Annals of Medicine
ISSN: 0785-3890 (Print) 1365-2060 (Online) Journal homepage: http://www.tandfonline.com/loi/iann20
Binge Eating in the Obese Martina de Zwaan & James E. Mitchell To cite this article: Martina de Zwaan & James E. Mitchell (1992) Binge Eating in the Obese, Annals of Medicine, 24:4, 303-308, DOI: 10.3109/07853899209149959 To link to this article: http://dx.doi.org/10.3109/07853899209149959
Published online: 08 Jul 2009.
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Date: 23 April 2016, At: 16:31
Special Section: Eating Disorders
Binge Eating in the Obese
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Martina de Zwaan’ and James E. Mitchell2
This review will first describe problems in the definition of the term binge eating, especially in the absence of purging (vomiting, laxative abuse). We highlight current approaches in the classification of obesity, and then provide an overview of the available literature on differences between obese binge eaters and obese non-binge eaters. Many studies indicate that binge eating is common among the female obese, with a frequency ranging from 23 to 46% among those seeking treatment for weight reduction. Despite differences in the definitions of binge eating and variability among the samples investigated, there is strong evidence that binge eaters represent a distinct subgroup among the obese. Binge eating obese exhibit significantly more eating and weight-related pathology, as well as more psychopathology compared to their non-binge eating obese counterparts. Key words: binge eating; obesity. (Annals of Medicine 24: 303-308,1992)
Binge Eating Despite intensive study of this topic there is still disagreement among eating disorder researchers as to what eating behaviour constitutes binge eating. This lack of agreement has engendered a multiplicity of definitions (1). Those commonly applied range from ‘subjective’ overeating without a requirement for feeling a loss of control, to more ‘objective’ overeating episodes accompanied by the sense of not being able to control the eating episide (2-4). There is no accepted criterion for determining what amount of food ingested constitutes an overeating episode. Should there be a cut-off for the amount of calories ingested, or should every eating episode which is perceived by the individual as being excessive and/or outside voluntary control be labelled as a binge-eating episode? Calorie consumption varies considerably among and within subjects. For example, an analysis of 225 selfreported binge-eating episodes among non-purging bulimics revealed a wide range from 25 to more than 6000 kilocalories per episode (5). Some authors, thereFrom the Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, U.S.A. ‘Department of Psychiatry, University of Vienna, Austria. *Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, U.S.A. Address and reprint requests: James E. Mitchell, M.D., Department of Psychiatry, University of Minnesota, 420 Delaware Street, S.E., Box 393 Mayo, Minneapolis, MN 55455, USA.
fore, recommend that emphasis should be placed on the subjective feeling of lack of control rather than the quantity of food eaten to define a binge-eating episode (6). In a survey of 243 young women, aged 16-35 years, Beglin & Fairburn (4) demonstrated that the subjects themselves placed greater emphasis on loss of control than on the quantity eaten when asked to classify recent overeating episodes as binges or non-binges. However, the definitions of overeating used in the DSM Ill-R (2) (‘rapid consumption of a large amount of food in a discrete period of time’), and in the provisional criteria for the DMS IV (3)(‘eating in a discrete period of time an amount of food that is definitely larger than most people would eat during a similar period of time’) acknowledge the quantity of food eaten as an important variable in the diagnosis of bulimia nervosa and the proposed bingeeating disorder. The recently proposed DSM IV (3) criteria also acknowledge the importance of feeling a lack of control over the eating episode by including both overeating and the sense of loss of control in the definition of a binge-eating episode. This constitutes a major change from earlier diagnostic systems such as the DSM Ill-R (2). This problem with definitions makes it difficult to determine the exact frequency of binge-eating episodes in non-purging binge eaters. In purging bulimia nervosa patients, binge-eating episodes can be defined by the presence of vomiting or laxative abuse which terminate a binge, whereas with binge eaters who do not purge, the ending of an eating binge is not punctuated. Many patients, therefore, experience difficulties recalling and labelling binge-eating episodes (5).
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Obesity Obesity is a common condition (7) and is still resistant to treatment, especially in the long term. It is widely agreed that there is much diversity within the obese population, and it can be assumed that with better differentiation and classification of the obesity syndromes, more specific and successful treatment strategies will be developed. Subtypes have been formed on the basis of physiological variables such as fat-cell size and number, body fat distribution, resting metabolic rate, and severity (8). Furthermore, subgroups have been identified characterized by problematic eating behaviour such as binge eating (9, lo), mood disturbances (11, 12), or specific personality traits (13).Unfortunately, no characterization scheme for human obesity that ‘has been shown to predict outcome for specific treatments is yet available.
Obese Binge Eaters Binge eating among the obese has been recognized in the obesity literature since the early 1950s. In 1951, Hamburger (14) described a type of hyperphagia in eight obese patients characterized by ‘compulsive craving for food, especially candy, ice cream, and other sweets, which is frequentty uncontrollable’. The author compared this ‘most malignant‘ type of hyperphagia with the addiction to alcohol. In 1959, Stunkard’s frequently cited paper on ‘Eating patterns and obesity’ (15) was published, describing binge eating as a distinct eating pattern among some obese individuals. Stunkard characterized an eating binge as ‘having an orgiastic quality’, and noted that ‘enormous amounts of food are consumed in relatively short periods’.He noticed that the eating binge is ’frequently related to a specific precipitating event, and is regularly fo[lowed by severe discomfort and selfcondemnation’. In 1970, Kornhaber (16) identified the ’stuffing syndrome’ as a distil c t clinical entity among the obese, which is characterized by three symptoms: hyperphagia, emotional withdrawal, and clinical depression. Only recently has systematic research focused again on the occurrence of binge .eating among the obese.
Mitchell Conversely, it has been noticed that non-purging bulimics meeting DSM Itl-R criteria for bulimia newosa are frequently overweight (17, 18), e.g. the mean body mass index of 44 females participating in one study on non-purging bulimics was 32.6 kg/m2 (17).However, due to a lack of clear diagnostic criteria, definitions for distinguishing between binge eaters and non-binge eaters among the obese vary in the available literature, making a valid and reliabie comparison between studies difficult. Some studies apply quantifiable measurements such as the Binge Eating Scale (BES, 19), a 16-item self-rating questionnaire that assesses the severity of binge-eating tendencies in the obese population. This instrument has been demonstrated to successfully identify individuals with no, moderate, and severe binge-eating problems as assessed by expert interview (19), and has also been shown to highly correlate with a DSM 111 diagnosis of bulimia (20, 21). Other studies have used the Binge Scale (BS, 22),a 19-itemquestionnaire designed according to the DSM Ill criteria for bulimia to quantify the behavioural and attitudinal parameters of binge eating in normal-weight and overweight subjects (13, 23). Still others have employed qualitative definitions such as the DSM 111 criteria for bulimia (24, 25), or the OSM Ill-R criteria for bulimia nervosa (17, 18, 26) to identify binge eaters among obese individuals. In earlier studies binge eating was defined solely as frequent overeating (22,27, ZB),and it is not clear whether emotional or attitudinal parameters associated with binge eating were taken into account Finally, recent studies employ the provisional DSM IV criteria for binge-eating disorder (3,s) (Table 1). Table 2 shows some characteristics of studies describing the clinical features of obese binge eaters. The obese samples examined so far have usually been clinical samples of women in weight loss programmes, many of whom are in their forties (mean age range 33-52.5 years) and most of whom are moderately to severely obese ( > 30% overweight, or BMI of > 25 kg/m2 respectively). Control groups examined include clinical and non-clinical samples of non-binge eating obese, normal-weight bulimics, and normal-weight subjects without eating disorders. Binge eating has been assessed either by self-report or by expert interview, in person or over the phone. Regardless of the definition or
Table 1. Proposed diagnostic crlterla for binge-eating disorder.’
(A) Recurrent episodes of binge eating characterized by: (1) Eating, in a discrete period of time (e.g. in any 2-h period),an amount of food that is definitely larger than most people would eat during a similar period of time; (2) A sense of lack 01 control during the episodes, e.g. a feeling that one cannot stop eating or control what or how much one is eating. (3) Ouring most binge-eating episodes, at least three of the following behavioural indicators of loss of control: (1) eating much more rapidly than usual; (2) eating until feeling uncomfortably full; (3)eating large amounts of fodd when not feeling physically hungry; (4) eating large amounts of food throughout the day with no planned mealtimes; (5) eating atone because of being embarrassed by how much one is eating; ( 6 ) feeling disgusted with oneself, depressed or feeling very guilty after overeating. (C) Marked distress regarding binge eating. (D)The binge eating occurs, on average, at least twice a week for a &month period. (E) Does not currently meet the criteria for bulimia nervosa or abuse medication (0,s. diet pills) in an attempt to avoid weight gain. ‘Spitzer et al. 1991 (3).
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Binge Eating in the Obese Table 2. Characteristicsof studies on obese binge eaters. Control groupls) (if applicable)
Bingo eaters Weight (%overweight
N
Authors Hawkins & Clement
(I + m) 52
Diagnosis
Weight
or BMI)
N (I+ m)
Diagnosis
[%overweight) or BMI)
Obese-
-
-
-
Obeset
-
-
-
21
No bulimia
43.5 i.24%
155 77
EES 16-26 BES < 17
47.8% 38 5%
-
-
-
Binge Scale (BS)
1980 (22) Loro & Orleans 1981 (28)
280
Binge eating
Gormalty et al.
112
Binge Eating Scale
1982 (19)
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Keefe et al 1984 (24)
(BES)
23
DSM 111 Bulimia All, or all but one
49.5 f44.3%
criteria Marcus et al. 1985 (32)
198
EES Z 27
50.6%
Kolotkin el af 1987 (33)
207
BES
69.6 i.34.9%
DSM 111 Burimia All. or all but one
Obese$
44
No bulimia
Obese;
74.2f37.5%
47 47
No bulimia (ow) DSM 111 bulimia {nw)
- 3.3 k 96%
16 16 16 16
DSM II bulimia (nw) Obeselclinic
64.5%
Obese/community
40.2%
33
No bulimia BES G 17 -
Obese5
Tetch et al.
37
1988 (34)
criteria Hudson et al. 1988 (25)
23
Prather & Williamson 1ma (42)
16
DSM 111 Bulimia (OW)
DSM 111 Bufimia
57396
ION
Obese§
Normal-weight
S9.6
* 27.6%
1.6% 3A%
35
OSM 111 Bulimia BES 3 27
Wing et al. 1983 (30)
95
BES
Marcus et al.
22
BES > 29
37.9 f 6.5k g / r n 2
23
BfS < 17
38.4f6.7kg/m2
25
BES 3 29
38 2~6.5 kg/mz
25
BES < 17
37.5k6.4 kg/m2
41
BES 3 25 2 episodes/week for 3 months (ow)
20-1 00%
28
DSM Ill-R bulimia neiwosa (BULIT 3 102) (nw)
-2010 +20%
BES
36.316.1kg/m2
-
-
DSM fll-R bulimia nervosa
30.2+5.3kg/m2
20.
DSM Ill-R bulimia nervosa (vomiters)
21.4f2.7 kglm'
35.8k5.6 kg/rn2
42
No overeating or
36.7k 4.7 kg/m2
Marcus et al. 1988 (20)
-
1990 (46)
Marcus et al. 1990 (21)
Alger et al. 1991 (41)
Lowe & Caputo
436
-
1991 (31) McCann et al. 1991 (18)
31
de Zwaan et al.
22
(non-purgers) 1992 (29)
Overeating and loss of control
loss of control
'44!cl3% for f, and 41 f 15.9% for rn; t39.3S8.1% for sample 1, and 40.2*11.6% for sample 2; $BMI of 28.8 kg/m2 (range 23-42) for all subjects; 543 k 17%for all subjects; ow =overweight, nw = normal-weight.
assessment method employed, the frequency of severe binge-eating problems in weight loss participants has been surprisingly high, ranging from 23 to 46% (29). Consequently, roughly every fifth to every second woman in weight-reduction programmes presents with bingeeating problems. This problem behaviour seems to be significantly less prevalent in obese subjects not currently in treatment (22),as well as in the general population (9).Conversely, one study (26) found that only 4.2%
of 591 patients meeting full criteria for bulimia nervosa according to DSM Ill-R with the added criterion of purging were 2 130%above ideal body weight. Table 3 shows some clinical characteristics of obese binge eaters as compared to non-binge eaters. Demographic Characteristics. Binge eating seems to be more common in overweight women than men (9,2230, 31). Binge-eating obese appear to be significantly
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de Zwaan
Table 3. Number of studies with positive, negative or no correlation with binge eatlng (severity) in various varlablas of obese binge eaters vs. non-binge eaters. Variables
Correlation
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Positive Negative None Female sex Age (years) Weight (BMi, 34 overweight) Affective disorder Current depression (BD1, HAMD) Past psychotherapy Personality disturbance General psychopathology (SCL-90) Eating-related pathology (EDI) Body image (8DQ, EDI, SD) Maladaptive cognitions about dieting (CFS) Tendency for disinhibition (El) Perceived hunger (El) Early onset of obesity Age at first dieting
4 0 5
2 4 1 1
2 2 4 2 4
0
2
4
1
0 0 0 0 0 0
4 1’ 1’ 0 1 0 0 1 0
0 0
0
3
0 0
2
0
1
0
Mitchell have been suggested to be fundamentally related to anorexia nervosa and bulimia nervosa. It has been widely used in patients with both of these disorders. Results in obese patients demonstrate that binge eaters exhibit more eating-related psychopathology on this scale as compared to their non-binge-eating counterparts. Six of the eight subscales have consistently shown to positively correlate with binge eating. Two of those subscales, i.e. ‘Drive for Thinness’ and a feeling of inadequacy (‘Ineffectiveness?, seem to be the strongest predictors of binge-eating severity among the obese (211 31). Similar to the feeling of ineffectiveness, taw selfesteem has shown to be related to binge-eating severity (22,31).Binge-eating obese have also been shown to be more dissatisfied with their body image than non-bingeeating obese (21-23, 291, and equally dissatisfied with normai-weight bulimic subjects (18).
0
0 0 D
‘Depression was required as inclusion criterion for all subjects. BMI = Body Mass Index; 6D1 =Beck Depression Inventory (39); HAMD =Hamilton Depression Scale (40); ScL-90 = Symplom Checklist (43); ED1=Eating Disorder Inventory (38); BDQ = Body Distortion Questionnaire (44); CFS =Cognitive Factor Scale (19); El=Three-factDr Eating Inventory (36); SD = Semanlic Differential (45).
younger than non-binge-eating obese when they present for treatment (24,29, 31, 32),but significantly older than narmal-weight purging bulimics (18).
Eating and Weight-Related Variables. There seems to be a positive correlation between binge-eating severity and the degree of obesity (22,31-34). Some studies found no significant correlation between degree of obesity and binge eating (19, 24, 29, 30), but we could not find any studies supporting a negative correlation. Tbere is evidence that binge-eating obese have an earlier onset of obesity than non-binge-eating obese (28, 29), start dieting at an earlier age (29),start worrying about their weight at an earlier age (22), and have a higher prevalence of marked weight fluctuations in the past (9, 10). In summary, these results support the notion that dieting and binge eating are closely related (35). Several self-rating questionnaires assessing eating behaviour, as well as attitudes and cognitions towards eating and weight have shown to successfully distinguish between binge-eating and non-binge-eating obese. The tendency towards disinhibition of control over eating, and the susceptibility to hunger (Eating Inventory, 36) have consistently been shown to strongly correlate with binge eating among the obese (20,31,32,37). There are some data using the Eating Disorder Inventory (ED[, 38) with obese patients who have binge-eating problems, although the validity of the EOI in this group has not been established. This instrument was originally developed for adolescents and young adults of normal or low weight, and was designed to assess characteristics of eating behaviour as well as psychological dimensions which
General Psychopathology Two investigations found higher levels of general Psychiatric SymptOmatOlOgy in obese patients with binge eating than those without binge eating, as aSSeSSed by the SCL-90 (20, 37). Furthermore, there appears to be a positive relationship between binge eating and depressive symptoms s well a lifetime history of affective disorders. That is, binge-eating obese exhibit higher depression scores, and are more likely to have a history of depression than their non-binge-eating counterparts (20,21, 25, 29,30,37). It must be noted, however, that in most studies the total depression scores (e.g. BDI, HAMD, 39, 40) were in the normal to mildly depressed range (e.g. BDI scores of 11-1 7), raising questions about the clinical relevance of this finding. Comparisons to normal-weight purging bulimics concerning cornorbid psychiatric disorders show contradictory results. One study found a significantly higher lifetime prevalence rate of affective disorders in patients with normal-weight purging bulimia nervosa when compared with obese binge eaters (18). whereas two other studies found a similar prevalence rate (25, 41). The same conflicting results have been observed with regard to substance abuse (18, 25, 41). Differences in the criteria used to define bulimia (nervosa),and marked differences in the overall prevalence rates of psychiatric disorders between the samples examined in these investigations most likely account for these inconsistent results. The prevalence rates of personality disorders did not differ between overweight bulimics, normal-weight bulimics, and a sample of obese patients In a weight-loss programme, but there were significant differences when these three clinical groups were compared to normalweight controls and to .a community sample of obese individuals (42). This study emphasizes the higher prevalence of psychopathology in clinical samples as opposed to community samples, regardless of the diagnosis. However, another study on personality traits found a positive correlation between 12 subscales of the MMPl and binge-eating severity in a group of 207 obese individuals (33).
Binge Eating in the Obese
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Conclusions Despite differences in the definitions of binge eating and the variability among the samples investigated, there is strong evidence that binge eaters represent a distinct subgroup among the obese. Many studies indicate that such patients are common among the obese, with a frequency ranging from 23 to 46% among fernafe patients seeking lreatmenl for wejght reduction. Bingeeating obese exhibit significantly more eating and weight-related pathology, as well as more psychopathology in general compared to their non-binge-eating obese counterparts. On many variables they resemble normalweight subjects with bulimia nervosa. However, available studies suggest that obese binge eaters are less severely disturbed as compared to patients meeting full criteria for purging bulimia nervosa. Furthermore, there is strong evidence for a continuum of severity with respect to the behavioural and attitudinal parameters of binge eating as well as the degree of psychopathotogy rather than for a dichotomy of binge eaters vs. non-bingeeaters. Nevertheless, the use of operationalized crileria for this problem (e.g. binge-eating disorder, Table 1) might facilitate coordinated research in this area, especially in investigating the effectiveness of treatments specific to the needs of this putative subgroup of obese subjects.
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Emotional problems during weight reduction; advantages of a combined behavior therapy and antidepressive drug therapy for obesity. J Behav Ther f x p Psychiatry 1985: 16: 217-2 1. 12. Wadden TA, Stunkard AJ, Smoller JW. Dieting and depression; A methodological study. J Consult Clin Psychol 1986; 54: 869-71.
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ISSN: 0785-3890 (Print) 1365-2060 (Online) Journal homepage: http://www.tandfonline.com/loi/iann20
Binge Eating in the Obese Martina de Zwaan & James E. Mitchell To cite this article: Martina de Zwaan & James E. Mitchell (1992) Binge Eating in the Obese, Annals of Medicine, 24:4, 303-308, DOI: 10.3109/07853899209149959 To link to this article: http://dx.doi.org/10.3109/07853899209149959
Published online: 08 Jul 2009.
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Date: 23 April 2016, At: 16:31
Special Section: Eating Disorders
Binge Eating in the Obese
Downloaded by [University of Lethbridge] at 16:31 23 April 2016
Martina de Zwaan’ and James E. Mitchell2
This review will first describe problems in the definition of the term binge eating, especially in the absence of purging (vomiting, laxative abuse). We highlight current approaches in the classification of obesity, and then provide an overview of the available literature on differences between obese binge eaters and obese non-binge eaters. Many studies indicate that binge eating is common among the female obese, with a frequency ranging from 23 to 46% among those seeking treatment for weight reduction. Despite differences in the definitions of binge eating and variability among the samples investigated, there is strong evidence that binge eaters represent a distinct subgroup among the obese. Binge eating obese exhibit significantly more eating and weight-related pathology, as well as more psychopathology compared to their non-binge eating obese counterparts. Key words: binge eating; obesity. (Annals of Medicine 24: 303-308,1992)
Binge Eating Despite intensive study of this topic there is still disagreement among eating disorder researchers as to what eating behaviour constitutes binge eating. This lack of agreement has engendered a multiplicity of definitions (1). Those commonly applied range from ‘subjective’ overeating without a requirement for feeling a loss of control, to more ‘objective’ overeating episodes accompanied by the sense of not being able to control the eating episide (2-4). There is no accepted criterion for determining what amount of food ingested constitutes an overeating episode. Should there be a cut-off for the amount of calories ingested, or should every eating episode which is perceived by the individual as being excessive and/or outside voluntary control be labelled as a binge-eating episode? Calorie consumption varies considerably among and within subjects. For example, an analysis of 225 selfreported binge-eating episodes among non-purging bulimics revealed a wide range from 25 to more than 6000 kilocalories per episode (5). Some authors, thereFrom the Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, U.S.A. ‘Department of Psychiatry, University of Vienna, Austria. *Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, U.S.A. Address and reprint requests: James E. Mitchell, M.D., Department of Psychiatry, University of Minnesota, 420 Delaware Street, S.E., Box 393 Mayo, Minneapolis, MN 55455, USA.
fore, recommend that emphasis should be placed on the subjective feeling of lack of control rather than the quantity of food eaten to define a binge-eating episode (6). In a survey of 243 young women, aged 16-35 years, Beglin & Fairburn (4) demonstrated that the subjects themselves placed greater emphasis on loss of control than on the quantity eaten when asked to classify recent overeating episodes as binges or non-binges. However, the definitions of overeating used in the DSM Ill-R (2) (‘rapid consumption of a large amount of food in a discrete period of time’), and in the provisional criteria for the DMS IV (3)(‘eating in a discrete period of time an amount of food that is definitely larger than most people would eat during a similar period of time’) acknowledge the quantity of food eaten as an important variable in the diagnosis of bulimia nervosa and the proposed bingeeating disorder. The recently proposed DSM IV (3) criteria also acknowledge the importance of feeling a lack of control over the eating episode by including both overeating and the sense of loss of control in the definition of a binge-eating episode. This constitutes a major change from earlier diagnostic systems such as the DSM Ill-R (2). This problem with definitions makes it difficult to determine the exact frequency of binge-eating episodes in non-purging binge eaters. In purging bulimia nervosa patients, binge-eating episodes can be defined by the presence of vomiting or laxative abuse which terminate a binge, whereas with binge eaters who do not purge, the ending of an eating binge is not punctuated. Many patients, therefore, experience difficulties recalling and labelling binge-eating episodes (5).
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Obesity Obesity is a common condition (7) and is still resistant to treatment, especially in the long term. It is widely agreed that there is much diversity within the obese population, and it can be assumed that with better differentiation and classification of the obesity syndromes, more specific and successful treatment strategies will be developed. Subtypes have been formed on the basis of physiological variables such as fat-cell size and number, body fat distribution, resting metabolic rate, and severity (8). Furthermore, subgroups have been identified characterized by problematic eating behaviour such as binge eating (9, lo), mood disturbances (11, 12), or specific personality traits (13).Unfortunately, no characterization scheme for human obesity that ‘has been shown to predict outcome for specific treatments is yet available.
Obese Binge Eaters Binge eating among the obese has been recognized in the obesity literature since the early 1950s. In 1951, Hamburger (14) described a type of hyperphagia in eight obese patients characterized by ‘compulsive craving for food, especially candy, ice cream, and other sweets, which is frequentty uncontrollable’. The author compared this ‘most malignant‘ type of hyperphagia with the addiction to alcohol. In 1959, Stunkard’s frequently cited paper on ‘Eating patterns and obesity’ (15) was published, describing binge eating as a distinct eating pattern among some obese individuals. Stunkard characterized an eating binge as ‘having an orgiastic quality’, and noted that ‘enormous amounts of food are consumed in relatively short periods’.He noticed that the eating binge is ’frequently related to a specific precipitating event, and is regularly fo[lowed by severe discomfort and selfcondemnation’. In 1970, Kornhaber (16) identified the ’stuffing syndrome’ as a distil c t clinical entity among the obese, which is characterized by three symptoms: hyperphagia, emotional withdrawal, and clinical depression. Only recently has systematic research focused again on the occurrence of binge .eating among the obese.
Mitchell Conversely, it has been noticed that non-purging bulimics meeting DSM Itl-R criteria for bulimia newosa are frequently overweight (17, 18), e.g. the mean body mass index of 44 females participating in one study on non-purging bulimics was 32.6 kg/m2 (17).However, due to a lack of clear diagnostic criteria, definitions for distinguishing between binge eaters and non-binge eaters among the obese vary in the available literature, making a valid and reliabie comparison between studies difficult. Some studies apply quantifiable measurements such as the Binge Eating Scale (BES, 19), a 16-item self-rating questionnaire that assesses the severity of binge-eating tendencies in the obese population. This instrument has been demonstrated to successfully identify individuals with no, moderate, and severe binge-eating problems as assessed by expert interview (19), and has also been shown to highly correlate with a DSM 111 diagnosis of bulimia (20, 21). Other studies have used the Binge Scale (BS, 22),a 19-itemquestionnaire designed according to the DSM Ill criteria for bulimia to quantify the behavioural and attitudinal parameters of binge eating in normal-weight and overweight subjects (13, 23). Still others have employed qualitative definitions such as the DSM 111 criteria for bulimia (24, 25), or the OSM Ill-R criteria for bulimia nervosa (17, 18, 26) to identify binge eaters among obese individuals. In earlier studies binge eating was defined solely as frequent overeating (22,27, ZB),and it is not clear whether emotional or attitudinal parameters associated with binge eating were taken into account Finally, recent studies employ the provisional DSM IV criteria for binge-eating disorder (3,s) (Table 1). Table 2 shows some characteristics of studies describing the clinical features of obese binge eaters. The obese samples examined so far have usually been clinical samples of women in weight loss programmes, many of whom are in their forties (mean age range 33-52.5 years) and most of whom are moderately to severely obese ( > 30% overweight, or BMI of > 25 kg/m2 respectively). Control groups examined include clinical and non-clinical samples of non-binge eating obese, normal-weight bulimics, and normal-weight subjects without eating disorders. Binge eating has been assessed either by self-report or by expert interview, in person or over the phone. Regardless of the definition or
Table 1. Proposed diagnostic crlterla for binge-eating disorder.’
(A) Recurrent episodes of binge eating characterized by: (1) Eating, in a discrete period of time (e.g. in any 2-h period),an amount of food that is definitely larger than most people would eat during a similar period of time; (2) A sense of lack 01 control during the episodes, e.g. a feeling that one cannot stop eating or control what or how much one is eating. (3) Ouring most binge-eating episodes, at least three of the following behavioural indicators of loss of control: (1) eating much more rapidly than usual; (2) eating until feeling uncomfortably full; (3)eating large amounts of fodd when not feeling physically hungry; (4) eating large amounts of food throughout the day with no planned mealtimes; (5) eating atone because of being embarrassed by how much one is eating; ( 6 ) feeling disgusted with oneself, depressed or feeling very guilty after overeating. (C) Marked distress regarding binge eating. (D)The binge eating occurs, on average, at least twice a week for a &month period. (E) Does not currently meet the criteria for bulimia nervosa or abuse medication (0,s. diet pills) in an attempt to avoid weight gain. ‘Spitzer et al. 1991 (3).
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Binge Eating in the Obese Table 2. Characteristicsof studies on obese binge eaters. Control groupls) (if applicable)
Bingo eaters Weight (%overweight
N
Authors Hawkins & Clement
(I + m) 52
Diagnosis
Weight
or BMI)
N (I+ m)
Diagnosis
[%overweight) or BMI)
Obese-
-
-
-
Obeset
-
-
-
21
No bulimia
43.5 i.24%
155 77
EES 16-26 BES < 17
47.8% 38 5%
-
-
-
Binge Scale (BS)
1980 (22) Loro & Orleans 1981 (28)
280
Binge eating
Gormalty et al.
112
Binge Eating Scale
1982 (19)
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Keefe et al 1984 (24)
(BES)
23
DSM 111 Bulimia All, or all but one
49.5 f44.3%
criteria Marcus et al. 1985 (32)
198
EES Z 27
50.6%
Kolotkin el af 1987 (33)
207
BES
69.6 i.34.9%
DSM 111 Burimia All. or all but one
Obese$
44
No bulimia
Obese;
74.2f37.5%
47 47
No bulimia (ow) DSM 111 bulimia {nw)
- 3.3 k 96%
16 16 16 16
DSM II bulimia (nw) Obeselclinic
64.5%
Obese/community
40.2%
33
No bulimia BES G 17 -
Obese5
Tetch et al.
37
1988 (34)
criteria Hudson et al. 1988 (25)
23
Prather & Williamson 1ma (42)
16
DSM 111 Bulimia (OW)
DSM 111 Bufimia
57396
ION
Obese§
Normal-weight
S9.6
* 27.6%
1.6% 3A%
35
OSM 111 Bulimia BES 3 27
Wing et al. 1983 (30)
95
BES
Marcus et al.
22
BES > 29
37.9 f 6.5k g / r n 2
23
BfS < 17
38.4f6.7kg/m2
25
BES 3 29
38 2~6.5 kg/mz
25
BES < 17
37.5k6.4 kg/m2
41
BES 3 25 2 episodes/week for 3 months (ow)
20-1 00%
28
DSM Ill-R bulimia neiwosa (BULIT 3 102) (nw)
-2010 +20%
BES
36.316.1kg/m2
-
-
DSM fll-R bulimia nervosa
30.2+5.3kg/m2
20.
DSM Ill-R bulimia nervosa (vomiters)
21.4f2.7 kglm'
35.8k5.6 kg/rn2
42
No overeating or
36.7k 4.7 kg/m2
Marcus et al. 1988 (20)
-
1990 (46)
Marcus et al. 1990 (21)
Alger et al. 1991 (41)
Lowe & Caputo
436
-
1991 (31) McCann et al. 1991 (18)
31
de Zwaan et al.
22
(non-purgers) 1992 (29)
Overeating and loss of control
loss of control
'44!cl3% for f, and 41 f 15.9% for rn; t39.3S8.1% for sample 1, and 40.2*11.6% for sample 2; $BMI of 28.8 kg/m2 (range 23-42) for all subjects; 543 k 17%for all subjects; ow =overweight, nw = normal-weight.
assessment method employed, the frequency of severe binge-eating problems in weight loss participants has been surprisingly high, ranging from 23 to 46% (29). Consequently, roughly every fifth to every second woman in weight-reduction programmes presents with bingeeating problems. This problem behaviour seems to be significantly less prevalent in obese subjects not currently in treatment (22),as well as in the general population (9).Conversely, one study (26) found that only 4.2%
of 591 patients meeting full criteria for bulimia nervosa according to DSM Ill-R with the added criterion of purging were 2 130%above ideal body weight. Table 3 shows some clinical characteristics of obese binge eaters as compared to non-binge eaters. Demographic Characteristics. Binge eating seems to be more common in overweight women than men (9,2230, 31). Binge-eating obese appear to be significantly
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de Zwaan
Table 3. Number of studies with positive, negative or no correlation with binge eatlng (severity) in various varlablas of obese binge eaters vs. non-binge eaters. Variables
Correlation
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Positive Negative None Female sex Age (years) Weight (BMi, 34 overweight) Affective disorder Current depression (BD1, HAMD) Past psychotherapy Personality disturbance General psychopathology (SCL-90) Eating-related pathology (EDI) Body image (8DQ, EDI, SD) Maladaptive cognitions about dieting (CFS) Tendency for disinhibition (El) Perceived hunger (El) Early onset of obesity Age at first dieting
4 0 5
2 4 1 1
2 2 4 2 4
0
2
4
1
0 0 0 0 0 0
4 1’ 1’ 0 1 0 0 1 0
0 0
0
3
0 0
2
0
1
0
Mitchell have been suggested to be fundamentally related to anorexia nervosa and bulimia nervosa. It has been widely used in patients with both of these disorders. Results in obese patients demonstrate that binge eaters exhibit more eating-related psychopathology on this scale as compared to their non-binge-eating counterparts. Six of the eight subscales have consistently shown to positively correlate with binge eating. Two of those subscales, i.e. ‘Drive for Thinness’ and a feeling of inadequacy (‘Ineffectiveness?, seem to be the strongest predictors of binge-eating severity among the obese (211 31). Similar to the feeling of ineffectiveness, taw selfesteem has shown to be related to binge-eating severity (22,31).Binge-eating obese have also been shown to be more dissatisfied with their body image than non-bingeeating obese (21-23, 291, and equally dissatisfied with normai-weight bulimic subjects (18).
0
0 0 D
‘Depression was required as inclusion criterion for all subjects. BMI = Body Mass Index; 6D1 =Beck Depression Inventory (39); HAMD =Hamilton Depression Scale (40); ScL-90 = Symplom Checklist (43); ED1=Eating Disorder Inventory (38); BDQ = Body Distortion Questionnaire (44); CFS =Cognitive Factor Scale (19); El=Three-factDr Eating Inventory (36); SD = Semanlic Differential (45).
younger than non-binge-eating obese when they present for treatment (24,29, 31, 32),but significantly older than narmal-weight purging bulimics (18).
Eating and Weight-Related Variables. There seems to be a positive correlation between binge-eating severity and the degree of obesity (22,31-34). Some studies found no significant correlation between degree of obesity and binge eating (19, 24, 29, 30), but we could not find any studies supporting a negative correlation. Tbere is evidence that binge-eating obese have an earlier onset of obesity than non-binge-eating obese (28, 29), start dieting at an earlier age (29),start worrying about their weight at an earlier age (22), and have a higher prevalence of marked weight fluctuations in the past (9, 10). In summary, these results support the notion that dieting and binge eating are closely related (35). Several self-rating questionnaires assessing eating behaviour, as well as attitudes and cognitions towards eating and weight have shown to successfully distinguish between binge-eating and non-binge-eating obese. The tendency towards disinhibition of control over eating, and the susceptibility to hunger (Eating Inventory, 36) have consistently been shown to strongly correlate with binge eating among the obese (20,31,32,37). There are some data using the Eating Disorder Inventory (ED[, 38) with obese patients who have binge-eating problems, although the validity of the EOI in this group has not been established. This instrument was originally developed for adolescents and young adults of normal or low weight, and was designed to assess characteristics of eating behaviour as well as psychological dimensions which
General Psychopathology Two investigations found higher levels of general Psychiatric SymptOmatOlOgy in obese patients with binge eating than those without binge eating, as aSSeSSed by the SCL-90 (20, 37). Furthermore, there appears to be a positive relationship between binge eating and depressive symptoms s well a lifetime history of affective disorders. That is, binge-eating obese exhibit higher depression scores, and are more likely to have a history of depression than their non-binge-eating counterparts (20,21, 25, 29,30,37). It must be noted, however, that in most studies the total depression scores (e.g. BDI, HAMD, 39, 40) were in the normal to mildly depressed range (e.g. BDI scores of 11-1 7), raising questions about the clinical relevance of this finding. Comparisons to normal-weight purging bulimics concerning cornorbid psychiatric disorders show contradictory results. One study found a significantly higher lifetime prevalence rate of affective disorders in patients with normal-weight purging bulimia nervosa when compared with obese binge eaters (18). whereas two other studies found a similar prevalence rate (25, 41). The same conflicting results have been observed with regard to substance abuse (18, 25, 41). Differences in the criteria used to define bulimia (nervosa),and marked differences in the overall prevalence rates of psychiatric disorders between the samples examined in these investigations most likely account for these inconsistent results. The prevalence rates of personality disorders did not differ between overweight bulimics, normal-weight bulimics, and a sample of obese patients In a weight-loss programme, but there were significant differences when these three clinical groups were compared to normalweight controls and to .a community sample of obese individuals (42). This study emphasizes the higher prevalence of psychopathology in clinical samples as opposed to community samples, regardless of the diagnosis. However, another study on personality traits found a positive correlation between 12 subscales of the MMPl and binge-eating severity in a group of 207 obese individuals (33).
Binge Eating in the Obese
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Conclusions Despite differences in the definitions of binge eating and the variability among the samples investigated, there is strong evidence that binge eaters represent a distinct subgroup among the obese. Many studies indicate that such patients are common among the obese, with a frequency ranging from 23 to 46% among fernafe patients seeking lreatmenl for wejght reduction. Bingeeating obese exhibit significantly more eating and weight-related pathology, as well as more psychopathology in general compared to their non-binge-eating obese counterparts. On many variables they resemble normalweight subjects with bulimia nervosa. However, available studies suggest that obese binge eaters are less severely disturbed as compared to patients meeting full criteria for purging bulimia nervosa. Furthermore, there is strong evidence for a continuum of severity with respect to the behavioural and attitudinal parameters of binge eating as well as the degree of psychopathotogy rather than for a dichotomy of binge eaters vs. non-bingeeaters. Nevertheless, the use of operationalized crileria for this problem (e.g. binge-eating disorder, Table 1) might facilitate coordinated research in this area, especially in investigating the effectiveness of treatments specific to the needs of this putative subgroup of obese subjects.
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