Binge-Eating Disorder in Adults

Binge-eating disorder (BED), the most common eating disorder, affects approximately 3% of U.S. adults in their lifetime (13). It is characterized by recurrent (1 per week for 3 months), brief (2 hours), psychologically distressing binge-eating episodes during which patients sense a lack of control and consume larger amounts of food than most people would under similar circumstances. Full diagnostic criteria are available in Appendix Table 1. Binge-eating disorder is more common in women (3.5%) than men (2.0%) and in obese individuals (5% to 30%) (4, 5), especially those who are severely obese and those seeking obesity treatment (3, 6). It typically emerges in early adulthood (1, 7) but may surface in adolescence (8) and persist well beyond midlife (9). In May 2013, the American Psychiatric Association (APA) officially recognized BED as a distinct eating disorder with a lower diagnostic threshold (in terms of frequency and duration of symptoms) than formerly accepted (10). The numbers of persons presenting for evaluation, receiving a BED diagnosis, and requiring treatment are expected to increase (11, 12). Appendix Table 1. DSM-5 Diagnostic Criteria for Binge-Eating Disorder BED is associated with poorer psychological and physical well-being, including major depressive and other psychiatric disorders (13, 14), relationship distress and impaired social role functioning (1416), chronic pain (13, 14), obesity (13, 14, 17), and diabetes (1821). Binge eating and BED predispose individuals to metabolic syndrome independent of weight gain (17), type 2 diabetes (22), earlier-onset diabetes (20), and worse diabetes-related complications and outcomes owing to nonadherence to recommended dietary modifications (2325). Similarly, binge eating is implicated as a treatment-limiting factor in patients undergoing bariatric surgery, approximately 25% of whom experience loss-of-control eating (26) that interferes with adherence to postsurgical nutritional recommendations and may impede weight loss and reduce quality of life (27, 28). Treatment aims to reduce binge-eating frequency and disordered eatingrelated cognitions, improve metabolic health and weight (in patients who are obese, diabetic, or both), and regulate mood (in patients with coexisting depression or anxiety). Treatment approaches include psychological and behavioral treatments (hereafter psychological), pharmacologic treatments, and combinations of the 2 approaches. Table 1 describes common treatments for BED. Table 1. Interventions Commonly Used in Treating Patients With Binge-Eating Disorder Current guidelines from the APA (29, 30) and the National Institute for Health and Care Excellence (NICE) (31) support the use of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors, but they differ in content and timing. The APA recommends a team approach (including psychiatrists, psychologists, dietitians, and social workers) with CBT as the cornerstone and medication as adjunctive therapy. In contrast, NICE recommends a CBT-based self-help approach but also endorses medication monotherapy as sufficient treatment for some patients. Best practices for weight management are unclear, in part because of different perspectives on dieting-based approaches (32, 33) and bariatric surgery (3437) in obese individuals with BED. Moreover, little is known about the effect of patient-, provider-, and setting-level factors on treatment outcomes. Our group at the RTI InternationalUniversity of North Carolina Evidence-Based Practice Center conducted a systematic review for the Agency for Healthcare Research and Quality (AHRQ) (38) that updates and extends the scope of our 2006 AHRQ review on eating disorders (39, 40) by including studies of loss-of-control eating, examining nearly twice as many randomized, controlled trials (RCTs) of BED therapies, and applying meta-analytic techniques to measure BED treatment effectiveness. Methods Our methods, complete search strategies, and detailed evidence tables are available in the full systematic review (38). Our protocol (41) was guided by key questions reflecting previously identified evidence gaps, input from key informants and a technical expert panel, and analytic frameworks depicting treatment effectiveness and harms (Appendix Figure 1). Key questions focused on the effectiveness of psychological treatments compared with waitlist, pharmacologic treatments compared with placebo, and combination treatments compared with placebo or waitlist. Primary outcomes were behavioral (reducing binge-eating frequency and increasing abstinence from binge eating), psychological (improving levels of eating-related and general psychological outcomes), and physical (reducing weight and improving other markers of health where relevant), and also included harms from treatment. Appendix Figure 1. Analytic framework for treatment effectiveness and harms. BMI = body mass index; GERD = gastroesophageal reflux disease; KQ = key question. * Effectiveness of treatment. Differences between subgroups. Data Sources and Searches We searched EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov from inception to 18 November 2015, and MEDLINE from inception to 12 May 2016 (Supplement). We hand-searched reference lists and relevant systematic reviews. Supplement. Search Strategy for Full Report* Study Selection We used a PICOTS (populations, interventions, comparators, outcomes, timing, settings, and study designs) approach to identify studies that met our inclusion and exclusion criteria. The population of interest was adults with a diagnosis of BED based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth or Fifth Edition. Interventions included pharmacologic, psychological, and behavioral treatments, as well as complementary and alternative medicine. We limited inclusion to RCTs that measured outcomes at the end of treatment or later in 10 or more randomly assigned patients; included active intervention, placebo, or waitlist control groups as comparators; were conducted in outpatient, inpatient, or home-based settings (such as self-help); and were published in English. We included trials conducted in any country. We selected abstracts for full-text review of articles if they met predefined inclusion and exclusion criteria (Appendix Table 2). Two reviewers independently evaluated the full texts of selected articles to determine whether they should be included; disagreements were resolved by consensus discussion or with help from a third senior reviewer. Appendix Table 2. Inclusion and Exclusion Criteria* Data Abstraction and Risk-of-Bias Assessment One reviewer abstracted details regarding study design, patient population, interventions and comparators, outcomes, duration of treatment and follow-up, settings, and results. A second reviewer checked the abstracted data for accuracy. For each study, 2 independent reviewers rated the risks of selection, performance, attrition, detection, and outcome reporting bias; they summarized their assessment overall as low, medium, or high risk of bias. Statistical Analysis For our investigation of treatments, we omitted studies with high risk of bias, except for harms and sensitivity analyses of meta-analyses. We graded the strength of evidence (SOE) for each major outcome with guidance from the Evidence-Based Practice Center regarding study limitations, consistency, precision, directness of the evidence, and risk of reporting bias (42, 43). The SOE grades are high, moderate, low, or insufficient, reflecting levels of confidence that the evidence represents the true effect. A grade of insufficient means that evidence either was unavailable or did not permit estimation of the effect. In this review, we report results with SOE grades of low, moderate, or high; see the technical report for more detailed results, including those with insufficient SOE (38). For available trials using comparable treatment methods, durations, and outcomes, we performed an unadjusted random-effects meta-analysis using restricted maximum likelihood models (OpenMeta[Analyst] [Brown University Center for Evidence-Based Medicine]). Across studies, the percentage of patients achieving abstinence for each trial uses the number of all randomly assigned patients as the denominator to reflect a true intention-to-treat analysis (that is, to correct variations in results of modified intention-to-treat analyses from individual trials). We derived risk ratios (RRs) for abstinence (defined as 0 binge episodes recorded in the most recent assessment period, usually the past month) and mean differences (MDs) for binge episodes per week, binge days per week, eating-related obsessions and compulsions, body mass index (BMI), weight, and depression scores. We assessed statistical heterogeneity using the I 2 statistic. In considering psychological studies for pooled analyses, we did not combine data from studies using different modes of delivery (for example, individual and group therapy) for the same treatment. If relevant, we conducted sensitivity analyses to measure the effect on pooled results of including studies rated high risk of bias. We also conducted qualitative syntheses of trials with interventions or outcomes that we judged insufficiently similar for meta-analysis. Role of the Funding Source This research was funded by AHRQ. Agency staff participated in developing the scope of the work, refining the analytic framework and key questions, resolving issues regarding the project scope, reviewing the draft report, and distributing it for peer review. AHRQ did not engage in selecting studies, assessing risk of bias, or synthesizing or interpreting data. The authors are solely responsible for the content and the decision to submit this manuscript for publication. Results Overview of Trials We identified 34 trials with low or medium risk of bias (Appendix Figure 2 and Appendix Table 3). Of these, 9 were waitlist-