeted to risk factors and may include measures of fasting glucose and lipids, thyroid studies, an ECG, and an electrolytes panel (if purging or laxative use is a concern). Additional tests may be ordered at the clinician's discretion.
Psychiatric and nutritional evaluation For several reasons, patients suspected of having BED should be evaluated by a mental health professional.6,7 Comorbid psychiatric conditions such as depressive and anxiety disorders are more common in patients with eating disorders, as is substance abuse;3 and cognitive behavior therapy (CBT)8 and interpersonal psychotherapy (IPT)2,6 have been found to be helpful treatments. Primary care clinicians can perform the initial mental health screening and refer patients for further assessment as appropriate. Additionally, a thorough nutritional assessment should be completed by a professional trained in nutritional health who can provide ongoing nutritional counseling to the patient with BED. Ideally, the patient should be referred to a psychiatric team specializing in the treatment of eating disorders.
Treatment General medical care and close follow-up, IPT and CBT, group psychotherapy, nutritional counseling, and in some cases pharmacotherapy are all part of the multifaceted treatment of BED. The condition has a high rate of relapse, which may account for the varying degrees of treatment success seen in studies thus far.2 Data are still very limited, however.2 Most medications that have demonstrated some efficacy for patients with BED have not been FDA approved for this use.2 Serotonin reuptake inhibitors such as fluoxetine (Prozac, Sarafem, generics)3 and sertraline (Zoloft, generics)9 have been utilized to treat binging behavior and concomitant depressive disorders. Drugs such as topiramate (Topamax, generics)10 and sibutramine (Meridia)11 have also demonstrated an ability to reduce binging episodes, body weight, and BMI. Although demonstrated efficacy is important, initial medications should be selected both to treat comorbid conditions and to reduce the frequency of binging with minimal adverse effects. Finally, comorbid disease states such as hypertension, hyperlipidemia, and diabetes, should be addressed as soon as possible and while the BED is being treated, in the interests of the patient's overall health.
CONCLUSION
Many experts think that BED has gone underdiagnosed for quite some time and that the condition is difficult for primary care providers to recognize. If patients are offered a thorough medical and psychiatric evaluation and nutritional assessment, BED will be easier for PAs to identify and manage. Appropriate psychiatric referrals and use of a registered dietitian should be considered early on to give patients the comprehensive care they need. Such care is the best way to achieve long periods of remission and optimal outcome. JAAPA
Louise Lee is an assistant professor of PA studies at the Massachusetts College of Pharmacy and Health Sciences-Manchester in Manchester, New Hampshire. She has indicated no relationships to disclose relating to the content of this article.
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