Salience of loss of control for pediatric binge episodes: does size really matter?

Binge eating, defined as overeating an objectively large amount of food while experiencing a lack of control over what or how much is being eaten, is the core symptom of bulimia nervosa and binge eating disorder (BED).1 Although few children and adolescents meet full DSM-IV-R criteria for bulimia nervosa or the proposed research criteria for BED, the prevalence of binge eating behavior among school and community samples of children and adolescents is high, with estimates ranging from approximately 6% to 40%.2–7 The assessment of binge eating behavior in youth is complicated by difficulty in determining what constitutes an objectively large amount of food in developing children with varying nutritional needs. Thus, a number of research groups have opted to study the experience of loss of control (LOC) over what or how much is being eaten, regardless of the reported episode size. Objective binge eating (OBE) refers to episodes during which individuals report LOC while consuming an objectively, unambiguously large amount of food. Subjective binge eating (SBE) refers to episodes during which individuals perceive excessive consumption with LOC, but the amount consumed is not objectively large.8 Estimates of LOC eating among non-treatment seeking youth are substantial, ranging from approximately 4% to 33%.9–15 The experience of LOC itself, apart from the reported amount of food consumed, appears to be a salient marker of pediatric disordered eating. Studies examining children and adolescents' LOC eating have found that youth who report the presence of at least one episode of SBE or OBE in the month prior to assessment have greater disordered eating cognitions and behaviors as well as greater depressive and anxiety symptoms than those who report no such episodes.10,11,14 Pediatric LOC eating also may be a risk factor for excessive weight gain. Children with LOC are more likely to be overweight and to have greater body fat mass than their counterparts without LOC eating.10,11,14,16 Among 6 to 13 year-old children, those who report at least one episode of LOC in the month prior to assessment have been found to gain an additional 2.4 kg of weight per year over 4–5 years than children who do not report LOC.17 Laboratory observations of children and adolescents' food intake suggest that those with LOC may be susceptible to greater weight gain in part because they consume more energy-dense palatable foods such as desserts and snacks.18 Despite the available evidence supporting the salience of LOC for pediatric binge eating episodes, it is not yet well understood whether the reported size of LOC eating episodes (i.e., SBE versus OBE) is relevant for distinguishing the degree of disordered eating pathology, associated general psychopathology, and risk for higher body fat among youth. Based on current DSM-IV-TR criteria for a binge eating episode,1 it is often an assumption that those who report OBE have more psychopathology than those who only report SBE. However, a number of adult studies suggest that LOC, rather than the episode size distinction, may be most central to identifying psychological disturbance among adults with eating disorders or obesity.19–23 Nevertheless, among youth, weight-loss treatment-seeking, obese adolescents who meet full symptom criteria for BED have greater disordered eating attitudes, more negative mood, and higher anxiety than youth reporting sub-threshold OBE or SBE.24 To our knowledge, only one pediatric study13 has directly compared the associations of SBE and OBE with psychopathology and disordered eating attitudes among children and adolescents. In an obese, treatment-seeking sample, a small subset of youth with SBE (n=15) had eating concern, shape concern, and emotional and external eating scores intermediate between those of youth with OBE (n=20) and those with no LOC eating (n=161).13 Youth with SBE differed significantly from those with OBE or from those reporting no LOC eating only in their frequency of emotional eating.13 Further investigation into whether episode size matters for pediatric LOC eating episodes is thus needed. To our knowledge, no study has directly compared SBE and OBE and their correlates in a non-treatment-seeking sample of children of adolescents that is adequately powered to detect significant differences. Such a comparison is especially warranted. In non-treatment-seeking pediatric populations, youth who report LOC typically report only one recent episode (e.g., once in the past month) and also, only one type of episode (i.e., either OBE or SBE).8 Understanding possible similarities or differences in the psychological and anthropometric characteristics of such youth with OBE versus SBE has potential to inform preventative approaches by possibly identifying those at particular risk for future development of BED or obesity. The objective of the current study was to compare non-treatment-seeking youth with no reported episodes of overeating (NE), objective overeating without a sense of LOC (OO), SBE, and OBE in their body composition, disordered eating attitudes and behaviors, and general psychopathology. Based on the notion that LOC may be the most salient marker of aberrant eating episodes in youth, we hypothesized that youth with either type of LOC eating (SBE or OBE) would have greater body fat, disordered eating, and general psychopathology than youth with NE or OO. Further, we expected that youth with SBE or OBE would have similar scores on measures of body composition, disordered eating, and general psychopathology.