Binge Eating Disorder
Binge eating disorder is characterised by recurrent episodes of eating large amounts of food with loss of control, without compensatory purging. It is the most common eating disorder.
Key Facts
Most common eating disorder — prevalence ~2-3%; F:M ~3:2 (more equal than other EDs) Binge eating episodes ≥1/week for ≥3 months without compensatory behaviours Associated with obesity: ~30-40% of those seeking weight loss treatment have BED First-line: Guided self-help based on CBT principles (NICE NG69) Group CBT if guided self-help ineffective No medication is first-line; SSRIs (fluoxetine 60mg) or lisdexamfetamine (specialist) may be considered Distinguished from bulimia nervosa by absence of compensatory behaviours Significant comorbidity: Depression (~50%), anxiety, metabolic syndrome, type 2 diabetes
Overview
Key Facts
BED is the most common eating disorder. It involves recurrent binge eating without compensatory behaviours. It is strongly associated with obesity and metabolic complications.
Epidemiology
Prevalence 2-3% in the general population. More equal sex distribution (F:M ~3:2). Peak onset late teens to early 20s but can present at any age. Found across all weight ranges but most commonly in overweight/obese individuals.
Aetiology
- Genetic: Heritability ~40-50%
- Psychological: Emotional eating as coping mechanism, low self-esteem, body dissatisfaction
- Dietary: History of dieting, food restriction → rebound binge eating
- Neurobiological: Reward pathway dysfunction, impaired impulse control, altered satiety signalling
Pathophysiology
- Emotional regulation model: Negative emotions trigger binge eating → temporary mood improvement → guilt → negative emotions → cycle continues
- Reward pathway dysfunction: Enhanced response to food cues, reduced post-meal satiety signalling
- Insulin resistance and metabolic syndrome develop secondary to obesity and binge eating patterns
Clinical Presentation
Diagnostic Features
- Recurrent binge eating episodes with ≥3 of: Eating rapidly, eating until uncomfortably full, eating when not physically hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterwards
- Marked distress about binge eating
- ≥1 episode/week for ≥3 months
- No compensatory behaviours (distinguishes from bulimia)
Associated Features
- Often overweight or obese
- Eating in secret, hoarding food
- Chaotic eating patterns
- Depression, anxiety, social withdrawal
- Type 2 diabetes, hypertension, dyslipidaemia (metabolic syndrome)
Red Flags
- Suicidal ideation (comorbid depression)
- Severe obesity with medical complications (BMI >40)
- Comorbid substance misuse
- Development of compensatory behaviours (reclassify as bulimia)
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Bulimia nervosa | Binge eating WITH compensatory behaviours | Clinical history |
| Obesity without BED | Overeating without loss of control or marked distress | Clinical assessment |
| Depression | Increased appetite/comfort eating but without binge criteria | PHQ-9 |
| Night eating syndrome | >25% caloric intake after evening meal, nocturnal eating | Food diary |
| Prader-Willi syndrome | Genetic condition, hyperphagia, intellectual disability | Genetic testing |
Diagnosis / Investigation
Bedside
- BMI: Often >25; assess weight trajectory
- BP, waist circumference: Metabolic syndrome assessment
- BED-7/EDE-Q: Severity assessment
Bloods
- HbA1c, fasting glucose: Diabetes screening
- Lipid profile: Dyslipidaemia
- LFTs: Fatty liver disease (NAFLD)
- TFTs: Exclude hypothyroidism
- FBC, U&Es: Baseline
Special Tests
- Formal assessment of binge eating: EDE interview
- PHQ-9, GAD-7: Comorbid depression and anxiety
Management
Non-pharmacological (NICE NG69)
- First-line: Guided self-help based on CBT principles (4-9 sessions)
- Second-line: Group CBT-BED (adapted for binge eating)
- Note: Weight loss is NOT the primary goal — reducing binge eating is the focus
- Exercise for wellbeing (not compensatory)
Pharmacological
- No medication is first-line for BED
- SSRI (fluoxetine 60mg OD): May reduce binge frequency (off-label)
- Lisdexamfetamine (Elvanse): Licensed in US for BED; specialist use only in UK (off-label); reduces binge days by ~50%
- Topiramate: Evidence for binge reduction and weight loss, but significant side effects (cognitive, teratogenic)
- Orlistat/GLP-1 agonists: For weight management if obesity is a concern, alongside eating disorder treatment
Referral Criteria
- Suspected BED — specialist eating disorder service
- Failed guided self-help — step up to group CBT
- Severe obesity with medical complications — combined ED and obesity service
- Comorbid depression/substance misuse — MDT approach
Prognosis
- Best prognosis of the eating disorders
- CBT: ~50-60% achieve remission from binge eating
- Often chronic-relapsing without treatment
- Weight loss is often limited even when binge eating resolves — separate weight management may be needed
- Medical complications: Related to obesity — T2DM, CVD, NAFLD, OSA
- Comorbid depression worsens outcomes
Other Relevant Information
BED vs Bulimia Nervosa
| Feature | BED | Bulimia Nervosa |
|---|---|---|
| Binge eating | Yes | Yes |
| Compensatory behaviours | No | Yes |
| Typical weight | Overweight/obese | Normal weight |
| Electrolyte disturbance | Rare | Common |
| Gender ratio (F:M) | 3:2 | 10:1 |