Humans have a preference for high calorie food. High-fat, sugary food desires are a wired-in, non-negotiable primal drive found in both humans and animals. Less fattening foods are often overlooked in favor of foods that stimulate the pleasure centers in the brain. This preference served as an evolutionary advantage in times of food scarcity. If food is unavailable or intermittently available, it makes sense to grab the highest calorie food one can find, to secure the most energy and fuel for the body.
What is an Eating Disorder?
Binge Eating Disorder (BED) is a chronic condition when high-fat, sugary foods are ingested without applying the brakes during an eating session. Repeated binge eating becomes habitual, and people are unable to stop eating or control what or how much was eaten. This disorder is often referred to as a Loss of Control (LOC) over-eating disorder. This affliction is distinguished from bulimia in that the purging aspect is not present. People overeat but do not use vomiting or laxatives to get rid of the food afterwards.
As can be expected from taking in too many calories, people often become overweight and obese. This leads to psychological distress and diminishment in health and quality of life. Loss of control eating can also be seen as hedonic hunger, as eating becomes less of a necessity and more of a pleasure driven activity like drug use, sex addiction and gambling. Restraining one’s eating becomes difficult as people eat more than wanted rather than less than needed.
Binge eating is clinically defined with diagnostic criteria. However, people from different countries, cultures and families may have differing viewpoints on how they lose control. In one study of college students, females were more likely meet diagnostic criteria of BED, but only because they reported they were losing control. Male students had the same proportion of BED but they were more likely to report that they had problems with specific foods like sweets and pizza.
A clinical diagnosis involves an average bingeing frequency of 2 days per week over the previous 6 months. While being careful about eating habits is healthy and encouraged, thinking about food and weight and diets almost all the time is not a good indicator. Having a high degree of guilt, shame and remorse is another sign of loss of control over eating. Denying, lying and trying to cover up the evidence should also alert a person to the seriousness of the situation.
Eating disorder of all kinds can cause serious medical problems and will even cause early mortality or death. Long-term over- eating leads to obesity. Obesity is a full scale epidemic in some countries and rising fast in incidence globally. Conservative estimates indicate that 5-10% of people have some type of eating disorder. Because of the guilt and secretiveness, many more cases are probably not reported.
However, one need only look at the obesity epidemic to get a more realistic picture of the incidence of BED, LOC, hedonic hunger, and compulsive eating. One third of all people in developed countries are significantly above their recommended weight due to binge eating. Direct and indirect health care costs in the U.S. are estimated to be $117 billion per year.
Causes of Binge Eating Disorder
Researchers are working to find genetic predictors for patients who may be susceptible to eating disorders. While susceptibility to genetic influences may help identify persons who may develop BED and may help find treatments, eating disorders develop for many more complex reasons. Culture, family, life changes and personality traits can trigger a genetic predisposition to an eating disorder. Having a genetic susceptibility does not remove responsibility from the individual to prevent and/or treat BED.
The top 25 most significant locations for eating disorder susceptibility have been identified. A single-nucleotide polymorphism (SNP) on chromosome 4 of the gene GABRGI has shown the strongest susceptibility to eating disorder symptoms. Also, the gene that codes for grehlin, a neuropeptide that increases appetite, was found to be different for people who consumed large amounts of sugar and alcohol.
The brain is responsible for releasing vital signals to start and stop eating, to apply force to the gas pedal or to put on the brakes. One study has found that once a high calorie diet is the norm, the brain cells form a barrier to stop the application of the brakes. The cells become insulated from the body and cells stop being able to detect signals of fullness. In addition, the insulation stops signals that would increase energy production, to exercise or move and burn off energy, calories/kilojoules. People with neural deficits may gain 30 per cent more weight.
People with BED seem to have greater neural activity in regions of the brain. These regional deficits are also found in people with substance abuse problems. Normally, the brain releases a chemical called dopamine when people eat tasty foods, conferring a rewarding or pleasurable feeling from eating. However the reward center in the mesolimbic regions of the brain is compromised for drug addicts and overeaters. The anterior cingulate cortex (ACC) and the medial orbitofrontal cortex (OFC) are over activated to anticipate pleasure from food. Physiologically, psychologically, and behaviorally a person may become reactive to food cues and become addicted.
Structurally, addictive brains show a different topography than normal brains. The dorsolateral prefrontal cortex (DLPFC) and insular cortices were significantly thinner in the brain of cocaine addicts. While some of the brain deficits were attributed to years of cocaine use, scientists were able to control for that, and still found differences in cortical thickness. A thinner cortex would confer a predisposition to addictive behavior and restrict decision making, attention and judgment.
Negative cognitive processing about food may develop from genetic and brain deficits. Thought development may include high perfectionism, high weight and shape concern, and low self-esteem. The brain’s self-reflection center, the medial prefrontal cortex, is shown to activate even in normal eaters, indicating anxiety about weight and body image. Those with BED may have increased deficits in their thinking processes and focus excessively and unhealthily on their appearance.
Young women especially, between the ages of 14 and 25, may be susceptible to eating disorders when they are feeling vulnerable and awkward. They are trying to figure out their place in the world, be under academic stress and coming to terms with their sexual orientation or sexual attractiveness. Eating disordered patients show a higher level of depression and anger indicating extreme unhappiness and sometimes self-loathing.
Young women are bombarded with messages from the media. Most fashion models are far thinner than all women. Bodily appearance and thinness may become the most important criteria in a young person’s life. They may not know how to respond and regulate their weight, and enter a cycle of dieting and overeating. Body image problems may lead to comfort eating and seeking pleasure and reward. This cycle may change their brain and lead to a physical and neural inability to stop eating. Young people who are exposed to high levels of media and who have friends with high media exposure, have a 60 percent increase in eating disorder symptoms.
Individuals with a high degree of impulsivity weigh an average 22 pounds more than others. The personality trait of impulsivity limits a person’s ability to control frustration, to persevere through difficulties and stay on task. Controlling one’s eating habits may be difficult for those with this trait. In addition, people also tended to gain a large amount of weight if they were antagonistic, cynical, competitive, aggressive and risk-taking.
Girls and boys grow up to be men and women, who have children of their own. Obese children are more likely to have obese parents. While overeating and obesity in children may simply be copying the parent’s behavior, or eating what is put in front of them, the family structure, dynamics and attitude are equally important to understand as other factors for BED. Most adults have a ‘love-hate’ relationship with food and may unwittingly pass on mixed messages about food to their children.
Researchers have found that children who eat when upset or bored are more likely to become overweight. Children who are fussy or slow eaters are more likely to become underweight. However, the parents trigger these types of food approach/avoidance behaviors. Food attitudes are encouraged by the parent, reinforced and become habitual.
Mothers especially are under increased scrutiny in passing on food attitudes. One study found that mothers who described their child as a “picky” eater, also fed their child much less fruits and vegetables. However, fathers are an important part of the equation, too. Fathers who are likely to eat out at fast food restaurants also have children who prefer fast food as well. Blaming the mother for everything is not helpful as the family is an ecosystem of its own where the parts affect the whole. Scientists have found the associations between parental attitudes and are working to develop recommendations for parents.
An eating disorder like BED may occur when eating is used to help block out painful feelings. Some people may feel that they live in a household where there are expectations for behavior, high academic achievement, sexual behavior, political affiliation and other standards. When young people are controlled, bullied, or just living in a bossy environment, they can feel that everyone else controls them. To establish independence or take back control, they may feel that their own bodies are the only resource to establish dominance over.
Stress and Trauma
Some individuals may have a specific stressor or a traumatic event which triggers BED. A change or loss, such as bereavement or sexual abuse can initiate problems with food. When a disruption occurs in a person’s life, one may seek comfort, not in the arms of friends or the safety of the bed, but in the kitchen and refrigerator. The body’s normal psychological defenses against stress may be insufficient to handle and adapt in positive ways. The stress hormone, corticotropin-releasing factor (CRF) makes them crave rewards. A pattern is born, control is lost and BED may be the result.
Women who become pregnant have a natural need to eat more. A developing fetus requires energy and nutrients to become viable. This places increased demands on the mother for increased food consumption. However, scientists are noticing BED increasing for pregnant women. New incidences of excessive food consumption are being unexpectedly found in this group. The development of disordered eating during pregnancy is on the rise. Women who already have an eating disorder when they become pregnant will have significant difficulties as well.
Sleep behavior is an important predictor for making bad food choices, weight gain and obesity. Researchers found that women sleeping 6 hours were 12% more likely to have a 15 kg weight gain, women sleeping 5 hours or less were 32% more likely to have a major weight gain, while women sleeping 7-8 hours had the lowest risk for weight gain. Sleep deprivation disrupts two major hormones, leptin and grehlin. Leptin produces a feeling of satiation or fullness, and grehlin affects how hungry you feel.
Research subjects who slept only four hours a night for two nights, had an 18 percent decrease in leptin, a hormone that tells the brain there is no need for more food, and a 28 percent increase in ghrelin, a hormone that triggers hunger. These hormones–ghrelin and leptin, both discovered in recent years, represent the ‘yin-yang’ of appetite regulation. Ghrelin, made by the stomach, connotes hunger. Leptin, produced by fat cells, connotes satiety, telling the brain when we have eaten enough.
Lack of sleep may also lead one to have poor food judgment. People are more likely to eat fast food and less likely to prepare meals at home. One night of sleep deprivation can affect food choices for many days afterward. Insomnia may also lead to night time eating and decreased activity during the day.
Consequences and Complications
People who chronically over-eat, under-eat or have any type of dysregulated eating, may face immune system, metabolism and psychological problems. Since binge-eating disorder is the most common eating disorder found in obese people, BED patients are at risk for all obesity related conditions including Type 2 diabetes, coronary heart disease, cancer, hypertension, high cholesterol, stroke, sleep apnea and respiratory problems. Other conditions which may develop:
- Osteoarthritis – a degeneration of cartilage, bone and joints.
- Gynecological problems – abnormal menses, infertility, and negative attitude towards pregnancy.
- Child to Adult – patterns developed in childhood and adolescence can persist into adulthood.
- Social Phobia – people with BED suffer from social phobia more frequently, with feelings of shame and guilt.
- Suicide – BED patients are often socially isolated, depressed, angry and are more likely to attempt and complete suicide.
- Intestinal diseases – increased serum amylase values, a gut enzyme, may factor into mucosal inflammation. Gastrointestinal perforations and reflux disorders may result from enlarged gastric capacity and reduced muscle tone in the gastric wall.
- Athletes – increased physiologic demands from training, and pressure to perform well and compete, can trigger eating disorders in athletes. Bulimia and anorexia is more commonly seen than BED, as being overweight is counterproductive to athletic goals. However, athletes may intermittently over-eat at times. Athletes may not self-report their symptoms and may deny their condition to medical professionals.
- Being Female – regardless of race, ethnicity or nationality, women are more vulnerable to developing disordered eating behaviors than men.
- Being Male – vulnerability to impulsivity and over-eating is found in males as well. Binge-eating disorder affects males and females almost equally, although males may describe their behavior differently and have less body image problems. Males have the same kind of emotional, physical and behavioral signs but they are less likely to seek treatment.
- Being bullied or abused – a history of childhood sexual or emotional abuse, or bullying leads to self-criticism and body dissatisfaction.
- Children – 42% of 1st-3rd grade girls want to be thinner with 81% of 10 year olds afraid of being fat. This may lead to maladaptive dieting behaviors and loss of control.
- Adolescents – One in five teenagers reported eating problems and much higher reports of unhappiness with their weight than their peers.
- Facebook – frequent Facebook users may develop a negative body image. Media exposure is a risk factor for developing eating disorders. Viewing gossip, fashion and music content confers a risk for negative self-image and eating disorders.
- Holiday season – unfulfilled expectations may lead to episodes of binge eating which can turn into a long-term problem. Dealing with stress by compulsive eating at the holidays can be overlooked, as over-eating is seen as normal during certain times of year.
- Being Gay – as many as 15-25% of gay men have suffered anorexia, bulimia or binge-eating disorders, compared to 5% in the heterosexual male population.
- Going to College – 91% of college women attempt to control their weight through dieting. Coping with the stress of being away from home, eating in cafeterias, academic pressures and new relationships may lead college students to binge eating.
- Inability or powerlessness to stop eating.
- Eating several times a day or continuously through the day.
- Middle of the night eating.
- Eating in secret.
- Guilt, shame or disgust after eating.
- Self-worth is based on looks, weight or body shape.
- Excessive meal planning, shopping and food procurement.
- Lying about how much was eaten.
- Denying that there is anything wrong.
- Hiding food.
- Eating when full.
- Bingeing only when alone.
- Eating when bored or lonely.
Binge Eating Diagnosis
Power of Food Scale (PFS) – a recently-developed measure of differences in appetitive responsiveness to food cues; can statistically describe food cravings and binge eating. Hedonic hunger in obese individuals is measured as obese people prefer and consume high palatability foods.
Yale Food Addiction Scale (YFAS) – a 27 question test about food habits and preferences over the last 12 months. A sample question reads, “I eat to the point where I feel physically ill.” The answers can be Never, Once a month, 2-4 times a month, 2-3 times a week, 4 or more times or Daily.
Eating Disorder Diagnostic Scale (EDDS) – a brief, self-reported test for eating disorders including BED. This test is proven to be reliable, valid, and consistent with other scales measuring eating pathology.
Figure drawing assessment – a simple self-drawing exercise can non-intrusively diagnose those with eating disorders. Since body image is distorted in eating disordered patients, asking a patient to draw himself or herself may provide clues to their self-image.
Many people with eating disorders do not admit to their problem. Instead they may seek medical care for their symptoms or for medical problems resulting from their eating disorder. The physician then has to sort out the situation and overcome the patient’s resistance to admitting and accepting their problems.
The physical exam should include measurements of weight and height, body mass index and checking the vital signs. Physicians can give screening tests and ask about eating and exercise patterns to confirm signs of eating disorders. Physicians can ask if any vitamins, minerals, laxatives or other supplements are being used. Patients can also be asked about their typical food intake. Laboratory tests may be ordered like a fasting blood count and thyroid functioning.
Psychological status should be addressed along with risks for suicide. However, an overweight or obese person is clearly likely to be experiencing a loss of control in eating. Medical causes of obesity can be ruled out, and binge eating disorder diagnosed according to DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) published and copyrighted by the American Psychiatric Association:
A. Recurrent episodes of binge eating. Binge eating is characterized by both of the following:
- eating, in a discrete period of time (within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances.
- a sense of lack of control over eating during the episode (feeling that one cannot stop eating or control what or how much one is eating).
B. The 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.
C. Marked distress regarding binge eating.
D. The binge eating occurs, on average, at least 2 days a week for 6 months.
E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (purging, fasting, laxatives, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.
Binge Eating Treatment
There are currently few drugs that are effective in helping patients address the three main goals of treatment: reduce binge eating, increase weight reduction, and treat accompanying psychiatric conditions.
- Sibutramine – an anti-obesity drug that reduces brain response in the hypothalamus and the amygdala. Patients who took Sibutramine showed reduced activity in those regions important in appetite control and eating behavior, ate less and lost more weight.
- Topiramate – an anticonvulsant medication to treat some types of seizures. Patients receiving Topiramate reported a reduction in binge frequency and binge day frequency. They also lost an average 13 pounds.
- Antidepressants – the most commonly prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs). However, atypical antidepressants, tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be prescribed as well.
- Appetite suppressants – Phentermine is a physician prescribed medication to decrease appetite. Over the counter suppressants may be available.
Surgery is an invasive option which can lead to sustainable long-term weight loss. However, if the psychological reasons for BED are not discovered and treated, surgery may not be successful. Surgery partitions the stomach and bypasses it to create a small stomach pouch. Newer procedures like the adjustable gastric band (LapBand) may be reversible. Any surgery carries risks and patients are carefully selected for surgery. Accepted patients have a Body Mass Index (BMI) of 35 or higher, have tried all other treatment, are psychologically capable and sufficiently motivated to make lifelong lifestyle changes.
Cognitive Behavioral Therapy (CBT)
CBT is the treatment of choice for BED. Patients who received psychological counseling showed improvement with better restraint and less hunger. Cognitive behavior therapy attempts to get to the root of the problem. Looking at the thinking behind the behavior challenges the patient to address the thoughts that trigger binge eating. The idea that food is rewarding and pleasurable is challenged and the patient is encouraged to find other ways of self-comfort that do not include food.
Counseling within the family framework may be helpful as well. Lifestyle behavioral interventions involving the whole family are the most effective strategies to prevent and combat eating disorders and childhood obesity. Family-based behavioral therapy for the pediatric overweight population can make changes in the family ecosystem and benefit everyone. Small changes in children’s diet and physical activity are recommended to change behaviors. Familial support is also important for adult BED sufferers.
New research shows that “framing” behavioral therapy is important. Gain framed messages were more successful than pain framed messages. When patients who scored low in self-control were given instructions that the exercise would be “fun”, they improved their self-control. When college students were given negative messages about binge drinking, they were not as effective in reducing that behavior as gain framed messages. Focusing on the positive aspects of controlling eating may help BED patients.
Another way to guide one’s thinking challenges the old notion that not giving into a craving will make it become stronger. New research shows that suppressing thoughts is not helpful. Instead they found that imagining consuming the desired food actually leads to less actual consumption. Imagining is thought to be a good substitution for sensory stimulation and may act to reduce cravings.
Nutritional counseling and physical activity counseling is also critical in the counseling procedure. Many times BED patients simply do not know, or are misinformed as to the role that proper nutrition and exercise plays in their disorder. Long-term weight maintenance is impossible without physical activity. However, many overweight and obese people should refrain from vigorous activity before they are ready. Stress from excess weight may overload joints, lead to injury and forever dissuade patients from exercising. Proper counseling from a registered dietician and physical therapist is important.
Self-help may be effective in conjunction with CBT, without CBT, and with or without drug use. Components of self-help include:
- Initiate self-monitoring of food consumption.
- Education about relationship between eating and weight, and establish standard eating schedule.
- Develop alternatives to bingeing.
- Develop problem-solving strategies.
- Reduce strict dieting.
- Develop relapse-prevention strategies.
Avoid eating traps – depending on the stomach or the brain to tell a person when satiation or fullness is reached, may not work. Binge eaters may not get those messages or choose to ignore them. They may not realize what they are doing. Planning in advance to avoid traps may be necessary. Changing the environment may be more useful than using willpower. Using smaller plates and putting food above eye level or out of sight has helped some people.
Eat Protein – eating a healthy breakfast, especially with protein, reduces cravings and hunger for the rest of the day. Any kind of breakfast can reduce unhealthy snacking, overeating, night eating, weight gain and obesity. Protein rich breakfasts have a much more potent effect on appetite.
No Free Day – some weight loss plans include a free day to eat whatever is desired. Some people think that a free day in the diet is beneficial because it makes metabolism speed up and reduces cravings. A new study challenges this notion. Researchers say intermittent diet cycles lead to compulsive behavior much like an addiction to drugs. A free binge day leads to overeating of sweet foods, under-eating of nutritious foods, withdrawal symptoms, and anxiety.
Dieting – while most people have been on a diet at some point, dieting may do more harm than good. People on diets gain more weight than those who are not on diets. Dieters report more binge eating and higher carbohydrate intake. Dieting is characterized by bouts of overeating/binge eating and periods of restricted eating. Small changes such as increasing physical activity and decreasing fat and sugar intake are more successful in the long run.
Family Eating – people make better food choices at home than when eating out. Adolescent girls who participated in family meals were protected from extreme eating behaviors. Interpersonal and familial relationships seem to make the difference for controlling food intake. Home environments may also give a sense of comfort and familiarity, stalling loss of control behaviors. A cycle of positive reinforcement may be more possible at home when people who are a good mood. People in a good mood tend to make healthier meals which leads to its own set of rewards of satisfaction and being in control.
Hedonic hunger is a reward based condition where high fat, sugary foods are preferred. The pleasure centers in the brain reinforce this activity with dopamine secretion and the cycle continues with more over-eating. The brain responds by blocking signals to stop eating. Binge eating is hard to stop as physiologically and psychologically, the brain acts to keep rewarding itself with highly palatable foods.
Binge eating disorder may begin in childhood as young humans copy the hedonistic eating of their parents. Subtle, unwitting messages from parents may also cause a child to adopt certain eating patterns. Having come through childhood with normal eating, an adolescent may succumb to peer pressure and media pressure to look a certain way. This leads to dieting, which is restricted eating, normal eating and binge eating combined. Metabolism and brain chemistry is thrown out of whack and an eating disorder may be born.
In others, a specific trigger or negative life event may happen. Comfort may be sought in food and rewarded in the brain with positive neurochemicals. Other triggers can include a single night of sleep deprivation which leads to bad food choices. Over-eating is continued and may develop into a disorder. In yet others, body image disturbances or personality traits of impulsivity may cause a loss of control.
Cognitive behavioral therapy is the treatment of choice in almost all cases. People who over-eat have issues that are extremely individualized and must be treated by an experienced counselor. Finding the reasons for binge eating and challenging the thinking process is the way to long-term healthy eating.
People with binge eating disorders may be likely to shift between related disorders as they seek pleasure and reward, and avoid negative thoughts and feelings. They may also be prone to other impulsive and compulsive loss of control behaviors:
- Binge drinking
- Intermittent binge eating
- Laxative Use
- Over Exercising
- Drug Use