Table 1.

Themes with Examples of Quotes

BED is highly prevalent but often a missed diagnosis; clinicians must elicit the diagnosis by questioning patients closely. (8 modules, 7 speakers)
  • “These patients often present for weight loss programs or with other comorbidities, such as depression, anxiety, or substance use, but the eating disorder frequently goes undiagnosed” (45).

  • “BED hides within previously diagnosed conditions” (46).

  • “Pushing a little further can elicit a diagnosis for BED” (32).

  • “That it is a hidden disorder that people do not report because they feel such shame, or they do not even know they are doing it” (39).

  • “Patients with BED often display discomfort, shame, or guilt regarding their weight and eating behavior. Many patients with BED are secretive about their binge eating and attempt to conceal their behaviors” (22).

  • “When you ask these questions to people with binge eating disorder, they often resonate, and people will answer affirmatively when they're specifically probed about their symptoms” (43).

  • “Just go one step further and ask that question about uncontrolled eating, and many times you will have a revelation at that patient visit” (40).

  • “… probe a little bit… Ask: ‘Kendra, tell me a little bit about the eating at night’” (41).

BED can occur in anyone regardless of age, gender, ethnicity, or weight. (12 modules, 5 speakers)
  • “BED is a disorder that affects everyone. It causes a lot of suffering across many groups of people” (41).

  • “BED can occur… in people of any size, weight, and shape” (31).

  • “BED occurs across all weight categories” (31).

  • “BED is found across all weight, age categories, as well as all ethnic and racial groups in United States” (37).

  • “Unlike anorexia nervosa and bulimia, BED appears to affect men and women at similar rates and has been identified across diverse community and clinical samples, ethnicities, and racial backgrounds” (25).

  • “… binge eating is more common than previously recognized, occurring in 2.6% of US adults, in both men and women, and in members of all ethnic/racial groups” (45).

  • “… of the eating disorders, BED occurs more in men” (33).

  • “BED is the most prevalent eating disorders in males” (47).

  • “You may be surprised to hear that almost half are male and actually the gender distribution is far less skewed with BED than it is with anorexia nervosa and bulimia nervosa, where it seems to occur more commonly among females” (29).

  • “Like other eating disorders, binge eating disorder affects women more often than men, but binge eating disorder is more common in men than other eating disorders” (43).

  • “It is a common problem for both men and women” (48).

BED results in poor quality of life. (7 modules, 5 speakers)
  • “The quality of life is impaired” (35).

  • “… binge eating disorder is associated with reduced quality of life and impairment in functioning that is actually comparable to that seen in people with bulimia nervosa” (40).

  • “… BED is associated with distress, reduced quality of life, and role impairment comparable to that seen with bulimia nervosa” (43).

  • “Kids as young as 5 years old are already being stigmatized for overweight. They have poor quality of life. They rated as poor as children with cancer” (34).

  • “With all patients with BED, there is an increased risk for them to suffer psychological distress, interpersonal problems, and some role impairments. There have been some reports on elevated suicidality” (27).

  • “Many people with BED have additional thoughts about the behavior and these thoughts can be very distracting and it impairs people’s ability to function optimally” (44).

  • “BED is a disorder that affects everyone, that causes a lot of suffering across many different groups of people” (41).

BED is associated with many other disorders, including obesity, depression, anxiety, substance use disorders, diabetes, dyslipidemia and metabolic syndrome. (7 modules, 7 speakers)
  • “Patients with this disorder may have greater impairment and poorer physical health, for example, worsened metabolic profiles, more rapid weight gain, and a worse response to weight loss treatment” (45).

  • “Beyond obesity, medical concerns such as metabolic syndrome and diabetes are also frequently associated with BED, leading to a reduced quality of life and impairment in functioning” (25).

  • “BED is associated with a huge amount of co-morbidities” (23).

  • “As noted, mood and anxiety disorders are commonly comorbid with BED…Presentations that suggest depression or anxiety should increase suspicion for BED” (22).

  • “Most clinicians in psychiatric space probably have a number of patients with BED who have presented them with comorbidity, depression, or anxiety - and questions about binge eating have never come up” (29).

  • “… BED often co-occurs with other psychiatric and medical disorders, in particular, mood disorders, and that includes both depressive and bipolar disorders, anxiety disorders, substance use disorders, impulse control disorders, including attention deficit hyperactivity disorder, and BED also co-occurs with obesity, and that includes severe obesity, as well as possibly metabolic syndrome”(43).

  • “Subjects showed increased frequency of anxiety disorders, substance-related disorders, depressive symptoms, trait anxiety, and higher external and emotional eating scores than subjects without BED” (42).

Many patients with BED are obese. (13 modules, 9 speakers)
  • “BED is associated with severe obesity” (31).

  • “Most patients with BED are obese” (33).

  • “Most people presenting for treatment for BED are obese” (36).

  • “It is associated with increased risk for obesity” (41).

  • “It is frequently associated with other medical and psychological co-morbidities, including obesity” (38).

  • “… BED does not automatically equate to obesity, but it definitely increases the risk of obesity – by about 75% in 1 large study” (39).

  • “Studies reveal overlaps among appetitive traits that likely increase risk for binge eating symptoms and excess weight gain … In this sense, the disorder is a biologically based subtype of obesity. The proneness to bingeing behaviors can lead to hyper-reactivity to the hedonic properties of food” (45).

  • “Overweight or obese BED patients are more likely to gain weight more rapidly” (23).

  • “The presence of binge eating episodes can lead to weight gain, even when patients engage in food restriction during the rest of the day” (22).

  • “Recent substantial weight gains, history of weight fluctuation or current reports of inability to lose weight those are things that need to be monitored and looked at for possible medical reasons as well as they signal for presence of this behavior in psychiatry problem” (37).

  • “I think there are clear red flags that determine when we definitely should ask about binge eating – most importantly, whenever somebody presents with a weight problem” (40).

  • “Weight issue is very important” (35).

  • “Let me talk about a clinical case study: Sally, a White 40 year old woman, who is not losing weight despite being on repeated diets. That alone should clue us in that we need to ask about eating behaviors” (29).

BED makes losing weight difficult. (2 modules, 2 speakers)
  • “These red flags include the presence of excess weight or obesity; a history of weight fluctuations, rapid weight gain, and difficulty losing weight” (45).

  • “If you can stop binge eating, you can stabilize weight gain” (36).

BED is not a character flaw. (8 modules, 3 speakers)
  • “BED is not a sign of weakness or character flaw. It is a medical condition” (36).

  • “…I believe we must convince our patients that this is a disease; this not a character flaw” (39).

  • “Educate the patient about BED - that it is a medical condition. It is not something that they are choosing to do or is a character flaw” (32).

  • “It is not a character flaw. It is not a personal failure” (40).

  • “We need to provide patients with education. Not only with information but with validation. How common it is and that it is not a character flaw” (25).

  • “I also tell them that binge eating disorder is a distinct medical condition that's classified in the DSM-5, and this can help patients realize that they have a disorder rather than a personal weakness” (43).

  • “BED is a diagnosable psychiatric disorder. This is a serious and formal disorder. It is not about willpower” (23).

  • “BED is a diagnosable psychiatric disorder. This is a serious mental and behavioral problem. It is not about weakness or it is not about lack of will power” (31).

BED is related to dopamine dysfunction. (4 modules, 4 speakers)
  • “BED is associated with dopamine dysfunction while controlling for obesity” (27).

  • “Basic research into the neurobiological mechanisms of BED has implicated different neurotransmitters and systems, with varying degrees of evidence. Potentially involved neurotransmitter systems include, among others: dopamine” (22).

  • “Studies in humans and animal models suggest a role for dopamine in the pathophysiology of BED” (30).

  • “It has been demonstrated that repeated stimulation of dopamine-containing neurons in the midbrain that project to the striatum is associated with the development and maintenance of binge eating” (24).

BED is a real, treatable disease, and treatment improves lives. (7 modules, 4 speakers)
  • “BED is treatable” (27, 28).

  • “Treatments exist and include evidence-based forms of psychotherapy and medications” (44).

  • “BED is a diagnosable disorder and a treatable disorder” (37).

  • “BED is a diagnosable and treatable disorder” (38).

  • “There are also some great self-help books out there so that they gain more of an understanding of the disorder and they get more empowered in the management of their own lives. Many times when they do that, it is not just the binge eating that improves, and it is not even the other chronic medical conditions” (39).

  • “When you identify BED and treat this patient effectively, the outcome can be outstanding, and you can really make a strong difference in patients' lives by preventing serious morbidity and just helping them to live better, live happier, and be more in control of their own lives” (40).

Lisdexamfetamine is effective for BED. (7 modules, 5 speakers)
  • “…lisdexamfetamine is the only agent to my knowledge with FDA indication for moderate to severe BED” (31).

  • “We don’t get results like this in many studies. This is incredibly positive data” (32).

  • “Once you move up to 50, 70mg [of lisdexamfetamine], then you see very impressive results” (25).

  • “Like lisdexamfetamine has more recently been studied with very positive results… the result has been SO positive” (33).

  • “Pharmacotherapies are widely available and they are not difficult to use. Because of this, this seems to be a very good model for treating BED… if they are not successful you can think about adding structured psychotherapy at that point” (35).

  • “It improved people's ability to inhibit their eating behavior when they wanted to. The drug also reduced hunger. And finally, lisdexamfetamine also reduced the obsessive-compulsive features of binge eating. So people spent less time thinking about eating or having urges to binge eat, and they felt more in control of their eating behavior” (43).

  • “Both of these studies showed VERY positive results for lisdexamfetamine for BED” (34).

Topiramate and other treatments for BED cause adverse effects. (5 modules, 5 speakers)
  • “Topiramate has been shown to be effective but complicated by high discontinuation rate and side effects” (31).

  • “… [topiramate] has been shown to be effective in both binge eating episodes as well as weight loss. The downside being some high discontinuation rates due to side effects” (33).

  • “Similarly, you will see effectiveness that was shown from the sibutramene. However, this medication has been withdrawn from the market” (33).

  • “One long-term study of topiramate had a duration of 42 weeks and showed continued improvement in BED and weight loss; however, the discontinuation rate for adverse events in this study was high” (45).

  • “Topiramate is associated with side effects (eg, parathesias, dry mouth, headache, dyspepsia, and cognitive impairment) that may have contributed to high drop out rates in some trials. It should be noted that topiramate is considered pregnancy category D and has been associated with increased risk for fetal defects” (22).

  • “More limited evidence describes similar outcomes with zonisamide, including greater reductions in binge frequency and body weight compared to placebo, as well as high rates of discontinuation” (22).

  • “… topiramate has been shown to be effective for reducing binge eating and also effective for weight loss, but there are high discontinuation rates with the compound because of side effects” (31).

  • “The anti-obesity agent, orlistat, has been studied in binge eating disorder as well…there's a high discontinuation rate with this drug because of side effects” (43).

  • “Lipase inhibitors or orlistat have been looked at… It just prevents fat absorption. It does produce weight loss but no significantly effect on binge eating. It is typically not tolerated – well tolerated” (31).

Other therapeutic options for BED are inferior options because they do not produce weight loss. (9 modules, 5 speakers)
  • “Anti-depressants have been studied. Their overall effect on BED has been modest. They do not significantly produce weight loss and their tolerability varies among different types of anti-depressants” (31).

  • “…there is no change in BMI with duloxetine” (32).

  • “Specialized psychotherapies are generally not effective for weight and obesity” (32).

  • “In anti-depressant realm, there has been some modest effect on binge eating episodes, but no significant effect on weight loss itself” (33).

  • “So antidepressants have been shown to be somewhat or modestly effective for reducing binge eating over the short term, but they're not usually associated with significant weight loss” (43).

  • “Psychological therapies, however, do not produce weight loss without a complementary weight-reduction or anti-obesity intervention” (45).

  • “Overall, studies of SSRIs in BED have reported greater reductions in binge eating compared to placebo, although weight reduction was modest in most trials” (22).

  • “Chronic use of SSRIs is associated with weight gain” (35).

  • “How well do these [nonpharmacological] things work? Do they work on binge eating? Well yeah, they work very well on binge eating… but the problem is that they don’t really result in weight loss” (35).

  • “Help manuals alone or with guidance from therapies may benefit some people with BED but should be only considered as first step in treatment. But not probably effective for many people… They don’t produce clinically meaningful or sustain weight loss” (28).

  • “The anti-obesity agent, orlistat, has been studied in binge eating disorder as well, but the results have been mixed. It's really not clear whether or not this compound reduces binge eating behavior, and in some studies, there was weight loss and other studies there wasn't” (43).

  • “The anti-obesity medication, sibutramine, has been studied in several randomized controlled trials in people with binge eating disorder, where it's been shown to be effective for reducing binge eating behavior and also effective for weight loss. But this compound has been withdrawn from the market because of safety concerns” (43).

  • “Unfortunately, CBT and some of other psychological treatments that are available in special centers the do not seem to produce weight loss unless, of course, there is complementary weight loss intervention or anti-obesity medication or anti-obesity intervention provided in adjunct” (34).

  • “Other agents such as SSRIs or anti-depressants appear to have some benefit for reducing BE but unfortunately they do not produce any weight loss” (37).

  • BED, Binge-Eating Disorder; SSRI, serotonin reuptake inhibitors; FDA, Food and Drug Administration ; DSM5, Diagnostic and Statistical Manual of Mental Disorders.