Binge Eating Disorder in Adolescents

By Ellen Rome, MD, MPH

Brittany is a 15-year-old girl coming in for her school physical. Her mother pulls you aside while the nurse is getting her height and weight. Mom is concerned about Brittany’s rapid weight gain this past year, and wants her to be more active. Brittany is 5’5” (165 cm) and 185 lbs (83.9 kg), with a BMI of 30.8. What more do you need to know?

In order to distinguish between a lack of physical activity, overeating and disordered eating, you’ll need to have more details about the patient’s eating habits, including how much she eats, where and when she eats, and how she feels afterward. Does she eat at regular mealtimes? Does she eat until she is uncomfortably full? Does she tend to eat alone or with friends and family? Does she feel guilty about her intake? Are there compensatory behaviors? Is Brittany dissatisfied with her body weight or shape? Are there undiagnosed or undertreated mental health issues, such as depressive symptoms?

Eating disorders can lead to serious health problems, and as in many other disorders, primary care physicians play an important role as front line and long-term providers in a successful multidisciplinary treatment team. In order to detect eating disorders, one must be aware of the risk factors, as well as signs and symptoms of a range of eating disorders, including anorexia nervosa and bulimia nervosa, as well as binge eating disorder. Understanding common myths related to eating disorders may also impact necessary patient communication.

Common myths about eating disorders in adolescents

Myths about eating disorders abound. For instance, we often hear, “Only thin people have eating disorders,” whereas disordered eating occurs in individuals of all shapes, sizes and ages. Another common myth is that only girls get eating disorders; boys get their fair share also, and transgender youth represent a subset at increased risk for disordered eating. Other myths are that minority populations don’t have eating disorders, nor do individuals from low socioeconomic backgrounds. Actually, eating disorders can be found in all walks of life, all genders and ethnicities, although recognition in lower income groups may represent a healthcare disparity to be addressed.

Another myth is that eating disorders are a phase; if that were true, it would be far easier to get kids into the next phase. One more common myth is that binges are “normal teen behaviors,” but the typical teen would not experience the same guilt or sense of loss of control as someone with binge eating disorder (BED). The last myth is that only thin patients have complications from eating disorders; in reality, BED can lead to all of the medical complications that come with overweight and obesity.

When does a binge count as disordered eating?

A standard teen “binge” — as might occur at a sleepover or family celebration — may result in some indigestion but does not come with the overwhelming sense of guilt or lowered self-esteem experienced by a young person with BED. Youth with anorexia nervosa may label a healthy, normal portion as a “binge,” but we relabel that a “subjective binge” since usually such eating does not approach even normal amounts of food. In contrast, BED involves eating higher amounts of food than the average person would normally eat. For some, these binges can be 10,000 calories; for others, it might be far lower, but equally beyond normal proportions, with accompanying guilt and sense of loss of control.

Binge eating disorder

Binge eating disorder occurs in about 1% to 3% of youth, with girls reporting binge eating twice as often as boys. Age of onset is a matter of question; we have youth as young as 5 years old already hiding what they eat, eating when not hungry, and with body image dissatisfaction. Formal diagnosis of BED tends to come in late adolescence.

According to the DSM-5, binge eating is defined as recurrent episodes of binge eating involving eating a larger amount of food than most people would eat in a discrete period of time, accompanied by a sense of lack of control over one’s eating during the binge. For BED, binges need to occur at least weekly for three months, with at least three of the five following characteristics:

• binges characterized by eating much more rapidly than normal
• eating until one feels uncomfortably full
• eating well beyond hunger
• eating alone out of embarrassment about how much is eaten
• feeling disgusted with oneself, guilty or depressed about binges.

In contrast to bulimia nervosa, where binges are accompanied by compensatory behavior, such as vomiting or hyperexercising, BED involves the same amount of distress but no compensatory behaviors. The bottom line is that binge eating disorder involves eating larger amounts than typical in a discrete period of time, with a sense of loss of control, and without compensatory behaviors to get rid of the calories.

BED can be an assault on a young person’s self-esteem. More research into common comorbidities is warranted; however, BED is associated with all of the morbidities of obesity, including hyperlipidemia, cardiovascular disease, hypertension and diabetes.

Treatment for binge eating disorder in youth

Only a handful of randomized controlled trials have looked at treatment for BED in youth. In adult BED, guided self-help cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT, or behavioral modification plus insight), and interpersonal psychotherapy have been evaluated, with CBT the most promising. For younger children and youth under 18 years, a parental component can help identify and change behaviors to support recovery rather than ongoing pathology. Strategies that may help include: family dinners, eating only at set meals and times and at the kitchen or dining room table (i.e., no food in front of the computer or television), keeping food out of the bedroom, incorporating family games, a family walk, or play time rather than a family trip to the refrigerator, and using distraction to help “outlast cravings.” Parents can also help by proportioning snacks and meals into finite plastic bags or reusable containers. Additionally, an adolescent with BED may benefit from parents’ packing their school lunch, even if the kid is “capable” of packing for themselves.

Importantly, distraction during “cravings” can be highly useful, as the craving tends to go away if delayed even for a little bit of time. Helping the young person differentiate from hunger and cravings can also be useful. If a 1 is “I’m so hungry, I could eat an elephant,” and a 10 is “I just ate the elephant”, we can help train young people to keep their hunger/eating between a 3 and 7. This kind of mindful or intuitive eating is a learnable skill.

In youth 18 years and older, lisdexamphetamine 30 mg has been approved for binge eating disorder. Prior to use of this medication, the young person should have an ECG to ascertain that she or he has a structurally normal heart. Lisdexamphetamine can help reduce cravings in a subset of youth with BED. Watch for mood disturbance, insomnia and disordered eating if the patient skips meals instead of simply succeeding at portion control. Medication in conjunction with counseling is likely to meet with longer term success, with further study warranted.

What’s the prognosis?

Eating disorders may last for years. Recovery in children and adolescents tends to go by the rule of thirds. One-third of people get better and go on to live normal, healthy lives. Another third of people get better, but when stressed slip back into abnormal eating attitudes and behaviors. The remaining third have a chronic and relapsing disorder. There is a need for further research on this topic. It is possible to retrain the body and to recover from BED, but we do not have exact data on recovery in youth. One thing seems clear though: the earlier an eating disorder is identified, the better, and early intervention helps prevent disordered eating attitudes and behaviors from becoming hard-wired in young people. We should aim to provide each patient with hope and strategies to aim for that top third of recovery.

Ellen Rome, MD, MPH, is Head of the Center for Adolescent Medicine at Cleveland Clinic Children’s. Dr. Rome is presenting on eating disorders in adolescents at the American Academy of Pediatrics 2019 National Conference & Exhibition.