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

Race/Ethnicity

The evidence related to rates of BED among ethnic minorities is equivocal, with some studies demonstrating that Caucasian women are more likely to experience clinical levels of BED symptoms [36,37], others finding comparable rates between Caucasian and African-American women [38,39], and still others discussing the possibility of finding the greatest rates of binge eating in ethnic minority samples [40], especially in light of the high rates of obesity observed in some ethnic minority groups [41,42]. Studies that focus on subclinical levels of eating pathology among undergraduate students are most likely to find significant ethnic differences, while studies of nonclinical samples utilizing diagnostic threshold find the fewest differences [43]. There is at least some research demonstrating the highest rates of body image disturbance or eating problems among Asian Americans [44,45]. In addition, Latino individuals with BED may have higher levels of ED-related psychopathology as compared with Caucasian individuals [46]. Finally, Caucasian individuals who experience BED may be more likely to utilize mental health services as compared with other ethnic groups [47].

Age

Lower rates of BED have been documented in elderly individuals relative to their younger counterparts in population-based studies [28]. However, this may be due to recall bias, birth cohort effects, restricted access to studies, and/or increased medical morbidity leading to premature mortality [48]. Guerdjikova et al [48] also noted that many treatment outcomes studies have exclusion criteria related to age. This is unfortunate, as elderly individuals and their younger counterparts appear to exhibit similar levels of BE behavior, distress due to BE, weight and shape concerns, psychiatric comorbidity, and obesity. However, elderly individuals have reported later onset, longer duration of illness, and less medical morbidity [48]. In another study, Mangweth-Matzek et al [30] surveyed women between the ages of 40 and 60; they found that very few respondents met full criteria for an eating disorder. However, when criteria were relaxed (ie, dropping associated symptomology for BED and frequency criteria for bulimia nervosa) an additional 4.8% of the sample met criteria. Notably, women with subthreshold eating disorders reported very similar levels of comorbid psychopathology as women whose symptoms met diagnostic criteria.

• What tools are available for assessment of BED in the primary care setting?

Two of the most commonly used questionnaires in specialty clinics are the Eating Disorders Examination– Questionnaire (EDE-Q [49]), and the Questionnaire on Eating and Weight Patterns – Revised (QEWP-R [50]). In the primary care setting, both appear to be low-cost and time-efficient methods of screening for BED. The EDE-Q, however, may underestimate frequency of binge eating episodes and overestimate the extent of eating-related pathology [51]. Notably, the QEWP has been revised to reflect DSM-5 criteria and is available free of charge (QEWP-5 [52]). The Binge Eating Scale [53] is a 16-item scale often used to assess severity of binge eating; it is free and easily accessible online. Regardless of what measure is used, research indicates that a higher proportion of people agree to having episodes where they ‘‘lose control over eating’’ than when asked about having episodes of ‘‘binge eating’’ [54], so asking about loss of control over eating might be the more advisable way to open the discussion with patients about their eating behavior. In assessing for binge eating, physicians should also be aware of some of the differences in clinical presentation observed for ethnic minorities (eg, lower drive for thinness among African-American women) as well as some research demonstrating that measures such as the Eating Disorder Diagnostic Scale do not assess equivalent constructs in African-American and Caucasian clients [55]. Finally, while self-report measures often serve a practical function of quickly assessing a large group, physicians may want to consider relying on interview-based techniques for clients with lower levels of education attainment and literacy; at least one study has demonstrated problems with readability and comprehensibility with most BED measures [56].