Is Binge Eating sabotaging your diabetes treatment?
Binge eating disorder (BED) is the most prevalent eating disorder but remains largely undiagnosed and untreated. BED is characterized by recurrent episodes of loss of control and consumption of unusually large amounts of food within a short period of time (<=2h). Episodes are associated with significant emotional distress but are not followed by purging behaviors (vomiting, misuse of laxatives, etc.), which differentiates BED from Bulimia Nervosa. In addition to psychological distress, BED is associated with medical complications including accelerated weight gain, metabolic abnormalities, functional impairment, and decreased quality of life. Untreated BED leads to worse clinical outcomes in a variety of medical and psychiatric conditions and poor treatment response in hypertension, diabetes, dyslipidemia, and obesity, which are commonly seen in primary care. Patients with BED stand to benefit from increased screening, diagnosis, and treatment, particularly patients with type 2 diabetes mellitus (T2DM).
Screening for BED is particularly important in patients with T2DM. While the prevalence of BED in the general population is estimated around 3%, prevalence is significantly higher in T2DM, where the prevalence of BED is estimated around thirteen times higher than in the general population. In fact, eating disorders are frequently encountered among patients with T2DM, with prevalence estimated around 20%. Diagnosis and treatment are important because the presence of binge eating greatly complicates management and is associated with worsened outcomes such as impaired glycemic control, dyslipidemia, and accelerated weight gain. BED is associated with decreased response to weight loss interventions (including dietary and bariatric surgical procedures), impaired glycemic control, dyslipidemia, and exacerbation of insulin resistance. Moreover, common pharmacotherapies for diabetes (such as insulin, sulfonylureas, and dietary restraint) have been implicated in the exacerbation of binge eating.
As we have seen, BED is a barrier to achieving treatment goals in T2DM. It is important to take binge eating into account when selecting treatment. Reducing the frequency and severity of binge eating can facilitate the achievement of treatment goals in T2DM. Primary care providers manage most patients with T2DM, but screening and management of BED is still overlooked. It is necessary to treat patients to decrease the frequency and severity of binge eating to help patients achieve treatment goals for diabetes. Optimal outcomes in treatment are not possible with untreated BED. Primary care providers face the challenge of identifying and initiating treatment for this population with complex needs.
Even though BED is an important comorbidity in T2DM, significant barriers to diagnosis and treatment persist. First, eating disorders are associated with significant stigma and patients may not readily disclose disordered eating behaviors due to shame. In many cases, patients are aware that some of their eating behaviors are abnormal, but they do not know that they are suffering from a treatable eating disorder. In addition, primary care providers may overlook binge eating as a possible factor when patients fail to achieve treatment goals despite intensification of treatment. In addition, primary care providers face time and financial constraints which limit their ability to diagnose, refer and treat. Finally, there are not enough trained clinicians who can offer specialized medication management, dietary counselling, and psychotherapy for BED. Medication options are still limited to an FDA approved agent (lisdexamphetamine), plus a couple of drugs used off-label. However, providers still have options to start addressing the needs of patients with T2DM and BED, including:
- Screening for eating disorders (BEDS-7 scale) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4956427/)
- Providing educational resources for Binge Eating and eating disorders https://lindnercenterofhope.org/eating-disorders/
- Monitoring for the emergence or exacerbation of binge eating with insulin and sulfonylureas
- Considering antidiabetic agents with a lower risk for exacerbating binge eating (metformin, GLP-1 agonists)
Further research is needed to understand the needs of patients with comorbid T2DM and BED as well as to develop treatments to lessen the occurrence of binge eating episodes clinical care guidelines.
The Research Institute at the Lindner Center of HOPE is conducting a clinical trial of an experimental medication for Binge Eating disorder. No prior diagnosis is required. For additional information, contact us at 513-536-0700 or visit: https://redcap.research.cchmc.org/surveys/?s=TP3C4TEA8J
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Keshen A, Kaplan AS, Masson P, Ivanova I, Simon B, Ward R, Ali SI, Carter JC. Binge eating disorder: Updated overview for primary care practitioners. Can Fam Physician. 2022 Jun;68(6):416-421. English. doi: 10.46747/cfp.6806416. PMID: 35701190; PMCID: PMC9197289.
Winston AP. Eating Disorders and Diabetes. Curr Diab Rep. 2020 Jun 15;20(8):32. doi: 10.1007/s11892-020-01320-0. PMID: 32537669.