When you hear the term “eating disorder,” what images come to your mind? I am going to guess a female-identifying person; perhaps in her teens or 20s; probably Caucasian; an urbanite; middle- or upper-middle class; anxious; perfectionistic; severely restricting food intake to the point of starvation; exercising intensely; and possibly using purging techniques (e.g., self-induced vomiting) to achieve an unhealthy weight.
You’re not entirely wrong. Many of us were taught this stereotypical image from our social media, TV shows, magazines (does anyone still read actual printed magazines?), and perhaps inadvertently even within our own health professional education programs. And it is true that some eating disorders, especially anorexia nervosa and bulimia nervosa, may present like this. But there is growing recognition that eating disorders disproportionately affect certain populations (e.g., LGBTQ+ youth) and are likely under-reported in others (e.g., male-identifying persons).
And now what if I asked you this: What images come to your mind when you hear “binge eating disorder?” Have you ever met someone with this illness? Have you ever treated someone with binge eating disorder (BED)? Have you ever wondered whether you yourself may be struggling (or may have at one point struggled) with BED?
To give context, binge eating patterns have been described in medical literature as early as the 1950s, though BED became a formal, standalone diagnosis only in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013.
BED is characterized by three key features:
Recurrent episodes of binge eating. These are defined as eating – within 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 a sense of lack of control over eating during these episodes.
Three or more associated features: 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 feeling embarrassed by how much one is eating; and/or feeling disgusted with oneself, depressed or very guilty afterward.
The presence of marked distress regarding binge eating.
The DSM-5 adds additional criteria, spelling out the minimum frequency and duration of symptoms needed for diagnosing BED (average of at least weekly binges for at least three months), as well as specifiers of severity depending on the number of weekly binge episodes. Finally, the DSM-5 stipulates that BED is not associated with any “compensatory behaviours” (e.g., self-induced vomiting) that may be seen in patients living with anorexia or bulimia nervosa.
Epidemiologic research suggests that BED is at least as common – though probably more common – than any other eating disorder, both in adult and adolescent populations (estimated point prevalence of 1.2 per cent and 1.32 per cent, respectively), and often goes under-reported and under-recognized.
So, why does this matter?
Binge eating, emotional eating or full-blown BED meeting DSM-5 criteria often come from a place of deep psychological pain and distress.
Research around adverse childhood experiences (ACEs) has shown a strong association between ACEs and the development of various physical and psychological illnesses in later life – perhaps best demonstrated by the landmark 1998 study by Vincent Fellitti and colleagues. BED – along with other eating disorders – is strongly related to ACEs, with one recent study identifying a dose-response relationship between childhood exposure to household violence, household criminality or growing up with a parent with mental illness, and an increased risk of developing BED. Other studies have linked both childhood food neglect (i.e., restricting a child’s access to food) and food insecurity (i.e., inadequate access to food) to risk of future BED. One study even found a connection between parental experiences of trauma – specifically, physical abuse in mothers and emotional abuse in fathers – and future risk of BED in their children, highlighting a multigenerational effect of trauma on health.
Other stressors include past-year experiences of emotional, physical and sexual abuse (as shown in a study of U.S. college students), being a war veteran or being subjected to weight-based teasing and body dissatisfaction. That the LGBTQ+ community is at greater risk of developing eating disorders has been attributed to various factors including minority stress and gender dysphoria.
The other important piece to highlight is that BED is associated with numerous medical and psychiatric comorbidities.
In the absence of compensatory behaviours (e.g., as would be seen in bulimia nervosa), BED predisposes individuals to weight gain and obesity and, in turn, various negative health outcomes (e.g., cardiovascular disease, Type 2 diabetes mellitus, liver disease, kidney disease and sleep apnea, to name some) and a worse quality of life. On a societal level, obesity is also linked with higher economic costs.
BED is strongly associated with the development of various psychiatric and behavioural disorders.
BED is also strongly associated with the development of various psychiatric and behavioural disorders. In a national study of U.S. adults, 70 per cent of people with BED reported a lifetime comorbid diagnosis of depression; 59 per cent, an anxiety disorder; 68 per cent, a substance use disorder; and 22.9 per cent had attempted suicide (this last statistic from a different study). Similarly frightening numbers have been reported in youth. In a large American sample of teens age 13-18, those who met criteria for BED commonly had comorbid mood disorders (45.3 per cent), anxiety disorders (65.2 per cent), substance use disorders (26.8 per cent) or a behavioural disorder (12.6 per cent meeting criteria for attention-deficit/hyperactivity disorder, 32.8 per cent for oppositional defiant disorder, and 28.5 per cent for conduct disorder). Youth with BED are also at a five times higher risk of a suicide attempt.
So, let’s go back to the question I posed earlier: What images come to your mind when you hear the term, “binge eating disorder?” Do those mental images capture the difficult realities we just reviewed? I know that at least for me, that was not the case until I took a deeper dive into this topic. I invite you to visit Google Images, type in “binge eating disorder,” and see how it is depicted. What I came across was quite disturbing. Rather than empathically capturing lived realities of people with BED, I found image after image after image that trivialized the suffering; dehumanized subjects with cut-off heads and faces; and, I would argue, generated further feelings of shame. And just to drive the point home, try the images here and here. Other than some potentially helpful infographics, I would argue that few images come anywhere close to a more sensitive and thoughtful portrayal.
People living with BED deserve a respectful and compassionate representation in our collective consciousness, along with appropriate, accessible and trauma-informed treatment and support.
Our health-care system is limited in terms of what it offers to people with BED, with or without obesity or other sequelae. But I want to end by leaving you with additional resources to inform and empower you – be it in your capacity as a person struggling with binge eating; a friend or relative of someone who may be living with binge eating; or a health-care provider who interfaces with children, youth and adults suffering from BED.
A few good websites to check out are the National Eating Disorder Information Centre (NEDIC) and the National Eating Disorders Association (NEDA). I also really like the Kelty Mental Health website that also features a self-help guide for people living with BED.
Health-care providers may find it useful to look at some screening tools, including the U.S. Preventive Services Task Force recommendations; this basic screening questionnaire for disordered eating; and some BED-specific screening questionnaires (this one for adults; this one for adolescents). For patients living with BED and obesity, some good communication tools include the 5A model – with a short primer adapted to the primary care setting and more detailed resources on Obesity Canada.
Treatment for BED involves a combination of psychotherapy (with evidence favouring CBT and structured self-help) and pharmacotherapy (with reasonable data on lisdexamfetamine or SSRIs). Given the high prevalence of obesity among people with BED, a referral to a specialized obesity management program may be warranted. And finally, given the high burden of trauma and mental illness among people with BED, special attention should be paid to screening for and addressing these comorbidities.
Lots of food for thought, I hope.
