From time to time, most of us overeat. Maybe we take another helping at a meal. Maybe we finish a whole pint of ice cream in one sitting. But at what point do these instances of overeating become a concern for a more serious, underlying problem: binge eating disorder (BED)?
BED is the most common eating disorder in the US, says the National Eating Disorders Association (NEDA). And it’s very different from just the occasional food binge. Here’s why clinicians say it’s something that may require treatment.
What exactly is BED?
BED in an eating disorder. Not only is BED the most common eating disorder in the country, but it’s also the newest one to be officially recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM–5)—the tool that clinicians use to diagnose eating disorders. Added to the DSM-5 in 2013, BED is characterized by repeated episodes of eating an amount of food that is more than what other people would eat in the same short time frame (usually within two hours).
A person with BED will binge eat, on average, at least once a week for three months. During these binges, a person feels a loss of control—as though they can’t stop eating or manage what or how much they’re eating. The behavior makes them feel distressed.
To meet the BED diagnostic criteria, the person must also do at least three of the following during (and, for the last, after) the binge:
- Eat much quicker than normal.
- Eat until they feel uncomfortably full.
- Eat large amounts of food even though they aren’t physically hungry.
- Eat alone because they are embarrassed by how much they’re eating.
- After the binge, feel depressed, guilty, or disgusted with themself.
People with bulimia nervosa will binge eat too. But with BED, and unlike bulimia nervosa, there is no act afterward to undo or make up for what was eaten, such as self-induced vomiting.
Debra Safer, MD, an associate professor in the Department of Psychiatry at Stanford University and the co-director of the Stanford Adult Eating Disorders Program, tells Health that a common misconception is that BED is just a lack of willpower. That is certainly not the case. “People [with BED] have a ton of willpower in so many ways in their lives,” she says. Their condition is complex, with biological, psychological, and societal underpinnings, she explains. “But it’s not a choice,” Dr. Safer adds. “No one wants to have an eating disorder.”
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What is considered a large amount of food?
Again, one of the defining features of BED is eating a large amount of food, usually within a two-hour window. Safer admits that “large” is a pretty vague definition for the amount of food someone eats during a binge. So, she says, most clinicians and patients have to use their own judgment.
And remember, that large amount of food is compared to what other people would typically eat, not only in the same time frame but also in the same context. So eating a lot during a Super Bowl party or at a holiday dinner wouldn’t really count as a binge-eating episode because everyone there is probably eating just as much. “I think what distinguishes a person with an eating disorder is the repetitive pattern of this kind of eating and the way it starts to take up so much space in someone’s mind. It becomes a defining feature that this person has lost control. They feel that food dominates their life,” Dr. Safer says.
What types of food do people binge?
According to Ariana Chao, PhD, an assistant professor at the University of Pennsylvania School of Nursing and the medical director at the Center for Weight and Eating Disorders at the Perelman School of Medicine at the University of Pennsylvania, the type of food that someone with BED binges on varies person to person. However, while she has seen patients who say they binge on carrots or other vegetables, she says it is more often higher-calorie, energy-dense foods that are easier to consume in larger quantities (think ice cream, cookies, or pizza) that most people eat during their binges.
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Who develops BED?
Compared to other types of eating disorders, BED develops later in life—typically in your early 20s, Chao says. And while BED tends to affect twice as many women than men, she says that the rates of BED are comparable across different racial and ethnic groups.
Although a person of any weight can develop BED, those with BED tend to be of normal or higher-than-average weight. And according to the NEDA, of people with BED, up to two-thirds are considered clinically obese (though most people who are considered clinically obese do not have BED).
As far as factors that can increase the risk of developing BED, stress or depression might be two. Some people may turn to food for comfort, as a coping mechanism to deal with negative emotions. Having been on a diet and developed a rigid, black-and-white mindset around eating (this food is bad, this food is bad) can also be a risk factor. “Just the way society is, with there being so much food around us, oftentimes it’s really hard for us to be exposed to these cues and not give in sometimes,” Chao explains. “So if someone has some of that rigid thinking, it might precipitate binge eating, especially if they feel like they’re not supposed to have that food. And if they do have that food, then they develop guilt and shame.”
What are the warning signs?
Weight fluctuation—both up and down—can be a sign of BED, according to Chao. She says that BED can be associated with weight and shape concerns, and so a person with BED may be having some distress over those factors as well.
Noticing that large amounts of food have disappeared in short periods of time or that there are a lot of empty wrappers and containers around can also be signs that someone you know has BED, according to NEDA. Someone with BED may also steal or hoard food in strange places, stop hanging out with friends or participating in usual activities, be worried about eating in public, or have gastrointestinal issues.
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What are the health risks?
BED can lead to weight gain and obesity over time. And so, a lot of the health risks that come with BED are the same health risks that are associated with obesity, according to NEDA. For instance, Chao points out that research has shown that BED increases the risk of type 2 diabetes and high blood pressure.
BED can also have health consequences similar to those of weight stigma, including depression, body dissatisfaction, and low self-esteem, NEDA points out.
What does treatment look like?
The goal with treating an eating disorder is to make it so that what somebody eats is not the defining piece of their life, Dr. Safer says. “We don’t want food to take up so much room, because then you’re missing out on so much of your life,” she explains. “…Societal repercussions are huge, and people with BED are more likely to have work problems; they’re not functioning in the ways that they could.”
There are two main treatment options available, and the treatment someone gets all depends on which would be most effective for that particular person. For most people, that treatment is cognitive behavioral therapy (CBT), which has been proven to lower the amount of binge eating episodes over time. Administered by a clinician either individually or in a group setting, CBT focuses on identifying different thoughts, feelings, and behaviors related to binge eating. By addressing those factors, Chao says that healthier eating behaviors can be developed over time, such as having a regular eating schedule (like three meals and two snacks a day).
While CBT might be most effective for people who don’t eat regular meals and then binge, Dr. Safer says that interpersonal psychotherapy (IPT) might be good for those who have a regular eating schedule but who may be driven to binge due to interpersonal issues, say, after an argument. IPT may also be effective for those who feel as though their interpersonal skills are not the best and that their food is almost like a friend to them.
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When should treatment be considered?
Again, there’s no definitive definition of what “a large amount of food” is. Instead, Dr. Safer suggests focusing more on other BED red flags—such as whether you are eating when you’re not physically hungry; eating in secret; or feeling a sense of regret, remorse, disgust after eating—because those are the factors that separate somebody who’s overindulged from someone who has an eating disorder. “It’s the loss of control that’s really the defining thing. And even if it’s not a lot of food but they feel like they’ve lost control, that’s a problem,” Dr. Safer says. “If a person is concerned and worried about their pattern of eating, they should [go] in and see somebody.”
During an initial visit, the clinician will probably ask about a person’s different eating episodes as well as about their shape and weight concerns, according to Chao. In appointments with patients, she asks about their weight history and view on certain foods.
Taking the step to set up that initial doctor’s appointment can be anxiety-provoking, though: “I think it’s important to recognize that it can be very scary and challenging and stressful to think that someone has [BED],” Chao says. “It also can be very embarrassing for people to admit they’re having this happen. So if a person does feel comfortable enough to tell someone else, that’s a really great sign they’re trying to get help for the behavior.”
And recognizing that there is even the opportunity for help is key. “Some people will say, ‘I’ve always been eating like this my whole life,’ and I think the recognition that there are treatments available that are helpful, evidence-based, and that work is really important,” Chao says.
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