Beating obesity: Help patients control binge eating disorder and night eating syndrome
These two eating disorders often can be treated successfully without referral to specialized centers.
Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.
Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:
- correcting eating disorder behaviors and thoughts
- identifying and managing psychiatric comorbidity
- identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
- helping them achieve and maintain a healthy (but realistic) body weight.
Characteristics of BED and NES
BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).
Provisional DSM-IV-TR criteria for binge eating disorder
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)
- The binge-eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of being embarrassed by how much one is eating
- Feeling disgusted with oneself, depressed, or very guilty after overeating
- Marked distress regarding binge eating is present.
- The binge eating occurs, on average, at least 2 days a week for 6 months.
- Binge eating is not associated with the regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Source: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
Provisional criteria for night eating syndrome
- Morning anorexia, even if the patient eats breakfast
- Evening hyperphagia, in which ≥50% of daily energy intake is consumed after the evening meal
- Awakening at least once a night and eating snacks
- Duration of at least 3 months
- Patient does not meet criteria for bulimia nervosa or binge eating disorder
Source: Birketvedt GS, Florholmen J, Sundsfjord J, et al. Behavioral and neuroendocrine characteristics of the night-eating syndrome. JAMA 1999;282:657-63.
Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,1 whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).2
Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.3 Binge eating may be more common among African-Americans than Caucasians.4
Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.7
Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.8 Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.9
Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:
- >6-fold for major depression
- >8-fold for panic disorder
- >13-fold for borderline personality disorder, compared with obesity alone.10
Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.11 They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.12 Most NES patients view their nocturnal eating as shameful,13 and distress and guilt are among the diagnostic criteria for BED.
Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.14
Diagnosis and evaluation
Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.
Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.15 Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).16 Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.
Differentiating characteristics of four eating disorders
Binge eating disorder
Sleep-related eating disorder
Snacks, unusual items
Awareness of eating
Low sleep efficiency
Treat sleep disorder; dopamine agonists
CBT: cognitive-behavioral therapy
SSRIs: selective serotonin reuptake inhibitors
Controlling binge eating
Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:
- The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
- Medications are less effective in reducing bingeing but are associated with modest weight loss.
Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.17 CBT techniques for BED adapt readily to self-help programs (Box 4).
In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:
- 46% with CBT
- 18.4% with behavioral weight loss
- 13.3% for controls.
Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.18 The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).
Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.
A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.19
Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.20
CBT principles for treating binge-eating disorder
- Keep detailed records of all dietary intake
- Look for patterns in timing, type, and amount of food eaten
- Note antecedents and consequences of binges
- Have 3 planned meals and 2 snacks per day
- Reduce cues to eat at other times
Substitute other behaviors for bingeing
- List pleasant alternate activities
- Recognize urges to binge
- Choose a substitute activity
- Review efficacy of substitute behaviors in preventing binges
Revise erroneous thinking patterns
- Reduce unrealistic expectations (especially about weight loss)
- Minimize self-criticism in response to lapses
- Change polarized thinking (“I’ve blown my diet; I may as well binge.”)
Limit vulnerabilities to relapse
- Reduce concerns about weight and shape
- Address problems with self-esteem, depression, or anxiety
- Maintain realistic expectations
Source: Fairburn CG. Overcoming binge eating. New York: Guilford Press; 1995.
Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.
Randomized, controlled trials of medications for binge-eating disorder (BED)
BED remission (%)
Weight loss (kg)*
20 to 60
100 to 300
20 to 80
50 to 300
50 to 200
50 to 600
* Difference between weight lost with drug and weight lost with placebo
† Sibutramine is a controlled substance (schedule IV) and is recommended only for obese patients with BMI ≥30 (≥27 if cardiac risk factors are present). Do not use with monoamine oxidase inhibitors or serotonergic agents, and monitor blood pressure.
Source: Carter WP, Hudson JI, Lalonde JK, et al. Pharmacologic treatment of binge eating disorder. Int J Eat Disord 2003;34:S74-S88
Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:21
- Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
- Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
- Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.
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.