Parents in your clinic may casually mention that their children seem to have an insatiable appetite or tend to overeat when feeling upset. These youths might present at their annual physical exams with significant weight gain or even obesity. Fluctuations in appetite are a normal and expected part of development. Distinguishing these typical changes from pathological overeating can be challenging. When should providers become concerned that overeating has progressed into an eating disorder?
If a patient endorses recurrent, uncontrollable episodes of eating large amounts of food in short periods of time, they may meet criteria for binge eating disorder. Additional diagnostic features include: eating more rapidly than normal, eating until uncomfortably full, eating large amounts of food when not physically hungry, eating alone due to embarrassment, and feeling disgusted with oneself, depressed, or very guilty after overeating. To meet DSM-5-TR criteria, binge episodes must occur at least once weekly for three months and cause marked distress. These episodes must not be accompanied by compensatory behaviors, such as purging or excessive exercise. Severity depends on the frequency of weekly binge episodes (mild: 1-3 episodes, moderate: 4-7 episodes, severe: 8-13 episodes, and extreme: at least 14 episodes).
Binge eating disorder affects approximately 1.8% of adolescents. It is associated with biological, psychological, and social risk factors including substance abuse, genetic polymorphisms, alterations in gut microbiome and cortical connectivity, premorbid negative affectivity, perfectionism, conduct problems, childhood obesity, family weight concerns and eating problems, parenting problems, parental psychopathology, and abuse. It often starts in late adolescence or early adulthood. It is relatively underdiagnosed partly due to limited screening tools. The Binge Eating Disorder Screener-7 (BEDS-7) is a validated screening tool for adults, while the Adolescent Binge Eating Disorder (ADO-BED; see Table 1) can be used to screen adolescents.
Question & Answer Options
Do you sometimes have a strong craving to eat although you are not really hungry or you have recently eaten?
Yes/No
In this situation, do you sometimes find yourself starting to eat and then being unable to stop? For example, have you in the past wanted to eat a few biscuits and been unable to stop until the pack was empty?
Yes/No
In these moments when you find yourself eating although you are not hungry or when you can’t stop eating…
Do you sometimes feel the need to be alone, to isolate yourself to eat?
Yes/No
Do you sometimes have the feeling of being very detached, not really in the moment, as if you were eating while day-dreaming?
Yes/No
Do you sometimes eat because you feel unsettled, unwell, sad, angry or bored?
Yes/No
Do you sometimes feel you eat too much or that you eat more than others?
Yes/No
Do you sometimes have regrets or feel ashamed after you’ve eaten?
Yes/No
How often do you experience not being able to stop eating or do you find yourself eating without being hungry?
At least once a month/2-3 times a month/2-3 times per week every day
Since when have you experienced this?
Less than 3 months/ More than 3 months
When you are in these situations do you sometimes need to take action to eliminate what you have just eaten (exercise, skip the next meal, self induce vomiting…)
Yes /No
Eating disorders are best managed by a multidisciplinary team, which may include a primary care physician, psychiatrist, therapist and nutritionist. First-line treatment for binge eating disorder involves individual and/or group psychotherapy using evidence-based modalities, such as cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), and dialectical behavioral therapy (DBT). Pharmacologic treatment may include lisdexamfetamine (Vyvanse), which is FDA-approved for binge eating disorder in adults, or selective serotonin reuptake inhibitors (SSRIs). There are no FDA-approved medications for binge eating disorder in youth at this time.
Patients with binge eating disorder should be screened and treated for comorbid medical conditions including: hypertension, hyperlipidemia, diabetes mellitus, gastroesophageal reflux disease, hepatobiliary disease, coronary artery disease, obstructive sleep apnea, and hypothyroidism. Evaluation and treatment for comorbid psychiatric diagnoses, such as anxiety disorders and mood disorders, are also essential. When specialized care is indicated, patients can be referred to eating disorder treatment centers, such as the UCSD Center for Healthy Eating and Activity Research, Center for Discovery, or Equip.
Providers are encouraged to provide this handout from Rady Children’s Hospital to parents of children struggling with binge eating. Parents can support their children in recovery by encouraging regular meals and snacks, avoidance of triggers, and physical activity. Mindful eating, or the practice of being fully present and attentive while eating, can also be an effective behavioral intervention.
References
Chamay-Weber C, Combescure C, Lanza L, Carrard I, Haller DM. Screening obese adolescents for binge eating disorder in primary care: the Adolescent Binge Eating Scale. J Pediatr. 2017;185:68-72.
Mars JA, Iqbal A, Rehman A. Binge Eating Disorder. Updated August 11, 2024. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; January 2025–. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551700/
National Eating Disorders Association. Binge Eating Disorder. National Eating Disorders Association. https://www.nationaleatingdisorders.org/binge-eating-disorder/. Accessed April 22,
AUTHOR:
Dr. Kristen Kim, MD
Child, Adolescent and Adult Psychiatrist
Vista Hill Foundation