Binge eatingBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7282.343 (Published 10 February 2001) Cite this as: BMJ 2001;322:343
A young woman has been binge eating for six months. She looks about normal weight, but she says she feels too fat. She is desperate for help to regain control of her eating.
What issues you should cover
Ask about current methods of weight control—Is she dieting at the moment? Does she make herself sick after eating? If so, how often? Does she take laxatives or diuretics to lose weight? How much exercise does she do? Is this extreme?
Definitions and criteria
Eating, in a discrete period of time, an amount of food that is larger than most people would eat in a similar period under similar circumstances
A sense of lack of control during the episode (feeling unable to stop eating or control what or how much to eat)
Diagnostic criteria for anorexia nervosa
Characteristic over-concern with shape and weight, with intense fear of becoming fat
Active maintenance of an unduly low weight (body mass index <17.5), achieved mainly by strict dieting, excessive exercising, and, in a minority of cases, self induced vomiting
Amenorrhoea for at least three months (if not taking the contraceptive pill)
Diagnostic criteria for bulimia nervosa
Characteristic over-concern with shape and weight
Frequent binges (bulimic episodes)
Extreme behaviour to prevent weight gain—such as self induced vomiting, misuse of laxatives and diuretics, and fasting
Atypical eating disorders
Disorders that do not fulfil the above criteria (problems related to binge eating are common, and the term “binge eating disorder” has been coined to describe recurrent episodes of binge eating without extreme weight controlling behaviour)
Ask about her attitude to her shape and weight—Is she happy with her shape and weight? Would she like to be thinner? How important are her shape and weight to her? Is anything more important to her?
Ask about her eating habits—Does she have episodes when she loses control of her eating? What does she eat during a binge? Is it a true binge? (See box below.) How often does she binge?
Weight—Ask her what she weighs (less threatening in a first consultation than weighing her). Calculate her body mass index (weight (kg)/(height (m)2).
Self help books
Cooper PJ. Bulimia nervosa and binge eating: a guide to recovery. London: Robinson, 1995.
Fairburn CG. Overcoming binge eating. New York: Guilford, 1995.
What you should do
You should now be able to determine the nature and severity of her eating problem and decide on management.
If she has a binge eating problem (including bulimia nervosa) she may well respond to a self help programme, and this can be supervised in primary care. In severe or complicated cases self help is unlikely to work. Early referral for more intensive treatment is advised for the following categories: very low weight (body mass index <17.5); eating disorder for over five years; previous treatment failure; alcohol or drug misuse; personality disorder; severe depression or marked suicidal ideation; and serious medical problems (for example, diabetes).
If self help is appropriate, suggest she buys a self help book that includes a treatment programme—available from most bookshops (or via the internet or by telephone) for about £10. Show her a self help book if you have one.
Most books give detailed information about binge eating as well as a step by step treatment programme based on cognitive behaviour therapy. This therapy has been shown to be the most effective treatment available for bulimia nervosa in over 40 randomised controlled trials. Programmes usually take about 12 weeks to complete and need motivation and commitment.
If she wants to follow a self help programme, offer to see her every two weeks for support and encouragement. Alternatively, this could be done by an interested practice nurse or counsellor, or you could simply arrange to see her again when she has completed the programme.
Depressive symptoms may resolve without specific treatment as the eating disorder improves, but if they persist three to four weeks into the programme, consider prescribing antidepressant drugs and/or referring her to a specialist.
Studies using written self help material for the treatment of binge eating suggest that a third to a half of patients recover using this relatively simple and cost effective intervention, though further research in primary care is needed. If self help does not work, consider referring the patient to a specialist.
The series is edited by Ann McPherson and Deborah Waller