Out on a Binge

Anyone running an obesity clinic is well aware of the surprisingly large number of patients who have Binge Eating Disorder (BED). Some reports put the number at around 30% of patients with severe obesity who seek help for their weight.

But you have to ask the right questions to make the diagnosis:

Do you ever, especially when you are alone and are not even really hungry, rapidly eat vast amounts of food that is not really a proper meal (e.g. a bag of chips followed by a box of cookies followed by a loaf of bread followed by all the cheese you can find followed by a bag of nuts followed by a pot of ice cream followed by……….you get the picture!) till you get uncomfortably full (or run out of food) and then end up feeling quite disgusted about yourself for having done it again but have no idea why you are doing this or how to stop yourself from doing it again?

If this behaviour occurs at least a couple of times a week over at least six months, this patient probably has BED, a well described eating disorder listed in the appendix of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

To me, the most important differential diagnosis is overeating because of true hunger (homeostatic hyperphagia) or as part of a planned social event (e.g. a birthday, a festival, a special treat, etc.).

Typically homeostatic hyperphagia occurs when you have not eaten enough during the day and your body craves calories so that when you finally allow yourself (or find the time) to eat, you end up eating the wrong things too fast till you vastly overshoot your actual caloric requirements. Also, overeating at social events, especially when there is plenty of great-tasting food (and alcohol), i.e. “pigging out at the buffet” – does not mean you have binge eating disorder.

The key differences are that the patient with BED is not eating because of any “need for calories” or physical hunger, is not eating as part of a regular meal or social event, and ends up feeling quite troubled and disgusted at the lack of control (unlike the “hedonic overeater” who truly enjoys splurging on tasty foods and actually feels quite happy and content after a large scrumptious meal).

Diagnosing BED (which, despite popular belief, occurs as commonly in men as in women!) is essential, as this condition is actually made worse by dieting and patients usually have long-standing histories of weight cycling (usually with the help of commercial weight loss programs). Given that patients have little control over their behaviour, recidivism of weight gain is extraordinarily high and long-term maintenance of weight loss is virtually impossible without addressing the pscychopthology specific to this condition.

Fortunately, BED is highly responsive to psychotherapy (e.g. cognitive behavioural therapy, group interpersonal therapy, etc.) with various investigators reporting upto 95% reduction in the frequency of binge-eating episodes with almost 80% of patients becoming completely free from binging. Pharmacotherapy also appears to provide some relief.

The bottom line is: “true” BED is common and needs to be treated as a separate and distinct psychiatric disorder before hoping to make any progress in weight management.

Luckily this is possible.