I’m embarrassed to say that my knowledge around binge eating disorder (BED) is sorely lacking compared to my understanding of the prevalence, correlates, treatments for, experiences of, and recovery from anorexia nervosa, bulimia nervosa, and OSFED (I still prefer “EDNOS,” but I’ll go with DSM 5 here). I don’t think this knowledge gap is uncommon; I’ve seen BED mentioned as a passing note in many an article, despite a general awareness that BED is relatively common. In order to begin to fill this knowledge gap (allow me a little self-indulgence as I fill this knowledge gap “out loud,” here), I thought I’d do a little reading and writing around BED. I also look forward to engaging in the comments, if you’re more savvy than I in this realm.
We know that BED is relatively common; general prevalence ranges from 0.7-4% (Latner & Clyne, 2008). In certain samples, for example people pursuing obesity treatment, this prevalence rate jumps to 15-50% (Johnson, Spitzer & Williams, 2001) (note, of course, that this large discrepancy might be partially due to the fact that those who are seeing doctors about weight-related issues could be more likely to report binge eating than people in the general population, who may not go to the doctor to seek help with binge eating). Though it has been on the radars of eating disorder clinicians for some time, and in 1994 the APA earmarked BED as a diagnosis “to watch,” placing it under EDNOS as a sub-category in the DSM-IV, BED was only introduced into the DSM as a diagnostic category unto itself in 2013 with the introduction of the DSM 5 (Myers & Wilman, 2014).
Despite its diagnostic “newness,” there is likely not much “new” about BED’s symptoms, which include binging type behaviours without compensatory behaviours (such as vomiting or exercise). Still, and as I mentioned, BED has arguably been less studied than other eating disorders. One area of focus where research lags is age of onset and association with prognosis: in other words, when is binge eating disorder likely to start, and how does this start time impact how well one fares as they seek to recover?
Brewerton, Rance, Dansky, O’Neil & Kilpatrick (2014) conducted a study about BED in which they used a (US) nationally representative sample to compare child/adolescent and adult onset BED in women. In this post, I’ll highlight the authors’ findings and what they mean for our increasing understanding of BED and how to support those experiencing BED.
The authors chose to use a nationally representative sample of 3006 women in the United States (from the National Women’s Study) to increase the reach of their findings beyond clinical populations. Women’s ages ranged from 28.8 to 63.4 (mean 46.1).
In terms of relationship between age of onset and future outcomes, they hypothesized that child-adolescent onset binge eating would be related to:
- A diagnosis of BN or BED later in life
- More severe BN/BED
Looking at which factors might be related to the development of BED, Brewerton et al. hypothesized that BED development would be more likely (across ages of onset) in those with a history of:
- Post-traumatic stress disorder (e.g. depression, substance abuse)
- Other psychiatric issues
Tying these together, the authors suggested that there would be a relationship between when binge eating started and when trauma/psychiatric issues had occurred.
The study took place over 3 waves beginning in 1989; this analysis is based on respondents from the third wave, which unlike the other 2 waves included questions related to experiences of disordered eating. 3,006 women were interviewed, of whom 23.5% had experienced binge eating over the course of their lives. Of these 707 women who had experienced binge eating (note: binge eating, not necessarily diagnosed BED):
- 30% reported binge eating beginning in childhood-adolescence, with an average age of 13.9 (range 11.1-16.7) at first binge
- 70% reported binge eating beginning in adulthood, with an average age of 27.7 (range 16.7-38.7) at first binge
As Brewerton et al. expected, binge eating in childhood-adolescence was related to an increased likelihood of developing BN or being diagnosed with an eating disorder later in life. However, there were no significant differences between the groups in terms of being diagnosed with BED itself; notably, only 30 women in the group had been diagnosed with BED. Bear in mind, however, that wave 3 (during which time these women were interviewed) was prior to BED’s classification as eating disorder in the DSM.
Interestingly, those who reported child-adolescent onset binge eating also tried dieting at an earlier age and reaching their highest adult weight at an earlier age; could this reflect in part the kind of dieting cycle that essentially means dieting rarely works?
Those who began binging in childhood and adolescence also engaged in disordered behaviours to a greater extent and severity, including diuretic use and excessive exercise, and were much more likely to have been to treatment for their eating disorder. 50.5% of the child-adolescent onset group binged several times per week, versus 40.6% of the adult-onset group.
The child-adolescent onset group were also more likely to have:
- Experienced major depression earlier
- A history of trauma (except disaster-related trauma) and at a younger age
- Been abused
- Been dependent on alcohol
- Smoked (past or present)
- A family member with emotional difficulties or drug problems
- Experienced PTSD over the course of their life
Despite these differences, there were no major between-group differences in terms of:
- Lifetime prevalence of major depression
- Current PTSD/associated symptoms
- Lifetime engagement in purging behaviours
- Minimum/maximum BMI
- Age at lowest weight
- Family members with drinking problems or history of arrest
First binge episodes were related to age at:
- First trauma
- Serious accident
- Natural disaster
- Witnessing violence
- Experiencing a major stressor
- Survival attempted homicide
- Trying a serious diet
- Being overweight
- Being at one’s lowest weight
- Having persistent depressive symptoms
- First alcoholic drink
- First use of some drugs (marijuana and cocaine)
The relationship between childhood or adolescent onset binge eating and negative eating disorder outcomes later in life is quite an interesting finding that could help us to intervene earlier in the development of eating disorders. Brewerton et al. hone in on the relationship between onset of binge eating and trauma; they note that first binge episodes often followed or co-occurred with first trauma in both childhood-adolescence and adult groups.
I also think that the relationship between binge eating and dieting warrants further comment; the finding that first binge episode was related to age when a person first tried a serious diet is telling. This isn’t really anything new, I suppose, as it is well established that dietary restriction often triggers binge eating. However, given the tie-ins between childhood onset binge eating and incidence of eating disorders later in life, it is especially important to take these kinds of findings seriously. While change at the individual level anti-dieting initiatives (i.e., telling people not to diet or to love their bodies) may not result in meaningful or lasting changes, targeting broader structures that promote diet culture and equate bodies with morals might.
I find it interesting that only 30 women in the sample had been diagnosed with BED, and would be quite curious to see whether the new diagnostic criteria for BED would alter the results in any way. As I mentioned earlier, the time at the interview (during which participants were asked to reflect on past experiences), BED was not well recognized in the psychiatric canon. Thus, I would think it unlikely that many people would seek out the diagnosis of BED. Of course, I tend to assume that any prevalence of BED in particular (and eating disorders in general) is an underestimate due to the stigma and misunderstanding that (distressingly) continues to plague eating disorders.
The authors comment on the predictive value of their findings, which I do think is an important conclusion; basically, early screening for binge eating might provoke action toward treating disordered eating prior to the development of a “clinically significant” eating disorder. Again, I’ll let my biases show and suggest that screening for binge eating might be especially important in a time at which anti-obesity efforts abound that may subtly (or not so subtly, in the case of things like the Georgia campaign against childhood obesity) tell children that they are the source of the obesity epidemic. We need to be incredibly mindful about the types of strategies deployed in the name of “public health,” lest they provoke unhealthy behaviours like restrictive dieting and binge eating.
Brewerton, T.D., Rance, S.J., Dansky, B.S., O’Neil, P.M., & Kilpatrick, D.G. (2014). A comparison of women with child-adolescent versus adult onset binge eating: results from the National Women’s Study. The International journal of eating disorders, 47 (7), 836-43 PMID: 24904009