W ith the problems of obesity and disordered eating growing in the United States and around the world public health professionals have focused research efforts on identifying potential causes and treatments for these related problems. The most obvious advancement made by this work has been the introduction of a diagnostic category for binge-eating disorder (BED) in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-R). In addition, there is a growing body of literature on binge-eating and obesity that has attempted to define the prevalence, causes, effects, and treatment options for this relatively new disorder. Dieting, in particular, has been implicated as a possible causal factor in the development of both BED and related obesity.
Binge-eating was first identified in i959 by Albert Stunkard as a distinctive pattern of eating observable in some obese persons (Stunkard 1959: 588-91; Spitzer 1991; Devlin et al. 2003: 627). In the following decades, there was much debate amongst clinicians about how to differentiate BED from already diagnosed "non-purging" forms of bulimia nervosa; it was not clear to many researchers that BED should be a separate diagnostic category (Spitzer 1991; Devlin et al. 2003: 627; Yanovski 1995: 403-4). Nevertheless, in 1991, a core group of eating-disorder clinicians and researchers recommended that BED be entered into the DSM-IV as a diagnosable eating disorder (Spitzer 1991; Devlin et al. 2003: 628). Today, BED is part of the Eating Disorder Not Otherwise Specified (EDNOS) category and appears in Appendix B
of the DSM-IV, among the "Criteria Sets and Axes Provided for Further Study" with roughly the same criteria recommended by Robert Spitzer and his colleagues in 1991. The DSM-IV research criteria for BED are (American Psychiatric Association; Grilo 2002: 178-9; Spitzer 1991; Yanovski et al. 1995: 139):
• Recurrent episodes of binge-eating, characterized by both eating an amount of food in a discrete period of time (two hours) that is definitely larger than most people would eat and a sense of lack of control over eating during the episodes.
• The binge-eating episodes are associated with three (or more) or the following: eating much more rapidly than normal, eating until uncomfortably full, eating large amounts of food when not physically hungry, eating alone because of embarrassment about the amount of food eaten, and feeling disgusted with oneself, depressed, or very guilty after overeating.
• Marked distress about binge-eating is present.
• Binge-eating occurs at least twice a week during a six-month period.
• The binge-eating is not associated with regular use of inappropriate compensatory behaviors (purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Yet, while BED is now recognized as a category distinct from bulimia nervosa (BN), researchers have struggled since the mid-1990s to sort out how to diagnose and treat this disorder, which overlaps and is frequently confused with BN and behavior subtypes of obesity (Devlin et al. 2003).
In addition, even though binge-eating is the central diagnostic criterion of BED and is generally considered to be a pathological form of eating, it is also present in non-clinical male and female populations (Waller 2002: 98), and many non-eating-disordered individuals may engage in some form of binge-eating at various times in their lives. In fact, a significant number of people engage in normative binge behaviors on holidays like Thanksgiving and Christmas, which can be attested to by the proliferation of articles like "Holiday Stress: A Recipe for Overeating?" (MSNBC) and "Your Stay Slim Holiday Survival Plan" (Prevention 2006). However, BED as a diagnosable mental disorder is distinct and affects a much smaller portion of the population than normative and occasional overeating.
Still, the complex overlap between BED and other eating disorders and BED and normative overeating may make it more difficult to exactly describe the prevalence of BED in the general population. Some studies have indicated that as much as 25-30 percent of obese people who enter treatment programs are suffering from BED (Spitzer et al. 1991: 138; Hsu et al. 2002: 1398; Yanovski 2003: S118). The high occurrence of BED in obese people seeking weight-loss treatment has led researchers to investigate the relationship between dieting, psycho-pathology, and BED in greater depth.
Information disseminated to the public by popular media also suggests that dieting can cause obesity and act as a "trigger for eating disorders" (Hunter 1999: 45; MSNBC; Hill 2004; Cannon and Einzig 1984). Certainly, the popular media has overwhelmingly suggested that overeating is an attempt to assuage emotional distress (Levine 1999; Roth 1982). There is some evidence to suggest that dieting does play a role in onset of binge-eating (Cannon 2005: 569; Wadden et al. 2004: 560). Studies testing restraint theory (the theory that says we are more likely to overeat if we attempt to restrain our eating) have shown that individuals who are currently dieting are more prone to overeat if they feel that they have broken their diets or if they experience disappointment or boredom (Howard and Porzelius 1990: 28; Lowe 1995: 88-9). Obese binge eaters generally report a history of frequent and extensive dieting (Howard and Porzelius 1990: 25; Devlin et al. 2003: S8; Giusti et al. 2004: 47). Yet this dieting history has not been shown definitively to precede or cause BED.
In studies of normal-weight patients with bulimia nervosa, dieting has been shown to nearly always precede binge-eating, and some researchers have suggested that dietary restraint may precipitate binge-eating in the bulimic patient (Devlin et al. 2003: S8; Howard and Porzelius 1990: 26). Furthermore, a 1993 study demonstrated that dietary restraint prescribed by a Very Low Calorie Diet induced binge-eating behaviors in patients who had no prior history of BED (Telch and Agras 1993; Howard and Porzelius 1990: 36; Wadden and Berkowitz 1995: 53 5). These studies, together with anecdotal evidence, point to the potential of dietary restraint to cause overeating and may implicate dieting in the development of BED; however, not all studies have found such an association (Wadden and Berkowitz 1995: 555-6; Reas and Grilo 2006: 2; Howard and Porzelius 1990: 31; Yanovski 1995: 404).
Even though no direct causal link has been made between dieting and onset of BED, weight status and dieting in childhood or adolescence do appear to be predictive of BED development (Reas and Grilo 2006: 2; Howard and Porzelius 1990: 30; Spitzer et al. 1991: 143 and 146). This evidence suggests that a history of repeated dieting attempts and failures plays an important role in development of BED, which may be a risk factor for extreme obesity (Howard and Porzelius 1990: 31; Hsu et al. 2002; Spitzer et al. 1991: 146). Some researchers have even gone so far as to suggest that treating BED may help to alleviate somewhat the growing obesity epidemic (Yanovski 2003: S117-S118).
Available treatments for BED include cognitive behavioral therapy (CBT), group therapy, and drug therapy (National Institute of Diabetes and Digestive and Kidney Diseases 2004). CBT has been shown to be effective in reducing disordered eating behaviors in BED patients, but it unfortunately has little impact on actual body weight when not combined with surgical or other dietary treatments (Vaidya 2006: 92; Wilfley 1995: 3512). Similarly, drug therapy appears to alleviate BED in the short term, but medication alone is not effective in the long term for most patients with BED (Devlin 1995: 356). Some people suffering from BED also use self-help methods with varied success, and others join support groups. Overeaters Anonymous (OA) is one of the most well-known support groups for people suffering from BED or compulsive overeating, which is sometimes referred to over-simplistically as an addition to food. While only a few studies have been done on the effectiveness of support groups in treating BED, their findings suggest that, when combined with other methods like CBT, these groups may provide important support for people struggling with compulsive overeating (Ghaderi 2006: 307; Stefano et al. 2006: 457-8; Wilfley 1995: 352).
Now that BED has been identified and studied as a diagnosable eating disorder, the etiology of compulsive overeating and the effects that it has on people's lives are becoming more evident. Research has shown that, while depression and anxiety may be factors in the development of BED, the disorder cannot simply be attributed to emotional overcompensation. Furthermore, restrictive eating may play a role in overeating behaviors, but dieting cannot be said to directly cause BED. Finally, because BED negatively impacts quality of life in substantial ways
(Rieger et al. 2005: 237), we can see that treatment of the underlying causes of BED in obese individuals is just as important as weight loss. Despite all that we have learned since Stunkard first recognized binge-eating in 1959, clinicians are still working on effective methods for diagnosing and treating BED and related obesity, and all agree that more research is necessary.
SLG/C. Melissa Anderson
See also Anorexia; Eating Competitions; Obesity Epidemic; Psychotherapy and Weight Change; Religion and Dieting; Very-Low-Calorie Diets
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