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Binge Eating Disorder, Obesity and Tobacco Smoking

Marney A. White, PhD, Carlos M. Grilo, PhD, Stephanie S. O’Malley, PhD,  and Marc N. Potenza, MD, PhD studied a clinical case who suffered from two frequently co-occurring disorders—binge eating disorder (BED) and obesity—which they describe in their article “Binge Eating Disorder, Obesity, and Tobacco Smoking.” Also including an addiction to nicotine, the case is one that is quite characteristic of BED; therefore, White and colleagues believe that it serves to clarify several issues regarding the disorder that currently surround clinicians and researchers.

Clinical Case Study[1

An African American woman, age 48, sought treatment for a binge eating disorder at a university-based program. Her doctor discussed her need to lose weight, yet offered no suggestions and failed to address her disorder. When she was initially examined, she was 64 inches tall and weighed 230 pounds, giving her a body mass index (BMI) of 39.5, reflecting obesity. Otherwise, aside from weight-related high blood pressure and high cholesterol, she was found to be healthy.

The patient stated that she had completed a master’s level of education and had worked as a special education teacher for the past 11 years. At home, she resided with her husband of 24 years and one of her two adult children. According to the patient, her home life was good, her job was enjoyable, and she had plenty of friends.

During childhood and throughout her teenage years, the patient reported being of average weight and having no body image concerns. During her 20s, she stated she maintained a weight of 150 (BMI 25.7). However, at 28, when she became pregnant with her second child, the patient reported that she never fully lost the “baby weight.” In fact, throughout her 30s, she began to gain weight gradually, even despite efforts to diet.

According to the patient, her patterns of binge eating began at age 16. Once or twice per month, the patient would snack on junk foods for an entire evening, until she felt ill. She stated that during these episodes, she felt as if she had lost control. She had not used purging behaviors.

Throughout her teens and early 20s, the patient continued binge eating at a rate of one or twice per month; however, during her 30s, the frequency increased. While she attempted dieting, in between failed attempts, she would binge eat two to three times per week. Over the past 18 months before seeking treatment, she had not attempted to diet, but would regularly skip meals to control her weight.

When her mother became ill six months ago, the patient stated that her binge eating further increased. While her mother was ill, she would binge eat three to four times per week, and after her mother’s death, it increased to six to seven times per week. As her mother died of cancer, the patient quit smoking cigarettes “cold turkey” after her death. However, since doing so, her urges to binge eat became more intense and when binge eating, her urges to smoke became more intense.

For treatment, the patient received 12 weekly sessions of cognitive-behavioral therapy (CBT), the best treatment for binge eating disorder. During the first four sessions, the patient was educated on the nature of binge eating and learned how to self-monitor and keep records of her eating habits in order to help develop healthier ones. During the next four sessions, the patient learned to identify insights to her eating habits, such as triggers. Finally, during the last four sessions, the patient focused on maintaining changes made and relapse prevention techniques. At the end of treatment, the patient had recovered fully from her binge eating disorder.

Discussion

White defines BED as the recurrent episodes of binge eating without the inappropriate use of weight control methods, such as laxatives or purging.1 When binge eating, the individual will eat a large amount of food, feeling a sense of lost control. For binge eating to be considered a disorder, it must occur at least two days per week within the last six months.1 Approximately 3.5 percent of women are diagnosed with BED—more than anorexia nervosa and bulimia nervosa combined.[2] The disease’s prevalence is evenly spread among men and women, ethnic and racial groups.2 As it is oftentimes linked to obesity, the chance for other co-occurring medical diagnoses increase, especially for diabetes and metabolic problems.1

White states that many patients who have BED are often not identified, and even fewer receive empirically-based treatment.1 Often, patients and primary care physicians view the patient’s binge eating as a reflection of their obesity and need for diet and exercise.1 Rarely, as in this case, is binge eating identified as a disorder. For example, the patient in the clinical case discussed weight loss with her doctor; however, BED was never addressed as a possible cause. White believes that many physicians are truly uncomfortable bringing up the subject of weight issues with patients, and many reasons why exist.1 Some feel they do not have the expertise to speak about it and others are concerned about damaging the therapeutic relationship they’ve established with the patient.[3] However, according to White, it is extremely important for physicians to be able to provide referrals to specialized care, to talk about options regarding weight loss, and to address the needs of the patient along the way.1

When obese patients are smokers, their risk of health consequences increases, especially for diabetes and cardiovascular disease.1 However, health consequences often motivate a smoker to quit, as was the case with the patient in the case study. According to O’Malley, women are less likely than men to continue being smoke-free for many reasons.1 For example, being smoke-free for one year leads to a gain of 11 pounds as being smoke-free leads to decreased energy and increased appetite.4 For overweight patients who quit smoking, especially those with binge eating problems, the weight gain after one year was significantly higher than the average-sized patients, at 24.6 pounds.[4] However, O’Malley believes that the case study patient’s binge eating also puts her at risk of smoking relapse.1 Her expectations that smoking could also limit her binge eating puts her at risk.1 O’Malley believes that the CBT for BED will aid patients in refraining from beginning smoking again, as they decrease the food deprivation that increase the smoking urges and help develop coping skills, as many use cigarettes to cope with situations.1

According to White and colleagues, cognitive-behavioral therapy (CBT) is the number one treatment for BED. In fact, studies of CBT for BED have shown remission rates of 50 percent and higher, along with improvements psychological and psychosocial functioning.[5] The only problem White and colleagues believe to be found with CBT for BED is the minimal amount of weight lost during the treatment.5 The patient in the case study lost a mere five pounds. However, CBT remains superior to other treatment options, such as behavioral weight loss therapy[6] and the medicine fluoxetine.[7] Also, the results achieved with CBT are known to be maintained after 24 months of completion.6 Overall, White and colleagues remain concerned that the failure to produce weight loss will lead to health problems in patients who have their BED in remission.1 Therefore, they propose that further research be done to find ways to enhance weight loss in patients who are obese and have BED.[8]



[1] White, M.A.; Grilo, C.M.; O’Malley, S.S.; Potenza, M.N. (2010). Binge Eating Disorder, Obesity, and Tobacco Smoking. J Addict Med 4(1): 11-18.

[2] Hudson JI, Hiripi E, Pope HG, et al. The prevalence and correlates of eating disorders in the NCS replication. Biol Psychiatry. 2007;61:348-358.

[3] Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity. 2009;17:941-964.

[4] White MA, Masheb RM, Grilo CM. Self-reported weight gain following smoking cessation: A function of binge eating  behaviour. Int J Eat Disorders. 2009 Aug 28. [Epub ahead of print] PMID: 19718662.

[5] Wilson GT, Grilo CM, Vitousek K. Psychological treatments for eating disorders. Am Psychol. 2007;62:199-216.

[6] Wilson GT, Wilfley DE, Agras WS, Bryson SW. Psychological treatments of binge eating disorder. Arch Gen Psychiatry. 2010; 67:94-101.

[7] Grilo CM, Masheb RM, Wilson GT. Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: A randomized double-blind placebo-controlled comparison. Biol Psychiatry. 2005;57:301-309.

[8] Grilo CM. What treatment research is needed for eating disorder not otherwise specified and binge eating disorder? In: Grilo CG, Mitchell JE, eds, The Treatment of Eating Disorders: A Clinical Handbook. New York: Guilford Press; 2010:554-568.

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