Binge-Eating Disorder: Prevalence, Predictors, and Management in the Primary Care Setting

Case Study

Initial Presentation

A 35-year-old Caucasian woman schedules an appointment for her annual physical examination with her primary care physician. She reports generally good health but complains of low mood, joint pain, and difficulties managing her weight. Her blood pressure is managed with 100 mg/day of metoprolol. The only other medication she takes is birth control (ethinyl estradiol 20 mcg).

Physical Examination

During physical examination, it is determined that the patient is 5'6" and weighs 286 lb, with a body mass index (BMI) of 46.2 kg/m ², placing her in WHO obesity class III. The patient’s blood pressure is 130/85 mm Hg (medically managed), and her heart rate is 83 bpm. The patient states that she has been experiencing episodes of low mood off and on most of her life; she recently ended a relationship, which has exacerbated her symptoms. The physician states that the patient has gained a significant amount of weight since her last physical examination. The patient reports that she quit smoking 6 months ago and has since gained approximately 30 lb; she has considered smoking again to manage her weight.

• What are the diagnostic criteria for BED?

BED diagnostic criteria (Table 1) have been closely examined for their validity and clinical utility, and several have been the subject of intense debate in the BED literature. The first BED criterion, recurrent episodes of binge eating, refers to 3 essential components: amount of food, time period, and a subjective experience of loss of control. The majority of debate regarding this criterion revolves around the requirement for consumption of a “large amount of food.” There are 2 primary arguments against this criterion. First, it is inherently subjective and requires the person making the diagnosis to distinguish between normative food intake and excessive food intake [6]. There is also some debate as to whether or not individuals with BED actually consume large amounts of food when they binge. However, research supports that those with BED may consume over 1000 kcal during binge episodes, far more than those without BED who are asked to binge eat in the lab [7,8].

Nonetheless, a distinction has been made between objective binge-eating episodes (OBE) and subjective binge eating episodes (SBE) [9]. OBEs are binge eating episodes that meet the full criteria including a large amount of food and a subjective loss of control. SBEs, in contrast, are binge eating episodes that include a subjective loss of control but not a large quantity of food. If consumption of a large quantity of food is essential to the underlying pathology of BED, one would expect that OBEs and SBEs would be associated with different clinical characteristics. However, several studies have failed to find significant difference between individuals reporting OBEs and SBEs with regard to age, age of BE onset, BE severity, interpersonal problems, depressive symptoms, generalized psychopathology, and ED-related psychopathology [10–13]. Results regarding prognosis are mixed, with some suggesting that SBE more readily responds to placebo, while others suggest that SBEs are slower to remit than OBEs [11,13,14]. With respect to primary care, this literature suggests that it is not necessary for busy primary care physicians to devote time to understanding the amount of food consumed by the patient; if the patient perceives that her eating is out of control and excessive, that can generally be considered valid data in terms of considering a BED diagnosis, particularly when combined with even moderately overweight status.