Binge Eating Disorder: An Introduction to the Most Common Eating Disorder

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Despite being the most common eating disorder, affecting about 2 percent to 4 percent of the U.S. population, binge eating disorder is underdiagnosed and undertreated. Registered dietitian nutritionists play an essential role in detecting BED and, following a diagnosis from a physician, assisting with treatment. Nutrition counseling for binge eating disorder can improve a patient’s quality of life and overall health.

Binge eating disorder is characterized by recurrent episodes of eating large quantities of food, often feeling a loss of control around these foods, followed by guilt and shame. These binges tend to include what the person believes are “forbidden” foods, commonly considered “unhealthy” or “junk” food. Often misunderstood by health care professionals, binge eating disorder is not simply overeating or a lack of willpower. About 30 percent of people who visit RDNs for weight management show signs of BED, but many are unaware they have a clinical eating disorder.

In 2013, binge eating disorder was added as an independent classification to the Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. (also known as the DSM-V). This inclusion was an important step in validating BED as its own diagnosis; formerly it was included under Eating Disorders Not Otherwise Specified.

Binge eating disorder is 3 times more common than anorexia and bulimia combined, yet is not often seen as the “typical presentation” of an eating disorder. Rather, eating disorders frequently are portrayed as affecting girls who are young, thin and white. Eating disorders affect people of all shapes, sizes, races, genders, ages, socioeconomic statuses, sexual orientations and physical abilities.

A history of dieting or irregular eating patterns may contribute to the development of binge eating disorder. Many factors can increase a person’s risk, including genetics, a history of depression, anxiety, mood disorders, trauma, addiction or abuse. Research has found increased rates of binge eating disorder among ethnic minorities and those who are food-insecure.

Conditions such as anxiety, depression, trauma, high cholesterol, hypertension and diabetes can cause complications if they are not addressed by an interdisciplinary team during treatment for BED.

While body size is not directly related to binge eating disorder, weight cycling is common with BED. Therefore, a health care provider cannot assume patients with a higher body weight have BED and those who weigh less do not. Weight stigma, or discrimination and stereotyping based on a person’s weight, is associated with adverse physiological and psychological outcomes. Emotional eating, yo-yo dieting or compulsive overeating are terms commonly used by clients or patients to describe binge eating, but they may not meet the full criteria for binge eating disorder diagnosis.

Key Diagnostic Criteria for Binge Eating Disorder

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
    1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
    2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
  2. The binge-eating episodes are associated with three (or more) of the following:
    1. Eating much more rapidly than normal.
    2. Eating until feeling uncomfortably full.
    3. Eating large amounts of food when not feeling physically hungry.
    4. Eating alone because of feeling embarrassed by how much one is eating.
    5. Feeling disgusted with oneself, depressed, or very guilty afterward.
  3. Marked distress regarding binge eating is present.
  4. The binge eating occurs, on average, at least once a week for 3 months.
  5. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Source: American Psychiatric Association. Feeding and Eating Disorders: DSM-5? Selections. Arlington, VA: American Psychiatric Publishing; 2016.

The role of the RDN in treating BED
RDNs are responsible for determining their level of competency when working with clients or patients who have disordered eating or eating disorders. The Standards of Professional Performance can help RDNs evaluate where they might need more education and training to gain greater competency. RDNs working with binge eating disorder need to understand professional boundaries, psychodynamics of eating disorders, and nutrition intervention and rehabilitation requirements for the life stage of the patient. As with all specialty areas, advanced training in eating disorders is required, so a referral to a specialist is recommended if an RDN lacks competency in this area.

RDNs who counsel people with binge eating disorder should be part of a multidisciplinary team that may include a behavioral health therapist, medical doctor and psychiatrist. BED treatment may include cognitive behavioral therapy, dialectical behavioral therapy, acceptance and commitment therapy, and mindfulness.

“Because the experience of binge eating can feel shameful to the patient, the nutrition assessment should be curious and exploratory, without judgment,” says Jessica Setnick, MS, RDN, CEDRD-S, author of the Academy of Nutrition and Dietetics Pocket Guide to Eating Disorders, 2nd Ed. (2016) and creator of Eating Disorders Boot Camp. “RDNs can ask a patient ‘How is your eating different when you’re alone?’ This gets to the heart of the secrecy and shame in a curious and nonjudgmental way.” The patient’s answer to this question often will lead the RDN to a better understanding about whether to screen further for disordered eating behaviors.

When seeing a client or patient with binge eating disorder, an RDN may use motivational interviewing skills to determine appropriate goals over the course of highly individualized treatment. RDNs may analyze the person’s nutrient consumption, meal and snack timing and behaviors around food and ask about weight loss attempts and weight cycling. Medical nutrition therapy recommendations may include eating an appropriate amount of calories each day, eating a variety of food groups and balancing macronutrients at meals and snacks. Timing of meals and snacks should be flexible, keeping consistent nourishment in mind.

Once a client or patient has an established eating routine, the RDN can focus on education: how to recognize hunger and fullness cues, and choose a variety of satisfying foods that meet the person’s preferences. Often this means strategically introducing “binge foods” into a patient’s meal plan, with the goal of normalizing all food. “Permission” to eat these foods may help overcome the restrictive mindset that led to binge episodes. RDNs also can help clients and patients who have urges to binge eat by reinforcing appropriate mindfulness tools and introducing coping skills for stressful emotions. These are some of the foundational principles of intuitive eating, created by Evelyn Tribole, MS, RDN, CEDRD-S, and Elyse Resch, MS, RDN, CEDRD, FIAEDP, FADA, FAND, which has been shown to increase health-promoting behaviors and better psychological health.

There is no clinical definition of binge eating disorder recovery; every individual is different. As with much of our clinical work, the RDN’s goal is to support clients and patients in their journey toward understanding their behavior, provide an environment in which they can express their thoughts and feelings, and help them adopt behavior changes that lead to their best quality of life.

References

American Psychiatric Association. Feeding and Eating Disorders: DSM-5? Selections. Arlington, VA: American Psychiatric Publishing; 2016.
Becker CB, Middlemass K, Taylor B, Johnson C, Gomez F. Food insecurity and eating disorder pathology. Int J Eat Disord. 2017;50(9):1031-1040.
Binge Eating Disorder. National Eating Disorders Association website. Accessed November 27, 2018.
Marques L, Alegria M, Becker AE, et al. Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. Int J Eat Disord. 2011;44(5):412-420.
National Task Force on the Prevention and Treatment of Obesity. Dieting and the development of eating disorders in overweight and obese adults. Arch Intern Med. 2000;160(17):2581-2589. Accessed November 27, 2018.
Ozier AD, Henry BW, American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-1241.
Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714-723.
Van Dyke N, Drinkwater EJ. Relationships between intuitive eating and health indicators: literature review. Public Health Nutr. 2014;17(8):1757-1766.
Wildes JE, Marcus MD. Diagnosis, assessment, and treatment planning for binge-eating disorder and eating disorder not other specified. In: Grilo CM, Mitchell JE, eds. The Treatment of Eating Disorders: A Clinical Handbook. New York, NY: The Guilford Press; 2010:45.
Wu YK, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018;74(5):1030-1042.

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Jennifer McGurk
Jennifer McGurk, RDN, CDN, CDE, CEDRD, is a New York-based registered dietitian nutritionist whose mission is to help people heal from diets and find peace and balance with their food choices. She is the owner of Eat With Knowledge and, as a Certified Eating Disorders Registered Dietitian, Jennifer combines her expertise in medical nutrition therapy, psychology and physiology to help clients understand their eating behaviors and gain the insight needed to make positive changes for their health.