The information in this article originally appeared in an Equip Academy presentation. Watch the presentation here, and register for future Equip Academy events to learn about other eating disorder-related topics and earn free CE credits.

Binge eating disorder (BED) is the most common eating disorder in the United States, and yet there’s a lack of awareness about this condition, both in the general population and the medical community. Binge eating disorder is often misunderstood or misdiagnosed, and many people with BED are given medical guidance that, while well-intentioned, can actually exacerbate their eating disorder. Today, we’ll look closely at BED, exploring what it looks like, available treatment options, and the importance of a weight-neutral approach.

What is binge eating disorder?

Binge eating disorder is an eating disorder characterized by recurrent episodes of binge eating. A binge is defined as eating an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances, accompanied by a sense of lack of control over eating during the episode. Also, binge eating 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
• Feeling disgusted with oneself, depressed, or very guilty after overeating
• Marked distress regarding binge eating

A major hallmark of BED is the absence of compensatory behaviors — like exercise or vomiting — that you see in other eating disorder diagnoses, like anorexia and bulimia.

Epidemiology of BED: General overview

To best treat patients with BED, it’s helpful to understand its epidemiology.

Here are some important and eye-opening facts about binge eating disorder:

• BED is the most prevalent eating disorder subtype in the U.S.
• BED is more common in females
• BED affects 3% of U.S. adults over their lifetime (3.5% of women, 3% of men)
• Estimates across ethnicity vary (some reflecting differences, some no differences)
• Onset is usually in young adulthood, though it’s not uncommon in adolescence, and persists through midlife
• Age of onset is older than what is typical for anorexia, bulimia, or ARFID
• 39% of those with a BED diagnosis report receiving treatment for BED
• 27% of U.S. physicians did not recognize BED as discrete eating disorder

Medical and psychological impact of BED

Like all eating disorders, BED has significant medical and psychological consequences for the person struggling.

Medical impact

Individuals with BED are at greater risk of developing:

• Type 2 diabetes
• Hypertension
• Dyslipidemia
• Cardiovascular issues
• Reproductive issues

It’s important to note that all of these potential medical consequences are independent from weight status.

Psychological impact

There are high rates of co-occurring mental health conditions in individuals with BED.

• 75% of people with BED will have at least one psychiatric disorder
• More than 40% will experience a co-occurring disorder with BED
• Common comorbidities include depression, PTSD, GAD, OCD, suicidality, impulse control disorder
• 2% report current suicidal ideation (adults)

Factors impacting the onset of BED

There is almost never one identifiable “cause” of an eating disorder, as they emerge out of a confluence of genetic, neurobiological, psychological, environmental, social, and other factors. However, research has associated certain factors with an increased risk of developing BED.

Some risk factors for BED include:

• Greater exposure to negative comments about shape, weight, and eating compared to individuals without BED
• Environmental factors like growing up in a larger body, family eating behaviors, etc.
• Genetic component, with heritability estimates of 30-80%
• Alterations in central and peripheral nervous system associated with regulation of appetite

Barriers to accessing BED treatment

Many people with binge eating disorder go undiagnosed or misdiagnosed, leaving them without the support they need to get better. Among those who do get diagnosed, some are given treatment advice that actually exacerbates the eating disorder.

Provider barriers

While providers have the best of intentions for their patients, they may inadvertently prevent those with BED from accessing treatment due to a variety of different unfortunate factors, including:

• Lack of awareness of BED
• Taking BED less seriously than other eating disorders
• Conflating BED with weight
• Assumptions about who gets BED
• Ineffective communication with patients
• Focus on weight or “lack of self-control” vs. focus on helping patients with coping strategies, compulsions, and negative emotions/mood states

The underlying reason behind many of these factors is the pervasive weight stigma and bias in healthcare. Weight stigma is defined as discriminatory acts and ideologies targeted towards individuals because of their weight and size. Weight stigma is a result of weight bias, which is defined as negative ideologies associated with obesity.

Weight stigma shows up in many different ways. Physicians have been found to have less respect for larger patients and spend less time with their higher weight patients, often making assumptions that higher weight individuals are lazy, weak, or unmotivated. The physical environment of medical spaces can also be an example of weight stigma, as many gowns, chairs, exam tables, and other elements can’t accommodate larger bodies.

According to researchers, weight stigma “has direct and observable consequences for the quality and nature of services provided to those with obesity, leading to yet another potential pathway through which weight stigma may contribute to higher rates of poor health. In terms of quality of care and medical decision-making, despite the fact that higher-weight patients are at elevated risk for endometrial and ovarian cancer, some physicians report a reluctance to perform pelvic exams and higher-weight patients (despite having health insurance) delay having them.”

Patient barriers

Those struggling with BED also come up against barriers themselves. These barriers may prevent them from recognizing that they’re struggling with an eating disorder at all, talking with a doctor about their concerns, or accessing treatment once they realize they need help. Some barriers that patients may face include:

• Lack of awareness of the potential of a BED diagnosis
• Shame around eating behaviors, and subsequent reluctance to discuss eating habits with providers
• Traumatizing prior experiences with providers around weight/eating habits
• History of multiple attempts to control/manage eating or weight, and subsequent loss of hope
• Trouble getting insurance coverage
• Difficulty finding specialists

All of these barriers can lead to a delay in seeking care, which can result in more severe outcomes once the individual is connected with a provider.

The importance of weight-inclusive care for BED

BED is a particularly challenging eating disorder to have and treat in the context of diet culture and our weight-obsessed world. The weight loss industry continues to boom, and there are prevalent societal norms around weight loss. At the same time, growing up in a larger body and negative family attitudes around weight/eating/body shape are risk factors for binge eating disorder.

The confluence of these two realities means that some patients with BED and/or their parents seek weight loss instead of or alongside eating disorder treatment. This almost always exacerbates the eating disorder, which is why taking a weight-inclusive approach is essential for BED treatment. In one study, people receiving weight neutral treatment instead of weight loss-focused treatment for BED reported less feelings of shame and had increased levels of resiliency following treatment.

What weight inclusive care looks like

Weight inclusive care is defined as empirically supported practices that enhance people’s health in care settings regardless of where they fall on the weight spectrum. Weight-inclusive BED treatment focuses on:

• Reducing binge-eating frequency and disordered thoughts
• Improving metabolic health
• Treating underlying mood disorders via psychological and pharmacological treatments
• Reducing idealized aesthetic evaluations of self-worth
• Focusing on enhanced quality of life
• Promoting “normal” versus “optimal” nutrition
• Creating safe space for the patient in regards to provision of weight inclusive care (and modeling this for parents)

Treatment for adults with BED

The first-line treatment for adults with BED is CBT-E, or enhanced cognitive behavioral therapy, a form of CBT developed specifically for treating eating disorders.

Treatment for adults with BED may also include:

• Interpersonal psychotherapy (IPT): Identifying and changing the role of interpersonal functioning in causing and maintaining negative mood, psychological distress, and unhealthy behaviors.
• Dialectical behavioral therapy (DBT): Mindfulness and skill development around emotion regulation, distress tolerance, and interpersonal relationships to help patients respond to stress and negative affect more effectively.
• Medications: Some medications have proven to be helpful in treating BED, including lisdexamfetamine dimesylate (e.g., Vyvanse), antidepressants, and anticonvulsants.

Overview of CBT-E

CBT-E targets the thoughts, behaviors, and beliefs that keep an eating disorder going, aiming to reduce negative emotions and undesirable behavior patterns by changing negative thoughts about oneself and the world. CBT-E is tailored to the patient by focusing on problematic eating-related cognitions and behaviors. CBT-E uses a collaborative approach, meaning that it never uses prescriptive or coercive procedures and therefore never asks you to do things that the patient does not agree to do.

CBT-E may be therapist-led or self-help (in which a patient follows a manual/book, with or without facilitator), but it’s worth noting that the APA recommends that people with BED seek treatment that uses a team approach with a therapist, dietitian, and psychiatrist when needed, with mentorship as an added bonus.

Some important facts about CBT-E:

• One of the most effective treatments of eating disorders
• ~ 66% of patients in remission in research sample
• Transdiagnostic, meaning it treats most forms of eating disorders
• Time-limited treatment with 20-40 sessions over a span of 6-12 months (on average)
• Not a “one-size fits all” treatment; varies by patient

Goals of CBT-E

When used for BED treatment, CBT-E has two primary goals:

1. Reduce binge eating behaviors: Establish regular eating, which means eating every 3-4 hours throughout the day, eating a wide variety of foods, normalizing attitudes and beliefs around eating, and having no “forbidden” foods.

2. Improve emotion regulation and/or overvaluation of weight or shape. This includes teaching coping skills, identifying and defining values, engaging in value-driven behavior, reducing investment in the thin-ideal, and testing body image attitudes & beliefs. This work helps reduce disordered, "emotional eating."

CBT-E treatment involves four stages, the scope of which is beyond this presentation, but you can learn more about them here.

Treatment for adolescents with BED

There are currently no level 1 or level 2 (probably efficacious) evidence-based treatments for youth with BED. Previous research in adolescent BED patients has used CBT, IPT, and DBT, however most are small studies or case studies, and thus findings are hard to extrapolate However, limited findings do show that compared to a waitlist control, CBT did better and in a trial utilizing DBT there was a reduction in binge eating. While it has not been formally tested, for youth with BED, FBT-BN did show a reduction in binge eating episodes in a case study.

Family-based treatment (FBT)

In the absence of a first-line treatment approach specifically for adolescents with BED, a good treatment option is FBT, which is the leading evidence-based treatment for eating disorders in young people. FBT empowers patients’ families to be active participants in recovery, and research shows that for children and adolescents with eating disorders, FBT has the highest rates of recovery and the lowest rates of relapse.

The goals of FBT for BED include:

• Stop loss-of-control eating episodes (i.e., binge episodes)
• Regulate eating every 3-4 hours
• Ensure patient is eating enough at meal/snack times (i.e., not restricting)
• Exposure to typical binge foods to normalize eating them in appropriate quantities without triggering a binge episode

FBT has three phases, the Family Management Phase, Return to Independence Phase, and the Quality of Life Phase. Here’s a quick overview of what each phase focuses on.

Family Management Phase

• Reduce compensatory behaviors
• Reduce binge/loss-of-control eating episodes
• Regular eating throughout the day; structured meals and snacks
• Family support during times of high binge likelihood

Return to Independence Phase

• Return of independence and developmentally appropriate oversight over eating.
• This will look different for patients depending on stage of development and family dynamics
• Education on physiological and psychological triggers for loss-of-control eating/binge eating

Quality of Life Phase

• Treatment of co-occurring psychological conditions
• Reducing appearance and weight-based ideals that influence self-worth
• Addressing other issues of adolescence

You’ll notice what’s NOT a focus of any of these phases: anything to do with WEIGHT.

Strategies for working with pediatric population

If the family of a pediatric patient with BED is pushing for weight loss, here are a few points to consider discussing with them:

• Be explicit that the goals of treatment of BED do not include weight loss
• Goals for younger people focus on eliminating loss-of-control eating rather than focusing on the amount of food eaten
• Children and adolescents are growing and we do not want to miss any growth opportunity
• Provide information on Health At Every Size (HAES) if families are asking for weight loss as a way for their child to be “healthier”
• Provide psychoeducation that engaging in behaviors that promote weight loss could strengthen the eating disorder and thus would not align with health
• Weight may stabilize once normative eating commences and binge eating stops, however weight stabilization is NOT the same as actively promoting or working towards weight loss
• Focus on other goals (i.e., self-esteem vs. weight loss)

Weight loss medications and BED

The rise of weight loss drugs like Ozempic has complicated BED treatment, with some putting forward these GLP-1 antagonists as “cures” for BED. To understand why weight loss medications aren’t a good approach to treating BED, it’s important to understand a bit more about how these medications work.

Glucagon-like peptide1 (GLP-1) agonists are medications that have long been used to treat type 2 diabetes, but some GLP-1 agonists have recently received FDA approval for weight loss. A GLP-1 agonist is a type of medication that facilitates the role of GLP-1 (a naturally occurring hormone) and makes the effects of GLP-1 even more pronounced. GLP-1 is a naturally occurring hormone with several important functions, including:

• Triggering insulin release: Insulin is a hormone that helps the body turn food into energy. When insulin is released, blood glucose is lowered.
• Blocking glucagon secretion: Glucagon is a hormone that raises blood sugar levels. When glucagon secretion is blocked, blood glucose is lowered.
• Slowing stomach emptying: Slower digestion means that the body releases less glucose from food into the bloodstream.
• Increasing feelings of satiety: GLP-1 affects areas of your brain that process hunger and satiety. All of these functions result in lowered levels of blood glucose and increased feelings of satiety.

Why are GLP-1 agonists risky for folks with eating disorders?

There are a number of different reasons that using GLP-1 antagonists to treat BED might backfire:

1. Interference with the goal of establishing regular eating patterns. Eating disorders impede the ability to notice and respond to hunger cues, which is why eating disorder treatment nearly always involves establishing a pattern of regular eating throughout the day. Medications that lead to decreased hunger cues, such as GLP-1 agonists, can interfere with regular eating and are often contraindicated.

2. Lack of research. There are currently no long-term studies on a diverse patient population that have examined how GLP-1 agonists affect eating disorder behaviors, medical complications, and rates of recovery/relapse. As such, we do not have compelling evidence that GLP-1 agonist medications lead to a sustained reduction in binge eating.

3. Perpetuation of the thin ideal. Using GLP-1 agonists for weight loss can perpetuate weight stigma/idealization of thinness, which is often a core symptom that maintains eating disorder psychopathology throughout the illness.

4. Lack of psychological considerations. Importantly, GLP-1s do not perform any of the functions that therapy does, like changing thinking patterns, working on emotion dysregulation, and addressing concerns about weight.

5. Risk of adverse consequences. Many of the side effects associated with GLP-1 agonists are similar to some of the more serious medical complications associated with eating disorders (e.g., gastroparesis, dehydration). Weight cycling (i.e., gaining and losing weight repeatedly) is associated with an increased risk of depressive symptoms, and those with eating disorders are already at heightened risk for depression.

What if my patient with BED wants to take weight loss medications?

If you have an adult BED patient who wants weight loss medication as part of their treatment, the points below can be helpful to discuss with them.

• Weight loss medications should not be taken as a treatment for BED.
• There isn't any long-term research to suggest that GLP-1s or other medications lead to a sustained reduction in binge eating.
• Symptoms that are masked by the medication could return if you stop taking the medication.
• Because GLP-1s and other weight loss medications affect hunger cues, they could be taking away the opportunity to learn how to respond effectively to hunger cues.
• Weight loss medications may lead to weight cycling, and weight cycling is linked with increased depression, creating more psychiatric challenges.
• If the medication is prescribed for type 2 diabetes, discuss the possible risks and benefits of treatment for BED while on this medication.

Conclusion: A weight-neutral approach to treatment of BED

Binge eating disorder is a common and serious eating disorder that affects people across gender, age, race, socioeconomic status, and body size. There are many misconceptions around its diagnosis and treatment, which are often exacerbated by diet culture and weight stigma in the healthcare space. In order to ensure that everyone struggling gets help, it's important for providers to understand the available evidence-supported treatment options.

Treatment goals for BED

• De-emphasize weight loss as an outcome
• Focus on quality of life and non-weight indicators of health
• Refrain from setting weight goals

Treatment methods for BED

• Greater emphasis on structured eating and inclusion of regular meals/snacks
• Mindful and judicious nutrition education (e.g., non-judgmental approach to quality of food)

Resources

• Offer education around HAES and weight stigma, specifically for parents of pediatric patients
• Connect patients with other providers who provide weight-inclusive care

For more in-depth information on a weight-inclusive approach to binge eating disorder, watch my recorded Equip Academy presentation on the topic. You can also explore past Equip Academy presentations and register for upcoming events here.