Evidence-Based Reviews

Beating obesity: Help patients control binge eating disorder and night eating syndrome

Current Psychiatry. 2006 June;5(6):17-28

References

1. Taraldsen KW, Eriksen L, Gotestam KG. Prevalence of eating disorders among Norwegian women and men in a psychiatric outpatient unit. Int J Eat Disord 1996;20:185-90.

2. Lundgren JD, Allison KC, Crow S, et al. Prevalence of the night-eating syndrome in a psychiatric population. Am J Psychiatry 2006;163:156-8.

3. Streigel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eating Disord 2003;34:S19-S29.

4. Striegel-Moore RH, Wilfley DE, Pike KM, et al. Recurrent binge eating in black American women. Arch Fam Med 2000;9:83-7.

5. Marshall HM, Allison KC, O’Reardon JP, et al. Night eating syndrome among nonobese persons. Int J Eat Disord 2004;35:217-22.

6. Spitzer RL, Yanovski S, Wadden T, et al. Binge eating disorder: its further validation in a multisite study. Int J Eat Disord 1993;13:137-53.

7. Fairburn CG, Cooper Z, Doll HA, et al. The natural course of bulimia nervosa and binge eating disorder in young women. Arch Gen Psychiatry 2000;37:659-65.

8. Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003;289:187-93.

9. Rieger E, Wilfley DE, Stein RI, et al. A comparison of quality of life in obese individuals with and without binge eating disorder. Int J Eat Disord 2005;37:234-40.

10. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric co-morbidity in obese subjects. Am J Psychiatry 1993;150:1472-9.

11. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res 2001;9:264-7.

12. Stunkard AJ, Allison KC. Two forms of disordered eating in obesity: Binge eating and night eating. Int J Obes Relat Metab Disord 2003;7:1-12.

13. O’Reardon JP, Peshek A, Allison K. Night eating syndrome: Diagnosis, epidemiology, and management. CNS Drugs 2005;19:997-1008.

14. Agras WS, Teich CF, Arnow B, et al. One-year follow-up of cognitive-behavioral therapy for obese individuals with binge-eating disorder. J Consult Clin Psychol 1997;65:343-7.

15. Cloak NL, Powers PS. Are undiagnosed eating disorders keeping your patients sick? Current Psychiatry 2005;4(12):65-75.

16. Kushner RF, Roth JL. Medical evaluation of the obese individual. Psychiatr Clin North Am 2005;28:89-103.

17. Wonderlich SA, de Zwaan M, Mitchell JE, et al. Psychological and dietary treatments of binge eating disorder: conceptual implications. Int J Eat Disord 2003;34:S58-S73.

18. Grilo CM, Masheb RM. A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge-eating disorder. Behav Res Ther 2005;43:1509-25.

19. Wilfley DE, Welch RR, Stein RI, et al. A randomized comparison of group cognitive-behavioral therapy and group interpersonal therapy for the treatment of overweight individuals with binge eating disorder. Arch Gen Psychiatry 2002;59:713-21.

20. Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol 2001;69:1061-5.

21. Pendleton VR, Goodrick CK, Poston WS, et al. Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Int J Eat Disord 2002;31:172-84.

22. Agras WS. Pharmacotherapy of bulimia nervosa and binge eating disorder: longer-term outcomes. Psychopharmacol Bull 1997;33:433-6.

23. Clinical guidelines on the identification evaluation and treatment of obesity in adults Executive summary, 1998. Bethesda, MD: National Heart, Lung, and Blood Institute. Available at: http://www.nhlbi.nih.gov/guidelines/obesity. Accessed April 18, 2006.

24. Tsai AG, Wadden TA, Womble LG, Byrne KJ. Commercial and self-help programs for weight control. Psychiatr Clin North Am 2005;28:171-92.

25. Wadden TA, Foster GD, Sarwer DB, et al. Dieting and the development of eating disorders in obese women: Results of a randomized controlled trial. Am J Clin Nutr 2004;80:560-8.

26. Pawlow LA, O’Neil PM, Malcolm RJ. Night eating syndrome: Effects of brief relaxation training on stress, mood, hunger, and eating patterns. Int J Obes Relat Metab Disord 2003;27:970-8.

27. O’Reardon JP, Stunkard AJ, Allison KC. A clinical trial of sertraline in the treatment of night eating syndrome. Int J Eat Disord 2004;35:16-26.

28. Winkelman JW. Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate. Sleep Med 2003;4(3):243-6.

29. Friedman S, Even C, Dardennes R, Guelfi JD. Light therapy, obesity, and night-eating syndrome. Am J Psychiatry 2002;159:875-6.

Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.²²

Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.⁹

Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.²³ Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.²⁴

Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:

1,000 kcal/d liquid meal replacement
1,200 to 1,500 kcal/d diet of conventional food
a non-dieting approach to weight control.

Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.²⁵

Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.²²

Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.

We recommend that you base each patient’s treatment on five factors:

treatment availability and cost
past treatment response
patient preference
psychiatric and medical comorbidities
BMI and past weight-loss experience.

For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.

Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment²³ when advising patients about exercise and weight loss.

Treating night eating syndrome

Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.²⁶

This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:

After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.²⁷
One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.²⁸
One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.²⁹

Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).

Related resources

For clinicians

Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.

For patients and clinicians

Anorexia and related eating disorders. www.anred.com (information about BED and NES).
Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
- Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
- Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov

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