Binge Eating Disorder: Audio transcript

1: What is binge eating disorder?

History of the diagnosis

First, let’s talk about the history of the binge eating disorder diagnosis. The introduction of binge eating disorder was in the DSM-IV. It was
introduced as a disorder – provisional diagnosis "in need of further study" – and it was included as a specific example of an eating disorder not
otherwise specified.

Excitingly, in 2013, binge eating disorder was included as a distinct disorder, and it was thought to be a stand-alone, front of the book diagnosis.
This was based on research conducted by myself and other colleagues establishing the clinical significance of binge eating disorder, so that in
2013 the Eating Disorder Work Group for DSM-5 recommended that “binge eating disorder be recognised as a free-standing diagnosis”, and it
was included as such in DSM-5.

What's really important about this is that it paves a way to allow for better recognition of the disorder, and better treatment for the disorder.

The DSM-5 definition

So what are the key diagnostic features of binge eating disorder in DSM-5?

Binge eating disorder is an eating disorder characterised by recurrent and persistent episodes of binge eating, and there are two features of
this. One is eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat in a similar period of
time under similar circumstances. And then the second feature is a sense of lack of control over eating during the episode.

One of the things to stress, in terms of a “discrete period of time”, is that it refers to a limited period, usually less than two hours. In terms of the
lack of sense of control during the eating, this is a feeling that one cannot stop eating or control what or how much one is eating. When
assessing this clinically, I sometimes use the example of a ball rolling down a hill, going faster and faster, to help bring this construct to life for
patients and help them ascertain whether this is something they experience.
One other thing to note is that the context in which eating occurs might affect a clinician's estimation of whether the intake is excessive. For
example, a quantity of food that might be regarded as excessive for a typical meal might well be considered normal during a celebration or
holiday meal. For example, in the United States, our Thanksgiving holiday usually involves the consumption of a very large amount of food –
typically two to three platefuls. And that's not uncommon, so in that particular situation, two platefuls of food may not be considered a
"definitely larger" amount of food.

What does a typical binge look like?

Here's an example of a typical binge eating episode. This was shared with me by a patient.

This is a 23 cm cheesecake; half a litre of low-fat frozen yogurt; and 20 oatmeal cookies – and this was all consumed within a 30-minute period.
And this was a typical size for the binge episodes that this patient was suffering with.

In general, a typical binge contains between 1,000 and 2,000 calories, with about a quarter of binge eating episodes containing more than
2,000 calories, which is close to the average daily caloric needs of many women. Snacks and desserts are particularly common binge foods –
generally foods with a high fat content. Most binges are composed of foods that the person is trying to avoid.

Diagnostic features – DSM-5

So in terms of other key diagnostic features of binge eating disorder, beyond just the large amount of food with a loss of control, the episodes
are associated with three or more of the following:

• 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 being embarrassed by how much one is eating, or
• Feeling disgusted with oneself, depressed, or very guilty after overeating

Often, individuals with binge eating disorder experience all five of these associated features of the binge episodes.

There are also other criteria:

• There must be marked distress regarding binge eating – that means being upset, being very distressed about the binge eating
 • The binge eating occurs once a week for at least three months – so it occurs regularly, and it's frequent over the three months. Often,
individuals have struggled with the disorder for many years before they get recognised, but in order for a diagnosis to be made, it needs
to be for three months
• There is an absence of regular inappropriate compensatory behaviours like we see in bulimia nervosa, such as vomiting, diuretics or
laxative – those would be irregular, because if they were regular, then the individual would be diagnosed with bulimia nervosa

Associated characteristics

There are a number of features or characteristics associated with binge eating disorder that are not associated with the official DSM-5 criteria.

People who struggle with binge eating often try to hide episodes of binge eating from others, because they feel ashamed of their eating
problems – so eating in secret is common.

A binge eating episode is most commonly triggered by negative affect or feelings, including feeling depressed, stressed, hopeless, bored,
lonely, angry, or anxious – experience sampling studies routinely show negative affect as a precursor to binge eating, so it's the most common
problem that occurs prior to binge eating episodes.

Then there are other triggers like restricting food intake, which can lead to mounting physiological and psychological pressure to eat, and once
eating starts, it can be difficult to stop. So what you see is that the type of restrictions are that they try to restrict the amount of food, the type of
food, so certain foods are "off-limits"; they have dietary rules, and breaking this dietary rule can trigger a binge; having unstructured time; feeling
"fat"; having other negative thoughts relating to body weight (which is the number that's on the scale) or shape (which is what they see when
they look in the mirror). All those things can trigger binge eating.

Also, studies have shown that binge eating disorder tends to aggregate in families, independently of BMI. Relatives of those with binge eating
disorder are twice as likely to meet criteria for the disorder. Some of the things that seem to be genetically based are: satiety responsiveness (or
a lack of satiety responsiveness); and also, finding food to be highly reinforcing and rewarding. Clearly, though, more research is needed in that
area.

Differentiating eating disorders

In terms of differentiating eating disorders, when you look at binge eating disorder, it is similar to the other two primary eating disorders included
in DSM-5 – anorexia nervosa and bulimia nervosa – in the sense all three of these eating disorders are typically characterised by:
 • Eating habits that are impairing other health or psychosocial functioning
• Low self-esteem, which is highly influenced by shape and weight, and also
• Poor social adjustment and high rates of psychiatric comorbidity

Even though there is significant overlap in the disordered eating symptoms across each diagnosis, and individuals with any diagnosis may
experience any of these behaviours to some degree, each disorder does have distinct characteristics, as shown in the chart.

So individuals with anorexia nervosa are underweight, and primarily restrict food intake; individuals with bulimia nervosa have binge eating
episodes and purging episodes (compensatory behaviours such as self-induced vomiting, misuse of laxatives, diuretics, or other medications),
fasting, or excessive exercise. Alternatively, the defining feature of binge eating disorder is binge eating episodes.

Differentiating binge eating disorder and obesity

In terms of differentiating between binge eating disorder and obesity, binge eating disorder can affect individuals across all the BMI categories.
However, it is about three times more common among individuals with overweight or obesity, and only 25% of individuals with binge eating
disorder fall within the normal BMI range. Research shows that 42% of individuals with binge eating disorder also have obesity, so you can really
see that there is a linear relationship between body weight and rates of binge eating disorder.

Also, we know that the heavier the individual is, the more likely they are to have obesity. Most individuals with obesity – so a full 58-64% – do not
have recurrent binge eating episodes, so it is important to note that obesity is not considered to be a mental disorder.

So how do you differentiate between binge eating disorder and obesity? Binge eating disorder is clearly associated with obesity, but it is also
clearly a distinct subset of individuals who struggle with overweight.

Compared to weight-matched individuals with obesity without binge eating disorder, those who have binge eating disorder are more likely to
have disturbed eating; they have more eating concerns, shape concerns, weight concerns; more chaotic eating patterns; they also have
poorer mental health and poorer quality of life; and they are also more prone to rapid weight gain and worse response to weight-loss
treatments, whether it's lifestyle treatments or actually surgical treatments.

Who develops binge eating disorder?

So who is it that develops binge eating disorder?

If you look at the rates of binge eating disorder, it's about 3% of the population, so it is the most common eating disorder, whereas bulimia
nervosa is about 1% of the population, and anorexia nervosa about 0.6% of the population. So it's important to note that binge eating disorder is
the most common eating disorder.

Interestingly, in terms of the gender ratio, it's also the most common eating disorder among men – so what you find is that about one out of
every 10 men have anorexia nervosa or bulimia nervosa, but it's much higher in binge eating disorder, because for every three women with
binge eating disorder, there are two men with the disorder. So clearly, you need to assess for binge eating disorder in both men and women.

Let's now look at the lifetime prevalence by race and ethnicity. As you see depicted in the graph, there are comparable rates across racial and
ethnic groups. So, again, it's important to note that binge eating disorder is important to assess across all racial and ethnic groups.

Weight management treatment-seeking samples

It is very common for people with binge eating disorder to seek weight loss advice from medical professionals. In fact, they don't usually present
for help with disordered eating, as they are not aware that they actually have a diagnosable eating disorder.

What you find in weight management programmes is that about three individuals in 10 actually have binge eating disorder – so across
treatment-seeking samples, rates of binge eating disorder increase with higher degrees of overweight, and when they do present, they often
feel like diet programme failures or diet programme drop-outs.

The importance of early symptoms in youth

What about looking at binge eating disorder in younger ages?

What we know is that youths can also show signs of binge eating disorder, and loss of control eating is a major risk factor for the later
development of the full-blown eating disorder. Loss of control eating is defined as when the individual feels like they just can't stop their eating –
however, they may not eat an unambiguously large amount of food. If it's not unusually large, then they are diagnosed with loss of control
eating instead of binge eating.

What we know is that loss of control eating is more common in youth with overweight, and is associated with psychological distress and
disordered eating attitudes – so a very similar pattern to what we see with adults.

A study conducted by Dr Marian Tanofsky found that reports of loss of control eating, ever, at baseline, when children were 10 years old on
average, served as a significant predictor of the development of partial or full binge eating disorder about five years later, even when
accounting for sex, race, and key baseline characteristics like age, disordered eating attitudes, and mood symptoms. Furthermore, youths who
ever had loss of control eating at baseline were ten times more likely to develop binge eating disorder at follow up five years later.

So in summary, these results indicate that children who experience loss of control eating, regardless of amount of food, are more likely to
develop binge eating disorder. Healthcare professionals who detect loss of control eating in young patients should conduct further assessment,
and carefully consider the treatment regimen required for these youths to prevent later development of an eating disorder.

2: Complications and consequences

Complications and consequences of binge eating disorder

So what are the health consequences and complications of binge eating disorder?

Binge eating disorder is associated with obesity-related comorbidities and numerous medical problems including hypertension, asthma,
respiratory illness, cardiovascular disease, chronic pain and diabetes, among others. Studies, including Thornton et al. in 2017, suggest that the
development of some complications such as metabolic syndrome and endocrine and respiratory illnesses could be related to binge eating
disorder and loss of control eating, independently of BMI and obesity, although future research is required to determine whether these
associations are causal, or if they reflect common underlying vulnerabilities. These findings demonstrate the great need for a thorough medical
examination in individuals presenting with binge eating disorder.

What about psychiatric comorbidities? Binge eating disorder is associated with significant levels of psychiatric comorbidity. Four out of five
individuals diagnosed with binge eating disorder have at least one comorbid psychiatric disorder, and almost half have three or more comorbid
psychiatric disorders. The most common psychiatric disorders include mood and anxiety disorders. Among those individuals with binge eating
disorder, you can find lifetime prevalence rates for any mood disorder to be as high as 46-54%, and any anxiety disorder ranging from 37% to
65%. So clearly both anxiety disorders and mood disorders are highly co-occurring with binge eating disorder.

What about the psychosocial consequences? Individuals with binge eating disorder report reduced quality of life in multiple domains, and more
so than in individuals who struggle with overweight or obesity but don't have binge eating disorder. So very high levels of impairment in physical
health, their social life, and work. A multinational survey found that 47% of respondents who met criteria for binge eating disorder had
impairment in role functioning.
3: Screening

Improving screening is critical

So how can healthcare professionals screen patients for binge eating disorder? It's really an important area, as improving screening for binge
eating disorder is critical for not only diagnosing the disorder, but also for providing access to care for those who struggle.

Notably, screening for binge eating disorder is also in alignment with the Provider Competencies for the Prevention and Management of
Obesity put forth in 2017 by a group of leading US health organisations that calls for the provision of evidence-based care for individuals with
obesity, including identifying and responding appropriately to the care for individuals who suffer with binge eating.

However, currently, a minority of individuals with binge eating disorder receive a diagnosis and/or treatment. Less than 3% of respondents to the
National Health and Wellness Survey who met criteria for binge eating disorder within the year had received a diagnosis from a healthcare
professional. Research has also indicated that less than 40% of those who meet criteria for binge eating disorder receive treatment.

Screening for binge eating disorder is critical, as it is a first step toward referring patients to care. Further, many clinicians find that many patients
are very relieved to learn that they have had this eating disorder – and that's what needs treatment – versus continuing with a cycle where they
are trying desperately to modify their weight.

Screening tools

So what are some screening tools? There are several. There's the Binge Eating Disorder Screener (the BEDS-7), a brief screener; the Questionnaire
for Eating and Weight Patterns; and also the Eating Disorder Examination Questionnaire.

One of the nice things about the BEDS-7 is that it's a fast self-report scale, and it's designed for primary care practice, to really help identify
patients who may need further assessment or referral. It assesses the DSM-5 binge eating disorder criteria – however, it is for screening purposes,
and not for diagnosis.

The next one is the Questionnaire for Eating and Weight Patterns. This is also a self-report questionnaire. More extensive, it assesses DSM-5 criteria
as well as dieting and weight history, binge eating frequency, duration, food eaten, time since previous meal, and associated distress.
The next assessment tool is the Eating Disorder Examination Questionnaire. It is also a self-report, and it assesses over the past month, a variety of
restriction questions, overeating and compensatory behaviours as well, and it looks at cognition, such as body image dissatisfaction, and
overvaluation of shape and weight – i.e. how much shape and weight enters into the individual's evaluation of themselves, which we find to be
very high (overvaluation of shape and weight) in individuals who have eating disorders like anorexia nervosa, bulimia nervosa or binge eating
disorder.

Open-ended questions

So I think the assessment of shape and weight concerns; looking at other weight control behaviours to try to understand the types of things that
individuals have been trying to do to lose weight or get to a smaller size; finding out about individuals' perceptions of what usually causes them
to overeat; and also how often and how long they have been having eating of this kind – those are some open-ended questions you can use.

4: Treatment

Referral to specialists

So what about treatment? What treatments are available for binge eating disorder?

There are a number of evidence-based treatments that have emerged, and it is recommended that healthcare professionals refer patients who
show signs of binge eating to mental health professionals specialising in eating disorders for further assessment and psychological treatment.

This is important for a number of reasons:

• Binge eating disorder is a clinically significant eating disorder that warrants treatment in its own right, and research has consistently
demonstrated that specialist psychological treatments for binge eating disorder have positive effects that are reliable – consistently
produced – and durable – they are long-lasting. Further, when abstinence from binge eating is achieved, this is associated with long-
term weight control
• I would also like to note that thoroughly addressing the binge eating provides a good foundation for those in need of weight loss
treatment (when indicated to improve health outcomes). If the binge eating is not addressed, weight loss treatment is typically not
successful
• Successfully treating binge eating disorder may also help with managing other psychiatric comorbidities, in that treating the eating
disorder can result in a reduction of other symptoms, like depression and anxiety
Comparing treatment types: Psychological

In terms of comparing treatments, there are really two main categories of treatment for binge eating disorder. There are psychological
treatments and pharmacological treatments. First, I'd like to review the psychological treatments for binge eating disorder, which include
cognitive behavioural therapy (or CBT), interpersonal psychotherapy (or IPT), behavioural weight loss (or BWL), and CBT guided self-help (or CBT-
GSH).

Research has indicated that psychological treatments for binge eating disorder, particularly CBT and IPT, demonstrate robust long-term
outcomes for binge eating and associated eating disorder psychopathology. So what happens is that there are the short-term changes that are
shown immediately post-treatment, but these changes have been shown to be maintained at one-year, two-year and even five-year follow
ups. These treatments produce favourable outcomes even in those with more severe eating disorder psychopathology and general
psychopathology, and also have preliminary support for treating youths. Notably these specialist treatments have also been found to result in
modest long-term weight loss among individuals who are overweight and cease binge eating, so that in these individuals who stop binge
eating, you can get anywhere from a 5% to 10% weight loss.

Patients tend to find interpersonal psychotherapy (IPT) highly acceptable. In line with this finding, IPT is associated with really strong retention
rates. In contrast, behavioural weight loss (BWL) is associated with high dropout rates, particularly in patients with high negative affect – perhaps
because they don’t perceive this treatment as meeting their needs, as it is not focused on addressing negative affect itself. In contrast, BWL is
focused on improvements in energy-balance behaviours like decreasing caloric intake and increasing energy expenditure in order to achieve
weight loss – so a very different focus from the focus of CBT and IPT, which are really focused on targeting the eating disorder and the
maintaining factors associated with the eating disorder.

Guided self-help (GSH) is based on CBT, and it has also demonstrated success for binge eating disorder. GSH involves the patient working
through a standardised protocol for a psychological treatment, which is often written down in book form, or is available through some other
media. The patient primarily works through the protocol independently, but also has the guidance of a therapist or coach. One of the nice
things is that this coach can provide a supportive or facilitative role, but it involves minimal time relative to standard treatment approaches.
Given this, the amount of contact in GSH is minimised relative to standard treatment approaches like full CBT.

CBT-GSH has been shown to be acceptable to patients, particularly those without associated comorbid problems; it's highly cost-effective; and
can be implemented successfully by a wide variety of individuals (e.g. nurses or non-specialists with no formal clinical qualifications). For these
reasons, as of 2017, the United Kingdom National Institute for Health and Care Excellence (NICE) guidelines for eating disorders recommended
CBT-GSH as a first-line treatment for binge eating disorder, meaning that it could be a first step in a guided self-help.
With CBT-GSH, it's interesting to see that patients who respond with an early response have long-term improvements, whereas those who don't
have an early response are likely better suited for a full course of treatment (e.g. of IPT or CBT). One of the nice things about IPT is that response
rate doesn't impact outcomes – so even if a person responds fast or slowly, there's no differential outcome over time. What it does suggest is
that it could well be a reasonable first step – CBT-GSH – for individuals suffering with binge eating disorder.

There has clearly been the development of a number of evidence-based psychological approaches for binge eating disorder. It represents an
enormous advance in the field – the research really has amassed over the last 20 years – however, further research is required to address non-
responders, as well as to close the treatment gap by making this treatment more widely accessible and available.

Comparing treatment types: Pharmacological

Regarding medications, three classes of medication have produced modest rates of reduction in and cessation from binge eating disorder in
the short term (about 11 to 16 weeks) in placebo-controlled trials.

Lisdexamfetamine is the first medication approved by the US Food and Drug Administration to treat moderate to severe binge eating disorder in
adults. It has also been approved as an indication for moderate to severe binge eating disorder in Australia. This is a stimulant that is also used to
treat ADHD. Notably, Vyvanse (lisdexamfetamine) has also demonstrated efficacy in reducing binge eating over a longer term period (six
months).

There are also anti-depressants, particularly SSRIs, that have been studied, and anticonvulsants, like topiramate.

Vyvanse and topiramate (but not SSRIs) also produce clinically meaningful reductions in body weight, particularly in short-term studies.

Other drugs including atomoxetine, dasotraline and anti-addiction drugs show promising initial results in reducing binge eating symptoms, but
have not been FDA approved.

Now let's look at some of the considerations in using pharmacotherapy for binge eating disorder. Probably one of the biggest concerns is that
there is a lack of information on durability of response – so if the medication is withdrawn, in many studies, a relapse occurs, so there needs to be
continuation. The nice thing is, for Vyvanse there are six-month outcomes, but in general, there has only been data to the 11-12 week mark –
and given that eating disorders are chronic and debilitating, we really need to focus on treatments where there is a durability of response.

Another potential consideration with pharmacological studies is that they tend to enrol very restricted samples that may not translate to routine
clinical practice. For instance, individuals with major depressive disorders or who have cardiovascular disease concerns are excluded, so those
are some of the potential limitations.
In terms of side effects, topiramate never received approval from the FDA for the treatment of binge eating disorder due to its negative side
effects – there were upper respiratory tract infections, taste problems, difficulty with concentration and attention, and other memory difficulties
– and this was probably the biggest issue limiting its clinical utility. In terms of side effects, Vyvanse has been shown to lead to headache,
insomnia, and potentially gastrointestinal upset as well as probably the biggest concern, the potential for abuse and dependence – so you
want to make sure that Vyvanse is not prescribed to individuals who have an abuse or dependence history.

More research is needed to know how well these medicines work to treat binge eating disorder in the long term, but the good news is that there
has been an enormous amount of work that has been completed on treatment for binge eating disorder; recovery is possible with effective
treatment. In particular, we know that specialist treatments like IPT and CBT cure well over half of individuals with binge eating disorder, and
maintain this durability of response over the long term. And also, the majority of the remainder respond with a reduction in binge eating
episodes as well.

Conclusions

Summary

In summary, what I would really like to stress is that:

• Binge eating disorder is an eating disorder that is important to recognise

• It is characterised by episodes of loss of control eating
• It is the most common eating disorder
• It affects people across all categories of race and ethnicity, gender and weight status
• It is associated with significant health complications, comorbid psychiatric disorders and impaired psychosocial functioning – so, high
levels of impairment in individuals who struggle with binge eating disorder
• Health care professionals can use screening tools such as the BEDS-7 to assess patients – it's a very brief screening tool, and
• It is important, once it is recognised that individuals have patterns of recurrent binge eating – eating large amounts of food with loss of
control – to refer those individuals to eating disorder specialists for treatment.