The Psychological and Medical Factors Associated With Untreated Binge Eating Disorder

The Psychological and Medical Factors Associated With Untreated Binge Eating Disorder

David V. Sheehan, MD, MBA; and Barry K. Herman, MD, MMM

ABSTRACT

Objective: Although binge eating disorder (BED) is the most prevalent eating disorder, the impact of untreated BED is underappreciated. This review describes the relationship of BED to physical and mental health, quality of life, and functionality.

Data Sources: PubMed searches were conducted on March 21, 2014; searches were limited to English-language research articles, meta-analyses, and reviews published between January 1, 2003 and March 21, 2014. Search terms included (binge eating OR binge-eating OR binge eating disorder) AND (cardiovascular OR metabolic OR metabolic syndrome OR gastrointestinal OR health OR rehabilitation OR recovery OR sleep OR pregnancy OR quality of life OR functional impairment OR activities of daily living OR QoL OR SF-12 OR ED-5D OR SF-36 OR psychosocial OR depressive OR anxiety OR self-esteem OR suicidality OR suicide OR productivity OR family).

Study Selection/Data Extraction: Of 326 identified publications, 43 were relevant to the topic and reported on the association of BED with psychiatric and medical comorbidities, quality of life, and functional outcomes.

Results: Individuals diagnosed with BED have increased rates of mental health comorbidities (eg, depression and anxiety) and more pronounced medical impairments (eg, cardiovascular disorders) compared with individuals without BED. BED is also associated with functional impairment and reduced quality of life.

Conclusions: Binge eating disorder is associated with impairments in physical and mental health, which can decrease quality of life and functionality and lead to increased health care utilization and decreased productivity. However, some caution is warranted in interpreting these findings because it remains unclear whether BED is an antecedent condition, a complication associated with a comorbid psychiatric condition, or an unrelated feature that occurs concurrently with these comorbidities and impairments. Much of the research on BED is based on observational or epidemiologic studies. Controlled studies are needed to clearly define the long-term impairments associated with BED.

Prim Care Companion CNS Disord 2015;17(2):doi:10.4088/PCC.14r01732

© Copyright 2015 Physicians Postgraduate Press, Inc.

Submitted: October 7, 2014; accepted December 19, 2014.

Published online: April 23, 2015.

Corresponding author: David V. Sheehan, MD, MBA, Department of Psychiatry and Behavioral Medicine, University of South Florida College of Medicine, Tampa, FL 33613 ([email protected]).

Binge eating disorder (BED) has recently received formal recognition in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a distinct eating disorder among previously recognized eating disorders, such as bulimia nervosa and anorexia nervosa.1 Binge eating disorder is characterized by recurrent binge-eating episodes that occur during a discrete period of time and are associated with the consumption of more food than is typical of most people. Binge-eating episodes are associated with feelings of lack of control over eating during the episodes and marked distress. For a diagnosis of BED, binge-eating episodes must occur at least once a week for a minimum of 3 months. Furthermore, episodes of binge eating must not be associated with recurrent inappropriate compensatory behaviors and must not occur exclusively during the course of bulimia nervosa or anorexia.1 Although the BED diagnostic criteria in the DSM-5 remained essentially the same as in the DSM-IV-TR, the binge-eating episode frequency criterion in the DSM-5 (at least once a week for a minimum of 3 months)1 is less stringent compared with the DSM-IV-TR criterion (at least twice per week for a minimum of 6 months).2

Twelve-month prevalence rate estimates for BED based on DSM-IV-TR provisional diagnostic criteria indicate that 0.8%-1.2% of the population has BED, which is twice the 12-month prevalence estimate for bulimia nervosa (0.3%-0.4%).3,4 Lifetime prevalence rate estimates are also higher for BED compared with bulimia nervosa (1.9%-2.8% vs 1.0%, respectively).3,4 With the new DSM-5 criteria, BED lifetime prevalence estimates are projected to increase by approximately 3% compared with those diagnosed using DSM-IV-TR criteria5 because the frequency and duration of symptoms required for a DSM-5 diagnosis are less stringent.6 In addition to being more prevalent than bulimia nervosa or anorexia nervosa, BED is estimated to have a mean lifetime duration (14.4 years) that is longer than that of bulimia nervosa (5.8 years) and anorexia nervosa (5.7 years).7 Consistent with the longer overall lifetime duration of BED, persistence estimates based on the ratio of 12-month to lifetime prevalence indicate that persistence is higher for BED (44.3%) than for bulimia nervosa (37.3%).3 In contrast, persistence curves indicate that BED persists for a shorter period than bulimia nervosa (mean duration: 4.3 vs 6.5 years), suggesting that BED symptoms may fluctuate over time. These epidemiologic data suggest that BED is the most prevalent eating disorder and, based on estimated 0.8%-1.2% 12-month prevalence rates of BED3,4 and a US adult population estimate of approximately 240 million,8 affects approximately 2 to 3 million people in the United States.

Despite the fact that BED is more prevalent than other eating disorders, a 2004 survey of physicians found that > 40% of physicians never diagnosed BED in their patients.9 In addition, many individuals with BED have expressed a desire for an increased knowledge of BED and its associated comorbidities from their health care providers.10 Therefore, there is a need for increased awareness of BED and its associated comorbidities among primary health care providers. To more fully elucidate the relationship of BED to physical and mental health, quality of life, and productivity, this review examines the association of BED with impaired physical and mental health, function at work, social life, family life, home responsibilities, and quality of life. The impact of these pervasive impairments on increased health care utilization and decreased work productivity is also explored.

• Primary care clinicians should be aware that individuals with binge eating disorder are at increased risk for mental health comorbidities, including depression, anxiety, and substance use disorders.
• Primary care clinicians should be aware that individuals with binge eating disorder are at increased risk for developing medical comorbidities, including obesity, type 2 diabetes, hypertension, dyslipidemia, and gastrointestinal tract problems.
• The medical and mental health comorbidities in individuals with binge eating disorder most likely play important roles in the decreased quality of life, impaired role attainment and daily functioning, and increased health care utilization.

METHOD

A search of PubMed was conducted on March 21, 2014, that included the period from January 1, 2003, to March 21, 2014; the starting date roughly coincides with when the DSM-IV-TR was published. The search was restricted to titles and abstracts of English-language systematic reviews, meta-analyses, clinical trials, randomized controlled trials, journal articles, and letters. The search terms used were (binge eating OR binge-eating OR binge eating disorder) AND (cardiovascular OR metabolic OR metabolic syndrome OR gastrointestinal OR health OR rehabilitation OR recovery OR sleep OR pregnancy OR quality of life OR functional impairment OR activities of daily living OR QoL OR SF-12 OR ED-5D OR SF-36 OR psychosocial OR depressive OR anxiety OR self-esteem OR suicidality OR suicide OR productivity OR family). Additional references were added based on the authors’ knowledge of relevant articles in the published literature and on a review of the reference list from relevant articles in the literature search.

RESULTS

Summary of Search Results

A total of 326 publications were retrieved; 284 were eliminated as being nonrelevant to the purposes of this article based on a review of the published abstract. The primary reason for article exclusion was a lack of information on the effects of untreated BED. Excluded articles did not describe impairments associated with BED. Rather, they focused on therapeutic intervention or pharmacotherapy for BED, the pathophysiology of BED, diagnostic criteria or predictors of BED, other eating disorders, binge-eating behaviors in individuals not diagnosed with BED, or discussion of the biologic and/or genetic correlates of BED. A total of 43 publications (42 from the literature review and 1 additional reference added based on the authors’ knowledge) were considered relevant for inclusion (Table 1).

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BED and Mental Health

Individuals with BED often report symptoms of depression and anxiety, with approximately 30%-80% showing lifetime comorbid mood or anxiety disorders.4,15-17,19,20,26,32,33 Depressive and anxiety symptom levels are higher in individuals with BED than in those without BED, including the general population, obese individuals without BED, and overweight relatives of individuals with BED.4,14,17,19,20,26 Estimated current and lifetime prevalence rates of any mood disorder in obese individuals with BED are 27.3% and 52.3%, respectively.20 In comparison, obese individuals without BED have markedly lower current (4.9%) and lifetime (23.0%) rates of any mood disorder.20 However, in another study,23 depressive scores on the Beck Depressive Inventory and the level of mental stress (a potential index of anxiety) in morbidly obese individuals (mean body mass index [BMI] of 47.0 kg/m2) classified as meeting DSM-IV-TR BED criteria did not differ from morbidly obese individuals who did not meet the BED criteria. Other psychiatric comorbidities reported in individuals with BED include gambling problems, bipolar disorder, attention-deficit/hyperactivity disorder, and substance abuse disorder.4,17,19,22,26,27 Individuals with BED are also at increased risk for abuse of or dependence on alcohol or illicit drugs (odds ratios of 2.2-4.9).3,4

The presence of comorbid depressive symptoms in individuals with BED does not appear to be solely related to obesity, as both obese (mean BMI of 38.7 kg/m2) and normal-weight individuals diagnosed with BED show similar levels of depressive symptom severity as measured by mean (SD) Beck Depression Inventory total scores (obese with BED: 22 [12]; nonobese with BED: 19 [12]).12 There may be complex interactions among binge eating, obesity, and comorbid mood disorders; it has been reported that individuals with eating disorders (including BED) and a comorbid mood disorder have higher BMIs and an increased frequency of binge eating compared with those with eating disorders alone.52

Ethnicity and race may also affect depression and anxiety in individuals with BED. Black and Hispanic individuals with BED are more than twice as likely as white individuals with BED to have comorbid mood and anxiety disorders.16 The lifetime prevalences of BED between white individuals (1.41%) and ethnic and racial minorities, including black individuals (1.48%) and Hispanics (2.11%), do not statistically differ.46 However, minority populations are less likely to utilize mental health care services,46 possibly leading to underdiagnosis of BED and associated comorbidities in these populations.

In a Swedish sample of women with BED,25 6.7% were reported to have made a suicide attempt (9/125). The presence of comorbid depressive symptoms in individuals with BED may impact rates of suicidality and suicidal ideation. In 1 sample of adult outpatients with BED,11 28% of individuals reported suicidal ideation on the Scale of Suicidal Ideation. Similarly, data from the Swedish Twin Registry indicated that women with BED and comorbid depression had higher suicide attempt and suicide completion rates compared with those with BED but without major depressive disorder.21 However, these results should be interpreted with caution because of the small number of individuals with BED included in this study and because there were no comparisons of depressed individuals with BED to depressed individuals without BED.21

It is unclear whether psychiatric comorbidities are antecedents of BED or complications resulting from BED or whether treatment for BED would alleviate their severity. However, a latent structure analysis indicated that although BED is often comorbid with mood and anxiety disorders, it is distinct from them.18 These findings suggest that, at least in some instances, BED is not the result of antecedent mood or anxiety disorders.

In addition to psychiatric comorbidities, individuals with BED report interpersonal, personality, self-esteem, self-criticism, and self-consciousness problems.13,20,24 For instance, in women with BED, more severe binge-eating behavior was associated with higher (worse) scores for interpersonal sensitivity, paranoid ideas, psychoticism, and obsessive compulsiveness on the Symptom Checklist-90.14

BED and Physical Health

Binge eating disorder is associated with increased medical morbidity and poor physical health,30 including cardiovascular problems, components of metabolic syndrome, and type 2 diabetes.32-35 Two studies reported greater decreases in high-frequency heart rate variability in response to mental stress (an index of decreased parasympathetic cardiac control) in obese individuals with BED than in obese individuals without BED32,35; such decreases in heart rate variability are associated with greater risk of coronary heart disease.53

Individuals with BED are at an increased risk of hypertension, dyslipidemia, and type 2 diabetes (ie, key components of metabolic syndrome) than are obese individuals without BED.34 Approximately 40%-60% of obese individuals with BED seeking weight-loss treatment meet criteria for metabolic syndrome, with higher rates of metabolic syndrome being observed in men than in women and in white individuals than in black individuals.29,36,40 In 1 study,41 approximately 8% of individuals met diagnostic criteria for both type 2 diabetes and BED, with black race and male sex being strong indicators of the co-occurrence of these disorders.

Individuals with BED report other physical health problems. After controlling for BMI and other relevant cofactors, BED is associated with significantly greater risk for upper and lower gastrointestinal tract problems, including acid regurgitation, heartburn, dysphagia, bloating, and diarrhea.31 Women with BED symptoms (ie, at least weekly binge-eating episodes without compensatory behaviors) before and during pregnancy report higher frequencies of sleep problems before and during pregnancy and for 18 months after childbirth relative to women without eating disorder symptoms before or during pregnancy.39 The effect of BED on sleep in pregnant women is consistent with studies reporting effects of BED on hormonal regulation and possible complications during pregnancy. More menstrual dysfunction (amenorrhea and oligomenorrhea) occurs in women meeting criteria for BED compared with women not meeting criteria for BED.28 Pregnant women meeting criteria for BED consume more total calories and fat but fewer nutrients, including vitamin C and folic acid, before and during pregnancy than pregnant women not meeting criteria for BED.37

BED, Quality of Life, and Functionality

The mental and physical impairments observed in individuals with BED can have direct consequences on quality of life. In 1 study, scores on all subscales of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) were lower than US norms among individuals with BED,47 indicating impaired quality of life was associated with BED. Consistent with this finding, another study reported lower mental health summary scores on the SF-36 in a sample of women with eating disorders (which included individuals with BED) compared with population norms.45 Individuals with BED also report reduced quality of life on the mental component of the SF-1250 and on the EuroQoL Group 5-Dimension 5-Level Self-Report Questionnaire.42 Some quality of life domains may be more impaired in women than in men with BED, with women with BED reporting more impairment on the mental health component of the SF-36 than men with BED.51

The association of BED with reduced quality of life may not be solely related to obesity because obese individuals with BED report greater levels of impairment than obese individuals without BED on the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) scale,49 a scale that assesses weight effects on physical function, self-esteem, sexual life, public distress, and work.49 Individuals with BED and high BMI (≥ 30 kg/m2) also score significantly lower on physical component scores of the SF-36 (ie, reported worse quality of life) than those with BED and low BMI (< 30 kg/m2).47 Another study reported lower quality of life in obese individuals with BED compared with obese individuals without BED.48 However, a role for obesity in impaired quality of life among individuals with BED cannot be fully discounted. Although IWQOL-Lite scores are reduced among individuals with BED, 1 study did not find an association between reduced quality of life and BED after controlling for BMI and psychological distress.44

Ethnicity and race may also influence the level of quality of life impairment associated with BED. In 1 study, black individuals with BED reported more physical impairment than white or Hispanic individuals with BED, and Hispanic individuals with BED reported more social impairment than black or white individuals with BED.48

In addition to its effect on quality of life, BED can also impair functioning. The Sheehan Disability Scale (SDS) assesses functional impairment in 3 domains: work/school, social life/leisure activities, and family life/home responsibilities.54 On the SDS, role impairment (ie, the ability to fulfill expected roles in different aspects of an individual’s life) was reported in individuals with BED (any role impairment: 46.7%, severe role impairment: 13.2%).3 In a study based on a World Health Organization survey,43 early onset BED was associated with reduced odds of being married among women with BED (but not among men with BED) and reduced odds of being employed among men with BED (but not among women with BED).

There are also more global and societal effects of BED. In a study of overweight women diagnosed with and/or seeking treatment for BED,42 self-reported total health care costs were more than 35% higher than the age- and sex-matched national average. A history of eating disorders (BED or bulimia nervosa) in young women from a community sample was associated with more emergency room visits compared to healthy controls.38 Although these differences were not statistically different, the authors concluded that a history of eating disorders was associated with increased health service utilization.

CONCLUSIONS

On the basis of the published literature, individuals with BED have increased rates of mental health comorbidities, including depression and anxiety. These associated mental health problems, particularly major depressive disorder, are associated with an increased rate of suicidal ideation and behavior in the BED population.21 It remains unclear whether the association of BED with suicidality is entirely a consequence of these other comorbidities, or if BED independent of major depressive disorder would still be linked to suicidal ideations and behaviors. BED is also associated with physical comorbidities, including increased cardiovascular and gastrointestinal disorders. Overall, these associated physical and mental health impairments are likely to play important roles in the decreased quality of life, impairment of functioning, decreased role attainment (ie, poor role functioning), and increasing health care utilization in those with BED.

Epidemiologic data suggest that BED is the most prevalent eating disorder, but the pervasive effects of untreated BED are underappreciated. This may be because BED was only accepted as a formal psychiatric diagnosis with the 2013 release of the DSM-5. Although it is not definitively known how the DSM-5 diagnostic criteria will alter BED prevalence rates compared with the provisional DSM-IV-TR diagnostic criteria, prevalence estimates are projected to increase because the frequency and duration of symptoms required for a DSM-5 diagnosis are less stringent.6

Although the weight of evidence suggests BED has important associations with physical and mental health, quality of life, role attainment, and functional ability, some caution is warranted in interpreting these findings. At this time, the relationship between the onset of BED, impaired quality of life, and associated psychiatric comorbidities is not clearly defined in the published literature. As such, it remains unclear whether BED is an antecedent condition, a complication associated with a comorbid psychiatric condition, or an unrelated feature that occurs concurrently with these comorbidities and impairments. Therefore, when multiple conditions are present in individuals with BED, it may be prudent to consider treating each potentially contributing or aggravating condition as a separate target. Much of the research to date on the relationship between BED, physical and mental health, and quality of life and functional impairment is based on observational or epidemiologic studies, which often draw conclusions based on data from secondary endpoints or post hoc analyses. As such, studies that include mental health and functionality assessments as prespecified primary endpoints and that include participants who meet stringent inclusion and exclusion criteria are needed to more clearly define the long-term effects of BED and impairments associated with this disorder.

Author affiliations: Department of Psychiatry and Behavioral Health, University of South Florida College of Medicine, Tampa (Dr Sheehan), and Shire Development LLC, Wayne, Pennsylvania (Dr Herman).

Potential conflicts of interest: Dr Sheehan has served as a consultant to Shire and is the creator of a scale that measures functional impairment (Sheehan Disability Scale). Dr Herman is a full-time employee of Shire Development LLC and holds stock and/or stock options in Shire.

Funding/support: Shire Development LLC provided funding to Complete Healthcare Communications, Inc, Chadds Ford, Pennsylvania, for support in writing and editing this manuscript.

Role of the sponsor: Shire Development LLC provided funding to support writing, proofreading, copyediting, and fact checking. The content of this manuscript, the ultimate interpretation, and the decision to submit for publication in The Primary Care Companion for CNS Disorders was made by the authors independently.

Acknowledgments: Under the direction of the authors, writing assistance was provided by Stefan Kolata, PhD, and Craig Slawecki, PhD (Complete Healthcare Communications, Chadds Ford, Pennsylvania). Drs Kolata and Slawecki report no conflicts of interest related to the subject of this article.

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