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

Finally, the last criteria for BED—which remains unchanged from the provisional criteria in DSM-IV-TR —is essentially a rule-out that states that BE should not be accompanied by the regular use of “inappropriate compensatory behaviors” or exclusively occur during the course of anorexia or bulimia. These criteria have also been criticized as being subjective, particularly in light of the fact that individuals with BED often report a history of infrequent purging behavior and frequently engage in weight-loss attempts [6,13,14]. However, the need for a rule-out is clear given that BE also occurs during the course of bulimia and anorexia, binge-eating/purging type, and it is supported by the low rates of crossover from BED to bulimia and/or anorexia [26].

Remission and severity specifiers are new to DSM-5. With respect to the latter, a recent study observed small but significant elevations in eating pathology among those with moderate severity BED, relative to the eating pathology experienced by those with mild severity, but there were no differences in level of associated depression. Interestingly, a better differentiator of severity of eating pathology and depression among patients with BED was overvaluation of shape/weight [27]. As such, the primary care physician might be better advised to focus on indicators of this important variable by querying the extent to which the patient’s shape and weight have influenced how she feels about (judges/thinks/evaluates) herself as a person, rather than using the number of BED symptoms alone as the indicator of severity.

• What is the epidemiology of BED?

Based on DSM-IV-TR criteria, the overall lifetime prevalence rate for BED has been reported to be 2.8%, and it is more common in women (3.5%) than men (2%) [28]; the overall 12-month prevalence rate is 1.2% (1.6% in women and 0.8% in men) [28]. Using DSM-5 criteria, a recent study observed that lifetime prevalence of BED by age 20 was 3.0% for BED and an additional 3.6% for subthreshold BED, with peak age of onset (for both) between ages 18 to 20 years [29]. Notably, even though prevalence rates are slightly higher using DSM-5 criteria (presumably, due to the relaxed criteria for frequency and duration of binge eating), effect sizes for impairment are also higher, suggesting that the revised criteria are not identifying BED cases marked by less impairment [29]. Although often thought of as a disorder common among young women, BED prevalence among middle-aged women (40–60 years) has a prevalence of at least 1.5%, with additional subthreshold cases being common in this age-range; groups meeting full BED criteria and subthreshold cases are both characterized by high levels of distress and impairment [30].

Gender Differences

Men engage in overeating as much or more than women but are less likely to endorse a loss of control and/or distress associated with BE [28,31], and thus are less likely to meet full BED criteria. However, when men do meet criteria for BED, they experience as much clinical impairment as their female counterparts [32]. Additionally, men’s BE may be more directly affected by body image dissatisfaction than women’s BE, and although it is associated with negative affect, it is less likely to be associated with interactions between negative affect and dietary restraint than seems to be the case for women [33]. In addition, in the primary care setting, men with BED were strikingly similar to their female counterparts on most historical and developmental variables [33]. However, men reported more frequent strenuous exercise, whereas women reported that onset of overweight and dieting occurred earlier in life [34]. That same study observed that men (57%) were more likely than women with BED (31%) to meet criteria for metabolic syndrome, even after controlling for race and BMI. A second study by the same research group again demonstrated that men with BED are more likely to show elevated blood pressure, triglycerides, and meet criteria for metabolic syndrome, whereas women are more likely to have elevated total cholesterol [35].