Weight gain despite dieting
Binge-eating disorder is more prevalent in women than men and has one of the strongest associations with obesity; among patients with obesity, lifetime prevalence of binge eating is approximately 5.5%. Large population studies suggest that binge-eating disorder may be present in 2%-4% of adolescents, with a mean age of onset of 12-13 years. This patient probably had milder binge-eating disorder as an adolescent and young adult, which was exacerbated by the pandemic.
Both new diagnoses and reports of clinical worsening in patients with preexisting diagnoses of binge-eating disorder during the pandemic have been documented. Food insecurity has been associated with binge eating, consistent with this patient's anxiety over food and grocery availability during the pandemic. The definition of binge-eating disorder includes recurrent specific episodes of overeating that are not consistent with the patient's usual behavior, eating to the point of being uncomfortably full, eating more quickly or when not hungry, and having feelings of loss of control during episodes and of guilt or disgust afterward.
Obesity and eating disorders share some common risk factors and approaches to management. Binge eating has been associated with type 2 diabetes, hypertension, asthma, sleep disorders, and menstrual disorders, all of which are also affected by obesity. The presence of both conditions increases the adverse outcomes associated with each, including negative impacts on cardiometabolic and psychological health. Workup of patients presenting with binge eating and obesity should always include complete blood/metabolic panels and cardiovascular and renal health, as well as assessments of nutrition status, electrolyte imbalances, gastrointestinal reflux disease, and chronic pain.
In general, where binge-eating disorder and obesity are concurrent, cognitive-behavioral therapy (CBT) for binge-eating disorder should be the first priority, with obesity management (medication or surgery) to follow. CBT has the strongest evidence of benefit for patients with binge-eating disorder and is the recommended treatment approach. Other psychotherapeutic interventions that may be of benefit include dialectical behavioral therapy (to reduce binge-eating frequency), technology-based options, and family-based therapy when symptoms are recognized in children or adolescents. Structured behavioral weight management strategies for management of obesity and overweight do not increase symptoms of eating disorders and may instead relieve some symptoms. An emerging approach to binge eating in patients with obesity is CBT that integrates therapeutic approaches to both issues.
Medications to treat binge-eating disorder are limited and should not be used without concurrent psychotherapy; lisdexamfetamine has demonstrated benefit, is recommended by the American Psychiatric Association, and is approved by the US Food and Drug Administration specifically to treat adults with binge-eating disorder.
The success of psychological interventions and lifestyle modifications for obesity is heavily dependent on the individual's ability and motivation to comply with recommended interventions. The American Gastroenterological Association and other organizations recommend treatment with antiobesity medications along with lifestyle modifications for patients with obesity (BMI ≥ 30) and weight-related complications (BMI > 27). Recommended medications include phentermine-topiramate and bupropion-naltrexone (which may benefit those with binge-eating disorder), as well as injectable glucagon-like peptide receptor agonists (GLP-1 RAs) at the approved dosage for obesity management (semaglutide 2.4 mg weekly or liraglutide 3.0 mg daily). Orlistat is not recommended. Ongoing research on the potential benefit of GLP-1 RAs in management of binge eating offers additional support for a role in patients, like this one, with binge-eating disorder and obesity.
Carolyn Newberry, MD, Assistant Professor of Medicine, Director of GI Nutrition, Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), Division of Gastroenterology, Weill Cornell Medical Center, New York, NY.
Disclosure: Carolyn Newberry, MD, has disclosed the following relevant financial relationships:
Serve(d) as a speaker or a member of a speakers bureau for: Baster International; InBody.
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