research proposal on binge eating disorder

The natural course of binge-eating disorder: findings from a prospective, community-based study of adults

Affiliations.

• 1 McLean Hospital, Belmont, MA, USA.
• 2 Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
• 3 Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
• 4 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
• 5 Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
• 6 Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA.
• 7 Accanto Health, Saint Paul, MN, USA.
• 8 Lindner Center of HOPE, Mason, OH, USA.
• 9 Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
• PMID: 38803271
• DOI: 10.1017/S0033291724000977

Background: Epidemiological data offer conflicting views of the natural course of binge-eating disorder (BED), with large retrospective studies suggesting a protracted course and small prospective studies suggesting a briefer duration. We thus examined changes in BED diagnostic status in a prospective, community-based study that was larger and more representative with respect to sex, age of onset, and body mass index (BMI) than prior multi-year prospective studies.

Methods: Probands and relatives with current DSM-IV BED ( n = 156) from a family study of BED ('baseline') were selected for follow-up at 2.5 and 5 years. Probands were required to have BMI > 25 (women) or >27 (men). Diagnostic interviews and questionnaires were administered at all timepoints.

Results: Of participants with follow-up data ( n = 137), 78.1% were female, and 11.7% and 88.3% reported identifying as Black and White, respectively. At baseline, their mean age was 47.2 years, and mean BMI was 36.1. At 2.5 (and 5) years, 61.3% (45.7%), 23.4% (32.6%), and 15.3% (21.7%) of assessed participants exhibited full, sub-threshold, and no BED, respectively. No participants displayed anorexia or bulimia nervosa at follow-up timepoints. Median time to remission (i.e. no BED) exceeded 60 months, and median time to relapse (i.e. sub-threshold or full BED) after remission was 30 months. Two classes of machine learning methods did not consistently outperform random guessing at predicting time to remission from baseline demographic and clinical variables.

Conclusions: Among community-based adults with higher BMI, BED improves with time, but full remission often takes many years, and relapse is common.

Keywords: binge-eating disorder; eating disorders; epidemiology; machine learning; natural course; outcomes; predictors; relapse; remission.

Binge Eating Disorder

• First Online: 08 November 2017

Cite this chapter

• Erin E. Reilly 3 ,
• Lisa M. Anderson 3 ,
• Lauren Ehrlich 3 ,
• Sasha Gorrell 3 ,
• Drew A. Anderson 3 &
• Jennifer R. Shapiro 4  

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Despite the fact that Binge Eating Disorder was only recently introduced as a formal diagnosis in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), there has been a substantial amount of research over the past decade investigating the prevalence, etiology, and treatment of binge eating and loss of control eating behaviors in children and adolescents. The present chapter provides a summary of the current literature on binge eating, loss of control eating, and overeating behaviors in youth. In particular, we aim to (1) provide an overview of different terms and definitions used in the study of binge eating and loss of control eating, (2) outline available assessment tools for measuring binge eating within child and adolescent populations, (3) review existing research in the etiology and treatment of binge eating behaviors in youth, and (4) discuss important trends in symptom presentation and course within this population. Overall, we hope to provide an informative summary of current work regarding eating-disordered behaviors in children, with the larger intent of highlighting the areas in which future research can enhance our understanding and treatment of this debilitating condition.

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Overview of Binge Eating Disorder

Eating Disorders

Prevalence of binge-eating disorder among children and adolescents: a systematic review and meta-analysis

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E. Reilly, E., Anderson, L.M., Ehrlich, L., Gorrell, S., A. Anderson, D., Shapiro, J.R. (2017). Binge Eating Disorder. In: Goldstein, S., DeVries, M. (eds) Handbook of DSM-5 Disorders in Children and Adolescents. Springer, Cham. https://doi.org/10.1007/978-3-319-57196-6_18

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• Published: 11 March 2002

Binge eating disorder: a review

• AE Dingemans 1 ,
• MJ Bruna 1 &
• EF van Furth 1  

International Journal of Obesity volume  26 ,  pages 299–307 ( 2002 ) Cite this article

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Binge eating disorder (BED) is a new proposed eating disorder in the DSM-IV. BED is not a formal diagnosis within the DSM-IV, but in day-to-day clinical practice the diagnosis seems to be generally accepted. People with the BED-syndrome have binge eating episodes as do subjects with bulimia nervosa, but unlike the latter they do not engage in compensatory behaviours. Although the diagnosis BED was created with the obese in mind, obesity is not a criterion. This paper gives an overview of its epidemiology, characteristics, aetiology, criteria, course and treatment. BED seems to be highly prevalent among subjects seeking weight loss treatment (1.3–30.1%). Studies with compared BED, BN and obesity indicated that individuals with BED exhibit levels of psychopathology that fall somewhere between the high levels reported by individuals with BN and the low levels reported by obese individuals. Characteristics of BED seemed to bear a closer resemblance to those of BN than of those of obesity.

A review of RCT's showed that presently cognitive behavioural treatment is the treatment of choice but interpersonal psychotherapy, self-help and SSRI's seem effective. The first aim of treatment should be the cessation of binge eating. Treatment of weight loss may be offered to those who are able to abstain from binge eating.

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Dingemans, A., Bruna, M. & van Furth, E. Binge eating disorder: a review. Int J Obes 26 , 299–307 (2002). https://doi.org/10.1038/sj.ijo.0801949

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New Research: Revealing the True Duration of Binge-Eating Disorder

Investigators at McLean Hospital found 61% and 45% of individuals still experiencing binge-eating disorder after 2.5 and 5 years after their initial diagnoses, respectively.

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A new 5-year study from investigators at McLean Hospital shows that binge-eating disorder lasts much longer and the likelihood of relapse is much higher than previously suggested, with 61% of individuals still experiencing binge-eating disorder after 2.5 years and 45% still experiencing it 5 years after their initial diagnoses. 1

"It's noteworthy that in high-quality randomized clinical trials of specific treatments for binge-eating disorder, the percentage of participants still experiencing binge eating several years after the treatment ended was lower than the analogous percentage of participants in our naturalistic study, few of whom were probably receiving evidence-based treatments,” study first author Kristin Javaras, DPhil, PhD, an assistant psychologist in the Division of Women’s Mental Health at McLean, exclusively told Psychiatric Times . “This suggests that adults with binge-eating disorder may be more likely to get better if they receive evidence-based care than if they do not undergo treatment.”

Investigators studied 137 adult community members with binge-eating disorder for 5 years in order to better understand the duration of this disorder. Participants included individuals who aged anywhere from 19 to 74 and had an average BMI of 36. They were assessed for binge-eating disorder at the study outset and reexamined both 2.5 and 5 years later.

After 5 years, most participants still experienced binge-eating episodes, with 46% of participants meeting the full criteria and a further 33% experiencing clinically significant but subthreshold symptoms. After 2.5 years, 61% of participants still met the full criteria for binge-eating disorder at the time the study was conducted, and a further 23% experienced clinically significant symptoms, although they were below the threshold for binge-eating disorder. Furthermore, approximately 35% of the participants in remission at the 2.5-year follow-up had relapsed to either full or subthreshold binge-eating disorder at the 5-year follow-up. Following the study’s completion, the criteria for diagnosing binge-eating disorder changed and under these new guidelines, an even larger percentage of the study’s participants would have been diagnosed with the disorder at the 2.5 and 5-year follow-ups.

“The big takeaway is that binge-eating disorder does improve with time, but for many people it lasts years,” Javaras shared in a press release. “As a clinician, oftentimes the clients I work with report many, many years of binge-eating disorder, which felt very discordant with studies that suggested that it was a transient disorder. It is very important to understand how long binge-eating disorder lasts and how likely people are to relapse so that we can better provide better care.” 2

Previous prospective studies had limitations, including a small sample size (less than 50 participants), and they focused only on adolescent or young-adult females, most of whom had BMIs less than 30, whereas around two-thirds of individuals with binge-eating disorder have BMIs of 30 or more.

Also worth noting is the study’s more accurate representation of binge-eating disorder’s natural duration, as the participants were community members who were possible receiving treatment, not actual patients enrolled in a treatment program. In comparing the community sample with those in treatment studies, it appears that treatments lead to faster remission. This reinforces the need for intervention in patients with eating disorders.

Investigators were unable to identify strong clinical or demographic predictors for the duration of binge-eating disorder. “This suggests that no one is much less or more likely to get better than anyone else,” Javaras said. 2

Binge-eating disorder is the most prevalent eating disorder, with 1% to 3% of US adults affected.3 Following the study’s completion, investigators have been working to develop treatment options and screening methods for this common disorder to best improve patient outcomes.

“We are studying binge-eating disorder with neuroimaging to get a better understanding of the neurobiology involved, which could help enhance or develop new treatments,” said Javaras. “We are also examining ways to catch people earlier, because many do not even realize they have binge-eating disorder, and there is a major need for increased awareness and screening so that intervention can begin earlier.” 2

Full results were published today, May 28, in Psychological Medicine .

1. Javaras KN, Franco VF, Ren B, et al. The natural course of binge-eating disorder: findings from a prospective, community-based study of adults. Psychol Med . 2024:1-11.

2. Binge-eating disorder not as transient as previously thought. News release. May 28, 2024.

3. Eating disorders. National Institute of Mental Health. Accessed May 24, 2024. https://www.nimh.nih.gov/health/statistics/eating-disorders

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Persistent Cravings: What a Five-Year Study Reveals About Binge-Eating Disorder

By McLean Hospital May 28, 2024

A five-year study by McLean Hospital found that binge-eating disorder persists longer than previously thought, with significant percentages of individuals still affected after 2.5 and 5 years. This challenges earlier research suggesting quicker remission and highlights the importance of continued intervention and improved treatment strategies.

McLean Hospital researchers show that binge-eating disorder lasts longer than expected and relapse is common, with many still affected years after diagnosis.

In the United States, binge-eating disorder is the most prevalent eating disorder. However, previous studies have presented conflicting views of the disorder’s duration and the likelihood of relapse.

A new five-year study led by investigators from McLean Hospital, part of the Mass General Brigham healthcare system, revealed that 61% of individuals continued to experience symptoms of binge-eating disorder 2.5 years after being diagnosed, and 45% still exhibited symptoms after five years. These findings challenge earlier prospective studies that suggested quicker recovery times, the researchers noted.

Key Findings and Implications

“The big takeaway is that binge-eating disorder does improve with time, but for many people it lasts years,” said first author Kristin Javaras, DPhil, PhD, assistant psychologist in the Division of Women’s Mental Health at McLean. “As a clinician, oftentimes the clients I work with report many, many years of binge-eating disorder, which felt very discordant with studies that suggested that it was a transient disorder. It’s very important to understand how long binge-eating disorder lasts and how likely people are to relapse so that we can better provide better care.”

The results were published May 28 in Psychological Medicine , published by Cambridge University Press.

Disorder Characteristics and Study Methodology

Binge-eating disorder, which is estimated to impact somewhere between 1 percent and 3 percent of U.S. adults, is characterized by episodes during which people feel a loss of control over their eating. The average age of onset is 25 years.

While previous retrospective studies, which rely on people’s sometimes-faulty memories, have reported that binge-eating disorder lasts seven to sixteen years on average, prospective studies tracking individuals with the disorder over time have suggested that many individuals with the disorder enter remission within a much smaller timeframe—from one to two years.

However, the researchers noted that most previous prospective studies had limitations, including a small sample size (<50 participants), and they were not representative because they focused only on adolescent or young-adult females, most of whom had BMIs less than 30, whereas around two-thirds of individuals with binge-eating disorder have BMIs of 30 or more.

Long-Term Trends and Treatment Insights

To better understand the time-course of binge-eating disorder, the researchers followed 137 adult community members with the disorder for five years. Participants, who ranged in age from 19 to 74 and had an average BMI of 36, were assessed for binge-eating disorder at the beginning of the study and re-examined 2.5 and 5 years later.

After five years, most of the study participants still experienced binge-eating episodes, though many showed improvements. After 2.5 years, 61 percent of participants still met the full criteria for binge-eating disorder at the time the study was conducted, and a further 23 percent experienced clinically significant symptoms, although they were below the threshold for binge-eating disorder. After 5 years, 46 percent of participants met the full criteria and a further 33 percent experienced clinically significant but sub-threshold symptoms. Notably, 35 percent of the individuals who were in remission at the 2.5-year follow-up had relapsed to either full or sub-threshold binge-eating disorder at the 5-year follow-up. The criteria for diagnosing binge-eating disorder have changed since the study was conducted, and Javaras notes that under the new guidelines, an even larger percentage of the study’s participants would have been diagnosed with the disorder at the 2.5 and 5-year follow-ups.

Javaras added that because participants in the study were community members who may or may not have been receiving treatment, rather than patients enrolled in a treatment program, the study’s results are more representative of binge-eating disorder’s natural time-course. When comparing this community sample to those in treatment studies, treatment appeared to lead to faster remission, suggesting that people with binge-eating disorders will benefit from intervention. There are major inequities in who receives treatment for eating disorders, according to Javaras.

Though there was variation amongst participants in the likelihood of remission and how long it took, the researchers were unable to find any strong clinical or demographic predictors for duration of the disorder.

“This suggests that no one is much less or more likely to get better than anyone else,” said Javaras.

Research Directions and Future Treatment

Since the study’s conclusion, the researchers have been investigating and developing treatment options for binge-eating disorder, and examining screening methods to better identify individuals who would benefit from treatment.

“We are studying binge-eating disorder with neuroimaging to get a better understanding of the neurobiology involved, which could help enhance or develop new treatments,” said Javaras. “We are also examining ways to catch people earlier, because many don’t even realize they have binge-eating disorder, and there is a major need for increased awareness and screening so that intervention can begin earlier.”

Reference: “The natural course of binge-eating disorder: findings from a prospective, community-based study of adults” by Kristin N. Javaras, Victoria F. Franco, Boyu Ren, Cynthia M. Bulik, Scott J. Crow, Susan L. McElroy, Harrison G. Pope and James I. Hudson, 28 May 2024, Psychological Medicine . DOI: 10.1017/S0033291724000977

Authorship: The corresponding author of the study was Kristin N. Javaras, DPhil PhD (McLean). Additional co-authors included Victoria F. Franco, MS(McLean), Boyu Ren, PhD(McLean) Cynthia M Bulik, PhD (UNC), Scott J. Crow, MD (UMN), Susan L. McElroy, MD (UCCOM); Harrison G. Pope, Jr MD, MPH (McLean), James I. Hudson, MD, ScD (McLean)

Disclosures: KNJ owned equity shares in Sanofi and Centene Corporation, and served on Clinical Advisory Board for Beanbag health, and received research funding from the NIDDK. JIH received grant support from Boehringer-Ingelheim and Idorsia. A full list of author disclosures can be found in the manuscript.

Funding: The family study and longitudinal study were supported in part by an investigator-initiated grant from Ortho-McNeil Janssen Scientific Affairs. Research reported in this publication was supported by the National Institute Of Diabetes And Digestive And Kidney Diseases of the National Institutes of Health under Award Number K23DK120517. Additional funding came from an NARSAD Young Investigator Grant from the Brain & Behavior Research Foundation, NIMH grants (R56-MH129437, R01-MH120170, R01-MH119084, R01-MH118278, and R01MH124871), and a Swedish Research Council grant (538-2013-88641).

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Binge-eating disorder not as transient as previously thought

Mclean hospital researchers show that binge-eating disorder lasts years rather than months for many people, and relapse is common.

Binge-eating disorder is the most prevalent eating disorder in the United States, but previous studies have presented conflicting views of the disorder's duration and the likelihood of relapse. A new five-year study led by investigators from McLean Hospital, a member of the Mass General Brigham healthcare system, showed that 61 percent and 45 percent of individuals still experienced binge-eating disorder 2.5 and 5 years after their initial diagnoses, respectively. These results contradict previous prospective studies that documented faster remission times, according to the authors.

"The big takeaway is that binge-eating disorder does improve with time, but for many people it lasts years," said first author Kristin Javaras, DPhil, PhD, assistant psychologist in the Division of Women's Mental Health at McLean. "As a clinician, oftentimes the clients I work with report many, many years of binge-eating disorder, which felt very discordant with studies that suggested that it was a transient disorder. It's very important to understand how long binge-eating disorder lasts and how likely people are to relapse so that we can better provide better care."

The results were published May 28 in Psychological Medicine, [JR1] published by Cambridge University Press.

Binge-eating disorder, which is estimated to impact somewhere between 1 percent and 3 percent of U.S. adults, is characterized by episodes during which people feel a loss of control over their eating. The average age of onset is 25 years.

While previous retrospective studies, which rely on people's sometimes-faulty memories, have reported that binge-eating disorder lasts seven to sixteen years on average, prospective studies tracking individuals with the disorder over time have suggested that many individuals with the disorder enter remission within a much smaller timeframe -- from one to two years.

However, the researchers noted that most previous prospective studies had limitations, including a small sample size (<50 participants), and they were not representative because they focused only on adolescent or young-adult females, most of whom had BMIs less than 30, whereas around two-thirds of individuals with binge-eating disorder have BMIs of 30 or more.

To better understand the time-course of binge-eating disorder, the researchers followed 137 adult community members with the disorder for five years. Participants, who ranged in age from 19 to 74 and had an average BMI of 36, were assessed for binge-eating disorder at the beginning of the study and re-examined 2.5 and 5 years later.

After five years, most of the study participants still experienced binge-eating episodes, though many showed improvements. After 2.5 years, 61 percent of participants still met the full criteria for binge-eating disorder at the time the study was conducted, and a further 23 percent experienced clinically significant symptoms, although they were below the threshold for binge-eating disorder. After 5 years, 46 percent of participants met the full criteria and a further 33 percent experienced clinically significant but sub-threshold symptoms. Notably, 35 percent of the individuals who were in remission at the 2.5-year follow-up had relapsed to either full or sub-threshold binge-eating disorder at the 5-year follow-up. The criteria for diagnosing binge-eating disorder have changed since the study was conducted, and Javaras notes that under the new guidelines, an even larger percentage of the study's participants would have been diagnosed with the disorder at the 2.5 and 5-year follow-ups.

Javaras added that because participants in the study were community members who may or may not have been receiving treatment, rather than patients enrolled in a treatment program, the study's results are more representative of binge-eating disorder's natural time-course. When comparing this community sample to those in treatment studies, treatment appeared to lead to faster remission, suggesting that people with binge-eating disorders will benefit from intervention. There are major inequities in who receives treatment for eating disorders, according to Javaras.

Though there was variation amongst participants in the likelihood of remission and how long it took, the researchers were unable to find any strong clinical or demographic predictors for duration of the disorder.

"This suggests that no one is much less or more likely to get better than anyone else," said Javaras.

Since the study ended, the researchers have been investigating and developing treatment options for binge-eating disorder, and examining screening methods to better identify individuals who would benefit from treatment.

"We are studying binge-eating disorder with neuroimaging to get a better understanding of the neurobiology involved, which could help enhance or develop new treatments," said Javaras. "We are also examining ways to catch people earlier, because many don't even realize they have binge-eating disorder, and there is a major need for increased awareness and screening so that intervention can begin earlier."

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Materials provided by McLean Hospital . Note: Content may be edited for style and length.

Journal Reference :

• Kristin N. Javaras, Victoria F. Franco, Boyu Ren, Cynthia M. Bulik, Scott J. Crow, Susan L. McElroy, Harrison G. Pope, James I. Hudson. The natural course of binge-eating disorder: findings from a prospective, community-based study of adults . Psychological Medicine , 2024; 1 DOI: 10.1017/S0033291724000977

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Binge-Eating Disorder Could Be Tougher to Kick Than Thought

By Ernie Mundell HealthDay Reporter

TUESDAY, May 28, 2024 (HealthDay News) -- Prior studies have suggested that binge eating disorder may not last long, but a more rigorous look at the illness finds that just isn't so.

“The big takeaway is that binge-eating disorder does improve with time, but for many people it lasts years,” said study first author Kristin Javaras , assistant psychologist in the Division of Women’s Mental Health at McLean Hospital in Boston.

“As a clinician, oftentimes the clients I work with report many, many years of binge-eating disorder, which felt very discordant with studies that suggested that it was a transient disorder," she said in a hospital news release. "It's very important to understand how long binge-eating disorder lasts and how likely people are to relapse so that we can better provide better care.”

In binge eating disorder, which typically arises around a person's mid-20s, people feel their eating is out of their control. Anywhere from 1 to 3 percent of American adults are thought to have the disorder.

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According to Javaras' team, prior studies looking at binge eating disorder were either retrospective (meaning they often relied on people's memory of their disorder).

If they were prospective (following patients through time) they were often very small (less than 50 people) or didn't include people tackling severe obesity.

In the new study, Javaras' team tracked outcomes for 137 adults diagnosed with binge-eating disorder for five years. People ranged in age from 19 to 74 and they had an average BMI of 36 (the threshold for obesity is a BMI of 30).

The people in the study were independently living within their communities and weren't in treatment programs, better reflecting "real-world" experiences with binge-eating disorders.

At the 2.5-year mark, 61% of people in the study still met all the criteria for a binge-eating disorder, and another 23% still had "clinically significant symptoms" although they fell shy of an actual binge eating disorder diagnosis, the researchers said.

By the five-year mark, most of the study participants still met the criteria for have a binge-eating disorder, although some had made improvements, the study authors said.

Even among those who were in remission at 2.5 years, 35% went on to have a full-blown binge-eating disorder by five years, Javaras' team said.

At the five-year mark, most people still had binge-eating episodes, although many had improved.

The findings were published May 28 in the journal Psychological Medicine.

Javaras notes that prior studies have suggested that treatment programs do help curb eating disorders, but not everyone has access to such programs.

More information

Find out more about binge-eating disorder at the Mayo Clinic .

SOURCE: McLean Hospital, news release, May 28, 2024

Copyright © 2024 HealthDay . All rights reserved.

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Binge-eating disorder not as transient as previously thought

by McLean Hospital

Binge-eating disorder is the most prevalent eating disorder in the United States, but previous studies have presented conflicting views of the disorder's duration and the likelihood of relapse. A new five-year study led by investigators from McLean Hospital, a member of the Mass General Brigham health care system, showed that 61% and 45% of individuals still experienced binge-eating disorder 2.5 and 5 years after their initial diagnoses, respectively. These results contradict previous prospective studies that documented faster remission times, according to the authors.

"The big takeaway is that binge-eating disorder does improve with time, but for many people it lasts years," said first author Kristin Javaras, DPhil, Ph.D., assistant psychologist in the Division of Women's Mental Health at McLean.

"As a clinician , oftentimes the clients I work with report many, many years of binge-eating disorder, which felt very discordant with studies that suggested that it was a transient disorder. It's very important to understand how long binge-eating disorder lasts and how likely people are to relapse so that we can better provide better care."

The results were published May 28 in Psychological Medicine .

Binge-eating disorder, which is estimated to impact somewhere between 1% and 3% of U.S. adults, is characterized by episodes during which people feel a loss of control over their eating. The average age of onset is 25 years.

While previous retrospective studies, which rely on people's sometimes-faulty memories, have reported that binge-eating disorder lasts seven to sixteen years on average, prospective studies tracking individuals with the disorder over time have suggested that many individuals with the disorder enter remission within a much smaller timeframe—from one to two years.

However, the researchers noted that most previous prospective studies had limitations, including a small sample size (<50 participants), and they were not representative because they focused only on adolescent or young-adult females, most of whom had BMIs less than 30, whereas around two-thirds of individuals with binge-eating disorder have BMIs of 30 or more.

To better understand the time-course of binge-eating disorder, the researchers followed 137 adult community members with the disorder for five years. Participants, who ranged in age from 19 to 74 and had an average BMI of 36, were assessed for binge-eating disorder at the beginning of the study and re-examined 2.5 and 5 years later.

After five years, most of the study participants still experienced binge-eating episodes, though many showed improvements. After 2.5 years, 61% of participants still met the full criteria for binge-eating disorder at the time the study was conducted, and a further 23% experienced clinically significant symptoms, although they were below the threshold for binge-eating disorder.

After 5 years, 46% of participants met the full criteria and a further 33% experienced clinically significant but sub-threshold symptoms. Notably, 35% of the individuals who were in remission at the 2.5-year follow-up had relapsed to either full or sub-threshold binge-eating disorder at the 5-year follow-up.

The criteria for diagnosing binge-eating disorder have changed since the study was conducted, and Javaras notes that under the new guidelines, an even larger percentage of the study's participants would have been diagnosed with the disorder at the 2.5 and 5-year follow-ups.

Javaras added that because participants in the study were community members who may or may not have been receiving treatment, rather than patients enrolled in a treatment program, the study's results are more representative of binge-eating disorder's natural time-course.

When comparing this community sample to those in treatment studies, treatment appeared to lead to faster remission, suggesting that people with binge-eating disorders will benefit from intervention. There are major inequities in who receives treatment for eating disorders, according to Javaras.

Though there was variation among participants in the likelihood of remission and how long it took, the researchers were unable to find any strong clinical or demographic predictors for duration of the disorder.

"This suggests that no one is much less or more likely to get better than anyone else," said Javaras.

Since the study ended, the researchers have been investigating and developing treatment options for binge-eating disorder, and examining screening methods to better identify individuals who would benefit from treatment.

"We are studying binge-eating disorder with neuroimaging to get a better understanding of the neurobiology involved, which could help enhance or develop new treatments," said Javaras.

"We are also examining ways to catch people earlier, because many don't even realize they have binge-eating disorder , and there is a major need for increased awareness and screening so that intervention can begin earlier."

The corresponding author of the study was Javaras, DPhil Ph.D. (McLean). Additional co-authors included Victoria F. Franco, MS(McLean), Boyu Ren, Ph.D.(McLean) Cynthia M Bulik, Ph.D. (UNC), Scott J. Crow, MD (UMN), Susan L. McElroy, MD (UCCOM); Harrison G. Pope, Jr MD, MPH (McLean), James I. Hudson, MD, ScD (McLean)

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Disentangling binge eating disorder and food addiction: a systematic review and meta-analysis

Ester di giacomo.

1 School of Medicine and Surgery, University of Milano Bicocca, Milano, Italy

2 Psychiatric Department-ASST Monza, Monza, Italy

Francesca Aliberti

Francesca pescatore, mario santorelli, rodolfo pessina, valeria placenti, fabrizia colmegna, massimo clerici, background and aims.

The concept of "Food Addiction" has been based on criteria of Substance Use Disorder. Several studies suggested a relationship between food addiction and eating disorders, but little is known about its extent or role.

We aim at exploring if food addiction is coincident with a specific eating disorder (binge eating disorder appears the closest) or it is a separate diagnostic entity that afflicts in comorbidity with eating disorders or other conditions like obesity or even in the general population.

This systematic review and meta-analysis analyzed observational studies with a comparative estimation on rates of subjects affected by binge eating disorder and food addiction.

Binge eating disorder shows higher comorbidity with food addiction compared to other eating disorders (OR = 1.33, 95% CI, 0.64–2.76; c 2  = 4.42; p  = 0.44;I 2  = 0%), or each eating disorder [anorexia nervosa purging type (OR = 1.93, 95% CI, 0.20–18.92; p  = 0.57) and restrictive type (OR = 8.75, 95% CI, 1.08–70.70; p  = 0.04)], obese patients (OR = 5.72, 95% CI, 3.25–10.09; p  =  < 0.0001) and individuals from the general population (OR = 55.41, 95% CI, 8.16–376.10; c 2  = 18.50; p  < 0.0001; I 2  = 0%)but has decreased prevalence when compared to bulimia nervosa (OR = 0.85, 95% CI, 0.33–2.22; c 2  = 0.35; p  = 0.74; I 2  = 0%).

Discussion and conclusions

Our data show that the prevalence of food addiction in binge eating disorder is higher than in other eating disorders except in bulimia nervosa. Moreover, it is a separate diagnostic reality and can be detected in people without mental illness and in the general population.

Food addiction might have a prognostic value, since in comorbidity, and should be addressed to boost treatment efficacy and patient’s recovery.

Level of evidence

I: Evidence obtained systematic reviews and meta-analyses.

Overeating, obesity and eating disorders are serious issues of the modern wealthy societies worldwide.

The reasons why some people chronically overeat and are unable to limit their food intake have been examined. A growing number of clinical and neurobiological evidence has shown that, in vulnerable subjects, persistent overeating may lead to a pattern of compulsive behavior similar to that of drug abuse and other addictive disorders  [ 1 – 4 ].

The need of a better definition of this behavioral model led to the formulation of the concept of "Food Addiction" which gained a growing interest in the scientific literature focused on eating disorders with particular attention to the underlying neurobiological and phenomenological mechanisms [ 5 ].

The term "Food Addiction" has been built on behavior and subjective experiences related to food consumption that resemble criteria of Substance Use Disorder (SUD) (e.g., strong urge to consume, exacerbated by abstinence, and failure to limit consumption despite the awareness of toxicity)  [ 6 ].

From a biological perspective, many neurobiochemical and neurogenetic studies proved typical mechanisms of addictions are crucial in problematic nutrition. Genetic similarities between overeating and substance addiction are variants in the genes encoding the dopamine D2 receptor allele of the ANKKI gene (e.g., Taq1 (rs1800497) and transporter (e.g., SLC6A3, DAT1) and opioid receptor genes (OPRM1 gene) [ 7 ]. Furthermore, illicit drugs and food exert the same gratifying effect through the activation of dopamine neurons in the ventral tegmental area with consequent release of dopamine in the nucleus accumbens and effects on the mesolimbic pathway  [ 8 ].

Although the definition of Food Addiction (FA) is not yet categorized in the Diagnostic and Statistical Manual of Mental Disorders, the academic debate on a possible addictive potential of food keeps going [ 9 ]. In fact, many overlapping criteria with the DSM-5 drug addiction include: (1) substance taken in larger quantities and for a longer period than expected; (2) persistent desire or repeated failed attempts to quit; (3) a large amount of time and energy spent on obtaining, using or disposing of substances; (4) reduction of important social, occupational, or recreational activities because of substance use; (5) continued use despite knowledge of the negative consequences; (6) tolerance; and (7) withdrawal symptoms  [ 10 ].

The Yale Food Addiction Scale (YFAS)

The Yale Food Addiction Scale (YFAS) has been developed by Gearhardt [ 10 ], as a first categorical attempt of the concept of FA.

The YFAS is a 25-item self-report questionnaire that adapts the diagnostic criteria of substance dependence of the DSM IV-TR to eating behavior or abuse of specific foods. Currently, it is the only validated tool for assessing symptoms of "food addiction".

It has several categories of scoring: symptoms count (seven diagnostic criteria) and a diagnostic threshold that reflects the criteria for the diagnosis of substance dependence (the presence of three or more symptoms plus clinically significant impairment or distress).

Up to 11.4% of the general population may show symptoms of food addiction, while approximately 25–42% of obese patients meet the YFAS criteria [ 11 ].

The concept of binge eating

Binge eating disorder (BED) is an eating disorder characterized by recurrent episodes of bingeing, in the absence of compensatory behaviors (purging, overexercize etc.). [ 12 ].

A binge episode is defined as eating an unusually large amount of food over a discrete period of time associated with a subjective sense of loss of control while eating  [ 13 ].

The presence of BED in individuals with obesity has been associated with a significant increase in the risk of psychosocial, psychiatric, and medical problems [ 14 ].

It is estimated that 15.7% to 40% of obese patients suffer from BED [ 15 , 16 ] as well as between 1.12% and 6.6% of the general population  [ 17 , 18 ].

The Binge Eating Scale (BES) is the basic tool used to confirm a clinical diagnosis of BED [ 18 ].

Association/overlaps between BED and FA

As mentioned above, phenotypic overlaps have been observed between the definition of food addiction and binge eating disorder [ 19 ].

Both BED and food addiction are characterized by the loss of control over consumption, continued overuse despite negative consequences, and repeated failed attempts to reduce consumption. Because of these similarities, measures of binge eating disorder (BED) and food addiction (YFAS) are often highly correlated, highlighting difficulties in assessing and distinguishing those two different constructs [ 20 , 21 ]. Some preliminary evidence reporting high frequencies of FA in patients with BED suggests that the co-occurrence of BED and FA may represent a more disturbed BED subgroup  [ 22 ].

Emerging research suggests that binge eating and food addiction, while sharing many characteristics, may have important distinctions. In samples of individuals with BED, the frequency of food addiction ranges from 42 to 57%, suggesting that, despite the multiple similarities, the constructs do not completely overlap. Furthermore, in the study by Gerhardt et al., authors show that, compared to patients with BED without food addiction, participants with BED and food addiction had significantly higher levels of low self-esteem, depression, negative affect, emotional dysregulation, but they did not show significantly different levels of dietary moderation. A link between the severity of food addiction and eating disorders was, therefore, hypothesized, providing FA with a prognostic value  [ 10 , 20 ].

Food addiction and other eating disorders (EDs)

Food addiction shows significant diagnostic overlaps with other EDs as well, especially with Bulimia Nervosa (BN), an eating disorder characterized by the presence of binge eating episodes with compensatory behaviors that do not occur in BED. Furthermore, BN is linked to impaired reward sensitivity in dopaminergic brain circuit, increasing the addictive potential [ 23 ]. Moreover, some studies emphasize that many patients affected by BN may have a body weight within the normal range but may also be addicted to food [ 24 , 25 ]. Additionally, even if without a systematic evaluation, some studies attest an association between FA and BN ranging from 81 to 97% [ 26 , 27 ]. Even with fundamental differences, in fact, common overlapping symptoms between FA, BED and BN exist (e.g., reduced feeding control, continued use despite negative consequences)  [ 1 , 11 ].

An interesting further point ascribes food restriction, typical of anorexia nervosa (AN) to addictive behaviors (or "hunger addiction") [ 28 ]. Szmukler e Tamtam suggest that "patients with AN are dependent on the psychological and possibly physiological effects of starvation. Increased weight loss results from tolerance to starvation necessitating greater restriction of food to obtain the desired effect, and the later development of unpleasant ‘withdrawal’ symptoms on eating” [ 29 ].

The existence of food addiction as a separate entity, as well as its role in several eating disorders is still unclear and poor explored. The aim of the present systematic review and meta-analysis is to attest to the prevalence of FA in different eating disorders and its existence.

This systematic review and meta-analysis was performed according to the Meta-analysis of Observational Studies in Epidemiology guidelines [ 30 ]. Procedures and study inclusion criteria were defined a priori and registered in PROSPERO (an international prospective register of systematic reviews-CDR42020215998).

Data sources and search strategy

A systematic search for articles published in electronic databases (PubMed, Embase and PsychINFO) through September 24, 2020, was performed with no time or language restrictions. The selected databases report documents whose titles and abstracts are in written in fluent English, sometimes together with titles and abstracts in authors’ native language. The manuscript main text might be in English or in authors’ native language, depending from each journal rules. Our search produced five results whose main text was not written in English but their titles/abstracts entailed their exclusion according to inclusion/exclusion criteria. Search phrases combined thesaurus and free-search indexing terms related to eating disorder and addiction, using combinations of the following search terms: binge eating disorder, food addiction . We contacted corresponding authors of selected studies if additional information was required.

Eligibility criteria

We included observational studies with a comparative estimation on rates of subjects affected by binge eating disorder and food addiction. We included studies that defined binge eating disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. We excluded studies without an appropriate comparison group, those that did not clearly define food addiction, and case reports. To reduce the risk of misclassification errors, we included only high-quality studies, with unequivocal definitions. If data from the same sample were published in multiple works, we retained only the studies published in peer-reviewed journals, excluding conference abstracts and dissertations.

Terms and definitions

According to Randolph, who introduced the concept in 1956, the term “Food Addiction” refers to specific food related behaviors characterized by excessive and dysregulated consumption of palatable and high calorie food.

More recently, food addiction has been defined as a chronic, relapsing condition caused by the interaction of many complex variables that increase the desire for certain specific foods to achieve a state of elevated pleasure, energy or arousal, or to alleviate negative emotional or physical states, coming closer to the criteria defining addictive disorders [ 11 , 31 ].

A food addiction or eating addiction is characterized by the compulsive consumption of palatable (e.g., high fat and high sugar) foods which markedly activate the reward system in humans and other animals despite adverse consequences.

Data collection process

Three authors (E.d.G, F.P., and F.A.) preliminarily reviewed titles and abstracts of traced articles. The initial screening was followed by the analysis of full texts to check compatibility regarding inclusion and exclusion criteria. Discordances were analyzed and disagreements were resolved by discussion among all the authors. When reported information was unclear or ambiguous or numerical data were not obtainable by percentages, the relevant corresponding author was contacted for clarification.

Data extraction

A standardized form was used to extract data, including information on year of publication, country, setting, characteristics of study participants (sample size, age, and percentages of men and women), eating disorders, and food addiction. If raw numerical data were not reported, they were calculated by percentages, deriving crude odds ratios (ORs). Two authors (E.d.G. and F.A.) conducted data extraction independently; extraction sheets for each study were cross-checked for consistency, and any differences were resolved by discussion among the coauthors.

Statistical analysis

Meta-analysis of the overall comparison of food addiction rates among subjects affected by eating disorders and each type of eating disorder compared with binge eating was performed, and pooled ORs with 95% CIs were generated using inversed variance models (DerSimonian–Laird) with random effects [ 32 , 33 ]. Results were summarized using conventional forest plots. Standard χ2 tests and the I 2 statistic (i.e., the percentage of variability in prevalence estimates attributable to heterogeneity rather than sampling error or chance, with values ≥ 75% indicating high heterogeneity) were used to assess between-study heterogeneity [ 34 ]. To test for publication bias, we performed funnel plot analysis and the Egger test on all studies stratified by eating disorder (bulimia nervosa, other eating disorders) and general population. Thus, three separate Egger tests were performed. The Egger test quantifies bias captured in the funnel plot analysis with linear regression using the value of effect sizes and their precision (SE) and assumes that the quality of study conduct is independent of study size. If analyses showed a significant risk of publication bias, we would use the trim and fill method to estimate the number of missing studies and the adjusted effect size [ 35 – 37 ]. Meta-regression analysis was performed to examine sources of between-study heterogeneity if of a high level ( I 2  > 75%) on a range of study prespecified characteristics (i.e., sample size, age, and country).

All analyses were performed using R, version 3.2.3 (meta and metaphor packages; R Foundation for Statistical Computing). Statistical tests were two sided and used a significance threshold of P  < 0.05.

Study characteristics

Six studies that involved a total of 2476 subjects (539 affected by binge eating disorder, 178 by bulimia nervosa, 18 by eating disorder NOS, 65 by anorexia nervosa restrictive, 33 by anorexia nervosa purging, 442 subjects with obesity and 1146 people from the general population without eating disorders) were included in the analysis (see Fig.  1 ). The studies were conducted in 5 countries (Australia, Canada, France, Spain and the United States). All articles were published after 2014 (one in 2014, two in 2017, two in 2019 and one in 2020). Most of the studies had sample weight of less than 10%, whereas one study had sample weight of 20% and one higher than 50%. All study characteristics are summarized in Table ​ Table1 1 .

Preferred reporting items for meta-analyses flow diagram

Characteristics of the studies included in the meta-analysis

EDs eating disorders, BED binge eating disorder, BN bulimia nervosa, ( ED_NOS ) eating disorder not otherwise specified, ( AN-R ) anorexia nervosa restrictive, ( AN-P ) anorexia nervosa purging, Gen_Pop general population

Prevalence of food addiction in binge eating disorder compared to other eating disorders

Patients affected by binge eating disorder have an increased prevalence of food addiction compared to patients with other eating disorders (OR = 1.33, 95% CI, 0.64–2.76; c 2  = 4.42; p  = 0.44; I 2  = 0%)(see Fig.  2 ).

Prevalence of food addiction in binge eating disorder and other eating disorders. FA food addiction, BED binge eating disorder, EDs other eating disorders

Prevalence of food addiction in binge eating disorder compared to each other eating disorder

The prevalence of food addiction in patients affected by binge eating disorder is reduced compared to that of patients with bulimia nervosa (OR = 0.85, 95% CI, 0.33–2.22; c 2  = 0.35; p  = 0.74; I 2  = 0%)(see Fig.  3 ) while it is increased compared to anorexia nervosa purging type (OR = 1.93, 95% CI, 0.20–18.92; p  = 0.57) and restrictive type (OR = 8.75, 95% CI, 1.08–70.70; p  = 0.04).

Prevalence of food addiction in binge eating disorder and bulimia nervosa. BED binge eating disorder, Bulimia N Bulimia nervosa

Prevalence of food addiction in binge eating disorder compared to obesity

Patients affected by binge eating disorder have an increased prevalence of food addiction compared to obese patients without any eating disorder (OR = 5.72, 95% CI, 3.25–10.09; p  =  < 0.0001).

Prevalence of food addiction in binge eating disorder compared to the general population

Patients affected by binge eating disorder have an increased prevalence of food addiction compared to subjects from the general population without eating disorders (OR = 55.41, 95% CI, 8.16–376.10; c 2  = 18.50; p  =  < 0.0001; I 2  = 89%)(see Fig.  4 ).

Prevalence of food addiction in binge eating disorder and the general population. BED binge eating disorder, GenPop general population

Publication bias

There was no evidence of publication bias in studies focused on the bulimia nervosa group (Egger test; SE,  – 1.20; 95% CI,  – 18.01 to 15.60; P  = 0.26), for studies focused on other EDs (Egger test; SE, 1.65; 95% CI,  – 4.29 to 7.60; P  = 0.24) and studies focused on the general population (Egger test; SE, 3.77; 95% CI,  – 10.23 to 17.78; P  = 0.09).

Sources of heterogeneity

Univariable and multivariable meta-regressions weighted for the study weight were performed on the following variables that were potentially associated with heterogeneity: (1) the country where the study was conducted (2) the year of publication. The mean age of the samples and the percentage of females within each group were not available or calculable in most of the studies.

None of the parameters, including the sample weight, or a combination of parameters was sufficient to explain heterogeneity detected in the studies focused on the general population.

The concept of “Food Addiction” arose thanks to the identification of common features between drug addiction and some behavioral disturbance in food intake. Even if it is not classified in the DSM-5, a diagnostic tool has been developed applying diagnostic criteria of drug addiction to food.

Starting from evidence of a comorbidity between food addiction and eating disorders, this meta-analysis focus on measuring the extent of that comorbidity in each eating disorder. Binge eating disorder was theoretically the closest construct to that of food addiction. On the contrary, data proves that the prevalence of food addiction in binge eating disorder is higher than in other eating disorders except in bulimia nervosa. People affected by bulimia nervosa, in fact, dwell with food addiction more than people with binge eating disorder, even if the result is not statistically significant. Such evidence is fascinating and deserves considerations. First of all, BED, BN and FA have overlapping symptoms that may contribute to those results. More interestingly, some authors supported the description of BN as an eating behavior similar to addiction. [ 25 – 27 ], thus reinforcing the addictive nature of that disorder.

Beyond overlaps that may justify the presence of FA in patients affected by a specific eating disorder or another, it is crucial to underline that FA is detected in subjects without any eating disorder, even if with obesity, but also in subjects from the general population and without any psychiatric issue. Even though the prevalence of FA in those people is sensibly lower, it is observed, encouraging the idea that FA might be a different and separate entity from a specific eating disorder. The presence of an addictive component in some subjects affected by eating disorders might influence their treatments and outcomes if not rightly addressed. A further consideration, which is supportive to the need of recognizing the presence of addictive characteristics in some subjects with eating disorders is stressed by authors who blame impulsivity for EDs treatment failure or relapses [ 38 ].

• Strength and limits—This study relies on a large and inclusive sample size, recruited through a systematic search of well planned and carried out studies without any restriction (language, time, country). A possible limitation is that the Yale Food Addiction Scale is a self-reported tool, but, at the moment, it is the only acknowledged instrument to measure food addiction.
• Other psychiatric comorbidities were not specifically reported in all studies as well as gender composition among participants. Furthermore, patients with eating disorders were recruited in Eating Disorders Psychiatric Departments, but their medications or psychotherapy were often omitted.

What is already known on this subject?

The concept of “Food addiction” gained more and more interest in recent years. Its neurobiology and possible comorbidity or inclusion within eating disorders are still poor examined.

What does this study add?

This is the first systematic research, to our knowledge, that demonstrates the existence of food addiction as a separate entity from any eating disorder or other psychiatric illness. This evidence stresses the need of further studies for a better comprehension and treatment implications.

Food addiction is a reality that gained more and more attention in the last years. Our work provides important evidences that FA is a separate entity from different eating disorders and afflicts each of them to a different degree. Some authors hypothesize that food addiction could have a prognostic value [ 26 ] and results from this systematic review allow the possibility to credit food addiction as worsening a comorbid eating disorder As a consequence, we strongly encourage the evaluation of the presence of food addiction in patients with eating disorders as well as in those with obesity to tailor their treatment with greater precision and address all the components that may influence patient’s response to treatment and his/her outcomes.

Acknowledgements

We thank Mrs Tanzi for her priceless work

Funding sources

Nothing declared.

Declarations

The authors declare no conflict of interest.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Research article
• Open access
• Published: 06 January 2021

Associations between autism spectrum disorder and eating disorders with and without self-induced vomiting: an empirical study

• Noriko Numata   ORCID: orcid.org/0000-0003-0117-7740 1 ,
• Akiko Nakagawa 1 ,
• Kazuko Yoshioka 2 ,
• Kayoko Isomura 3 ,
• Daisuke Matsuzawa 1 ,
• Rikukage Setsu 4 , 5 ,
• Michiko Nakazato 6 , 7 &
• Eiji Shimizu 1 , 4  

Journal of Eating Disorders volume  9 , Article number:  5 ( 2021 ) Cite this article

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Although approximately 23% of anorexia nervosa (AN) patients have concomitant autism spectrum disorder (ASD), it is clinically difficult to determine ASD coexistence in patients with eating disorders. Restrictive AN is more common in younger patients and self-induced vomiting usually appears during adolescence/young adulthood, in order to prevent gaining weight caused by overeating. However, some patients are tolerant of weight gain even if they start overeating. It is important to understand the essential difference between those who vomit and those who do not vomit. In this study, we hypothesised that the absence of self-induced vomiting may be associated with the presence of ASD and aimed to assess the presence of ASD traits in each eating disorder (EDs). Clarifying this association helps to consider the coexistence of ASD in the clinical setting and can lead to the next detailed ASD evaluation, and as a result, helps to determine the appropriate treatment and support individually.

We retrospectively evaluated 43 females aged 15–45 years who attended Chiba University Hospital between 2012 and 2016 using the Eating Disorder Examination Questionnaire (EDE-Q) and Autism-Spectrum Quotient (AQ) to quantify the severity of the EDs and to identify whether ASD traits were present.

There was no difference in the AQ score between bingeing-purging type AN and restricting type AN. However, there was significant difference in the AQ score between bulimia nervosa and binge EDs (BED). Of the 4 ED subtypes, BED had the highest ASD traits. The non-vomiting group with illness duration < 4 years had a significantly higher AQ communication score than the vomiting group with illness duration ≥4 years.

Conclusions

There was a difference in the AQ score by the presence or absence of self-induced vomiting. The results of this study suggest an association between high scores on AQ and non-vomiting. Thus, evaluation of patients for the absence of self-induced vomiting while assessing them for EDs may help us to understand the association with ASD traits.

Plain English summary

Although about 23% of anorexia nervosa (AN) patients have concomitant autism spectrum disorder (ASD), it is clinically difficult to determine ASD coexistence in patients with eating disorders (EDs). Restrictive AN is more common in younger patients and self-induced vomiting typically appears during adolescence, in order to prevent gaining weight caused by overeating. However, some patients state that they ‘would never ‘want to vomit’ and are tolerant of weight gain even if they start overeating.

We aimed to assess the presence of ASD traits in each subtype of ED and explore whether an association exists between ASD traits and EDs with or without self-induced vomiting. We retrospectively evaluated 43 females aged 15–45 years using the Eating Disorder Examination Questionnaire (EDE-Q) and Autism-Spectrum Quotient (AQ) to quantify the severity of the ED and to identify whether an ASD trait was present.

The AQ tended to be higher in the group without than in the group with self-induced vomiting. Patients with binge EDs (BED) had the highest AQ score. The results of this study suggest an association between high scores on AQ and non-vomiting. In case of absence of vomiting in EDs, the presence of ASD and a change in the treatment course must be considered. Further verification is required in the future.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), eating disorders (EDs) can be classified into anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) [ 1 , 2 ]. AN can then be further divided into a restricting (AN-R) type and a binge eating with self-induced vomiting (AN-BP) type. Patients frequently transition from one ED type to another, typically from the AN-R type to the AN-BP type [ 3 ]; this may be attributed to the fact that strict dietary restrictions cannot be maintained for a long time.

It is interesting that many of the common features of EDs are similar to the cognitive rigidity in the presence of changing environmental demands that is often seen in autism spectrum disorder (ASD) [ 4 ]. This may indicate a pathological link between the two disorders, with some studies indicating that 18–23% of patients with AN have comorbid ASD [ 5 , 6 , 7 ]. Other research has shown that scores on the Eating Disorder Examination Questionnaire (EDE-Q) were significantly and positively correlated with those on the Autism-Spectrum Quotient (AQ), 10-item version, but not with the body mass index (BMI) [ 8 ]. This correlation has also been observed in studies conducted on adults and adolescents with AN [ 9 , 10 ]. Studies have shown that prognosis may be worse when EDs and ASD are comorbid [ 4 , 5 , 11 ].

It is necessary to assess ASD traits when deciding the treatment policy for patients with EDs. However, clinically, it is difficult to determine the ASD traits of patients with EDs. Restrictive AN is more common in younger patients, and self-induced vomiting usually appears during adolescence/young adulthood in order to prevent gaining weight caused by overeating. However, we clinically observed some patients who say that they ‘would never want to vomit’ and are tolerant of weight gain even if overeating began. We aimed to determine the difference between those who vomit and those who do not vomit and thought that this difference might be related to the ASD trait. Therefore, we decided to investigate whether the presence or absence of vomiting was associated with the ASD trait.

To date, many studies have discussed links between ASD and AN restricting type [ 8 ]. Given that many patients transit between ED subtypes, it is logical that research should be more expanded to other subtypes of ED. In this study, we hypothesised that the absence of self-induced vomiting may be associated with the presence of ASD and aimed to assess the presence of ASD traits in each ED. Clarifying this association helps to consider the coexistence of ASD in the clinical setting and can lead to the next detailed ASD evaluation, and as a result, helps to determine the appropriate treatment and support individually.

The data were retrospectively sampled from outpatients from clinical records when they participated in one of three independent studies on ED were conducted at Chiba University Hospital between 2012 and 2016. The Institutional Ethics Committee of Chiba University Graduate School of Medicine approved this study (no. 3431). All subjects provided written informed consent.

Subjects were diagnosed by a psychiatrist with experience in EDs, using the DSM-IV revised criteria [ 12 ] and the DSM-5 [ 2 ]. AN, BN and BED were included if the criteria was fully met; however, one atypical ED who was chewing type was excluded from this study. Self-report questionnaires were completed by subjects at that time visited the hospital.

The collected sample size was 43, all were female. Among them, 42 subjects were finally analysed because the chewing type was excluded. Among those 42 subjects, 23 of BN, 8 of AN-BP, 6 of AN-R and 5 of BED were included. The subjects with self-induced vomiting (BN and AN-BP) were 31, and those without self-induced vomiting (AN-R and BED) were 11 at the time of assessment. The mean age of the 42 subjects was 26.2 (± 7.8). Vomiting was assessed by both a psychiatrist and self-reported questionnaire (EDE-Q).

Relevant demographic data were collected, including age, duration of illness and BMI. ED severity was assessed using the global EDE-Q score [ 13 ], whereas autistic tendencies were assessed using the AQ [ 14 ].

Eating disorder examination questionnaire (EDE-Q)

The EDE-Q is a standardised and well-validated 36-item self-report questionnaire that measures the severity of ED symptoms and behaviours in the 28 days leading up to the survey [ 13 ]. In the questionnaire, patients are asked to rate how often they have engaged in specific ED behaviours or held ED concerns during the previous 28 days. The questionnaire generates scores for four subscales—‘dietary restraint,’ ‘weight concern,’ ‘shape concern,’ and ‘eating concern’—together with a global score that reflects overall illness severity. The maximum global score is 6, with higher scores indicating greater severity. The optimal cut-off score is 2.5 for discriminating between those with the disorder and healthy controls [ 15 ]. Cronbach’s α ranged from.78 (Eating concern at Time 1) to.92 (Shape Concern at Time 2) for women [ 16 ]. In the Japanese version, Cronbach’s α coefficient was 0.94 for the global scale, 0.81 for the restricting subscale, 0.86 for the eating concern subscale, 0.88 for the shape subscale, and 0.79 for the weight subscale. It showed a significant correlation with the Eating Attitude Test-26 and the Eating Disorder Inventory-91 [ 17 ]. Considering the findings of previous studies [ 13 , 18 ], the EDE-Q appears to be a psychometrically sound self-report measure for the screening of EDs.

Autism-Spectrum quotient (AQ)

The 50-item AQ was developed to provide a brief self-report measure of autistic traits in adults but was not designed to be used as a diagnostic tool despite its widespread use. The AQ consists of five domains associated with ASDs: social skills, attention switching, attention to detail and communication and imagination. Each question allows the subject to indicate ‘definitely agree,’ ‘slightly agree,’ ‘slightly disagree,’ or ‘definitely disagree.’ Approximately half the questions are worded to elicit an ‘agree’ response and half to elicit a ‘disagree’ response in neurotypical individuals. The cut-off score for ASD is 33. The internal consistency of items in each of the five domains was also calculated, and Cronbach’s α coefficients were moderate-to-high (Communication = .65; Social = .77; Imagination = .65; Local Details = .63; and Attention Switching = .67) [ 14 , 19 ]. In the Japanese version, the global scale was α = 0.81. The α coefficient for each individual scale was as follows: 0.78 for social skills, 0.63 for attention switching, 057 for attention to detail, 0.64 for communication, and 0.51 for imagination [ 19 ].

Statistical analysis

All data were reported as means and standard deviations or numbers (number of people) and percentages as appropriate. Demographic data were analysed by Kruskal–Wallis analysis and multiple comparisons were performed by the Steel–Dwass method. In addition, AQ scores and EDE-Q scores of patients with and without self-induced vomiting and EDE-Q scores were compared using the Mann–Whitney test, because we had assumed that the variables would not be normally distributed owing to the relatively small sample size. Assuming that BMI is a confounding factor, Mann–Whitney test was performed between anorexic group and bulimic group. Furthermore, illness duration can be a confounding factor; therefore, Kruskal–Wallis analysis was conducted to confirm this. (Correlation analysis could not be performed owing to the relatively small sample size). Finally, the ratio of the subtypes and the number of patients who exceeded the cut-off value of the AQ score was determined, and the difference in the ratio of the number of patients was examined by Fisher’s exact test. We also calculated the effect size using Cramer’s V. A Cramer’s V > 0.10 was used as the criterion for a small effect, a value > 0.30 as a medium effect, and > 0.50 as a large effect ( http://jspt.japanpt.or.jp/ebpt_glossary/effect-size.html ). There was no missing value. There were some outlier values; however, all the numbers were clinically possible and were not excluded. Statistical analyses were performed using the STAT statistical package and js-STAR version 9.7.8j.

Demographic analysis and clinical characteristics in subtypes of ED

The 42 female outpatients aged 12–45 years (mean 26.2 ± 7.8 years) were analysed. The sample comprised the following diagnoses: 23 with BN (54.7%), 8 with AN-BP (19.0%), 6 with AN-R (14.3%), 5 with BED (11.9%). Among these patients, only 11 did not have self-induce vomiting (i.e. had AN-R and BED) at the time of visiting the hospital. The clinical and demographic characteristics are summarised in Table  1 .

As shown in Table 1 , the groups were not significantly different in their age, there was a significant difference in illness duration between AN-BP and AN-R (AN-BP: 10.0 ± 6.7, AN-R: 1.9 ± 1.7). However, the AN groups (AN-BP and AN-R) had a significantly lower BMI compared with the other groups (BN and BED) (AN-R: 15.6 ± 1.5, AN-BP: 17.0 ± 0.7; BN: 20.4 ± 2.4, BED: 24.3 ± 7.0) (H = 26.3, p  < 0.01). There were also statistically significant differences between the AN groups and BN in terms of the EDE-Q global scores for clinical severity (AN-R: 15.2 ± 11.5; BN: 74.5 ± 40.8; and AN-BP: 78.8 ± 39.4). AN-BP tended to be higher than the other subtypes in terms of restricting, eating and weight, that were the sub-items of EDE-Q, and there was a significant difference in the comparison with AN-R (Restricting: AN-BP 5.2 ± 1.0, AN-R 2.4 ± 1.5; Eating: AN-BP 4.9 ± 0.6, AN-R 2.0 ± 1.4, Weight: AN-BP 5.4 ± 0.6, AN-R 2.6 ± 1.9).

Table 1 also shows that the average of AQ total score was highest for patients with BED (32.4 ± 6.2), followed by those with AN-R (26.0 ± 7.5), AN-BP (25.3 ± 4.8), and BN (22.1 ± 6.4). The difference between BN and BED was significant for the attention to detail score (BN: 3.2 ± 2.0, BED: 7.6 ± 2.5) (H = 9.4, p  < 0.05).

Clinical characteristics, EDE-Q and AQ score by the presence or absence of self-induced vomiting

As observed in Table  2 , two groups were formed: 31 patients with self-induced vomiting and 11without self-induced vomiting. Although there were no significant differences in age or BMI, there was a significant difference in illness duration between vomiting present group and vomiting absent group (BN, AN-BP: 7.3 ± 6.2, AN-R, BED: 3.1 ± 3.0).

There were no significant differences in the EDE-Q, except for the ‘diagnosis’ category, which is expected to be affected by the frequency of self-induced vomiting. The AQ total scores of those who did not self-induced vomiting were significantly higher than for those who self-induced vomiting. In particular, the scores for social and communication skills—which are subscales of the AQ—were significantly higher in the group that did not have self-induced vomiting.

There were also statistically significant differences between the vomiting and non-vomiting groups in the EDE-Q global scores for clinical severity. Two bulimic vomiting subtypes (BN and AN-BP) scored higher than non-vomiting subtypes (U = 67.5, p  < 0.01, r = 0.46).

However, BMI was also considered to be a confounder of EDE-Q and AQ scores; therefore, the patients were divided by anorexic and bulimic, so only AN-BP to AN-R and BN to BED were analysed (Table  3 ).

Despite the significant differences in illness duration, BMI and age between AN-BP and AN-R, there were no differences in any of the AQ sub-items. In contrast, there was no significant difference in the illness duration, BMI and age between BN and BED. However, there was a significant difference in the social skills, attention to detail and communication in the AQ score.

In addition, illness duration could be a confounding factor for the EDE-Q and AQ scores. Therefore, we performed the multivariate analysis with 4 groups: illness duration of < 4 years for patients with and without vomiting and illness duration of ≥4 years for patients with and without vomiting. A Kruskal–Wallis analysis was conducted to confirm these groups, because illness duration of ≤4 years or more has been the common cut-off used for determining acute vs chronic EDs [ 20 , 21 ].

There were 22 patients (illness duration ≥4 years) and 9 patients (illness duration < 4 years) in the vomiting group and 3 patients (illness duration ≥4 years) and 8 patients (illness duration < 4 years or less) in the non-vomiting group. The results are shown in Tables 4 and 5 . Illness duration resulted in significant differences in AQ communication, EDE-Q diagnosis and age. The communication score of AQ was highest in the non-vomiting group with illness duration < 4 years, followed by the non-vomiting group with illness duration ≥4 years. The communication score of AQ in the non-vomiting group with illness duration < 4 years was significantly higher than that in the vomiting with illness duration ≥4 years.

AQ score cut-off value by ED subtype

Lastly, the ratio of the subtypes and the number of patients who exceeded the cut-off value of the AQ score were examined, and the difference in the ratio of the number of patients was examined using Fisher’s exact test. Three of eight patients of BED had an AQ score above 33, which well exceeded expected value in 60% of patients with BED. By contrast, one patient with BN had an AQ ≥33 (4.3%), and this amount was below the expected value. The difference between the BN and BED groups was significant ( p  = 0.02) (Table 6 ).

The aim of the current study was to examine the relationship between each subtype of EDs and ASD trait regarding the presence or absence of self-induced vomiting. We first compared the illness duration, BMI, EDE-Q scores, and AQ scores in the four groups (BN, AN-BP, AN-R, and BED). Next, the four subtypes were divided as per the presence or absence of self-induced vomiting; the illness duration, BMI, age, EDE-Q, scores and AQ scores were compared. Assuming that BMI is a confounding factor, we compared EDE-Q and AQ scores between anorexic group (AN-BP and AN-R) and bulimic group (BN and BED). Furthermore, illness duration could be a confounding factor; therefore, we performed additional analysis to confirm it. Finally, we examined the ratio of the subtypes and the number of patients who exceeded the cut-off value of the AQ score.

We had hypothesised that patients without self-induced vomiting had a higher tendency for ASD; however, there was no difference in the AQ between AN-BP and AN-R. The significant difference in the AQ score between BN and BED was clear. Of the four ED subtypes, BED had the highest ASD trait. Even after the statistical analyses were adjusted to determine confounding factors, such as low BMI and duration of illness, the significant AQ differences in our results can be explained by the difference between BN and BED. However, this finding is not completely aligned with our hypothesis that ASD traits are correlated with a lack of vomiting. That is, for EDs of patients within or above normal weight, ASD traits were associated with a lack of vomiting in this study. In addition, when the illness duration was divided into < 4 years and ≥ 4 years, non-vomiting was common in the < 4 year group and vomiting was common in the ≥4 year group. This result supports the rationale for a 4 year cut-off to designate the chronic and acute phases. Notably, early intervention in ED (before the transition from onset to vomiting) may be necessary.

In addition, the AQ communication score was significantly higher in the group without vomiting and with < 4 years of illness duration than in the group with vomiting ≥4 years of illness duration. Second, the non-vomiting group ≥4 years of illness duration scored higher than the vomiting groups. This result suggested that the non-vomiting groups tended to have a higher AQ communication score. A previous study had reported that all-or-none thinking about food and dieting was typical of patients with BED [ 22 ]. Some patients say that they ‘would never want to vomit’ and are tolerant of weight gain even if they start overeating. In these BED patients, the absence of self-induced vomiting means that they tend to be obese [ 19 ], and it is unclear why they do not vomit in the face of weight gain [ 21 ]. If considering the characteristics of ASD, it may be possible that some patients with BED do not vomit because another obsessive compulsion arising from ASD is stronger than the core psychopathology of the ED, i.e. fear of being fat and the failure of severe restriction leads to acceptance of weight gain. This is seen clinically in our practise with comments from patients such as ‘I am scared to vomit,’ ‘My life is over when I am vomiting,’ or ‘Looking at vomit disgusts me.’ In such instances, the fear or aversion to vomiting might be stronger than the desire not to gain weight. In addition, patients who were absorbed in dietary restrictions were able to postpone the desire to lose weight due to the disgust of vomiting along with the failure of restrictions, and to endure the weight gain somehow could not be explained by the psychopathology of EDs. In some cases, from the experience of vomiting once in the past, people have a strong sense to visceral sensations and/or disgust of vomiting; they are unable to forget the trauma and find it difficult to eat food because they do not want to vomit again. People with hyperaesthesia within the autism spectrum are reluctant to induce vomiting. In addition, some patients cannot eat because they are afraid of vomiting.

If there is an ASD trait, it is easy to fall into maladaptation to environment because of impairment of social skills, communication and lack of flexibility. In this study, social skills and communication scores of AQ in patients without self-induced vomiting were higher than those in patients with self-induced vomiting.

The maladaptation to environment may lead to routine behaviour, because certain routine behaviour, such as routine dietary patterns of patients, tends to reassure individuals. Environmental adjustment is the first requirement for such individuals.

For patients with EDs, it may be necessary to prioritise the identification of characteristics over the diagnosis or types. When assessing patients with EDs who never vomit, it is important to clarify the reason; i.e. determine what they are afraid of as a consequence of vomiting. Therefore, detailed assessments for appropriate recognition of each patient who does not vomit and the application of empirically derived treatments are required. Based on the above, for patients with BED with a high tendency towards ASD, environmental adjustment and psychoeducation regarding ASD may be necessary. In addition, patients should not be corrected in terms of their diet choices that are derived from sensory sensitivity (i.e. sense of smell, taste), and their feeling of disgust should not be ignored. It is also essential to take into consideration in their abnormal eating behaviour caused by the stress of their poor communication skills. For patients (AN-R and BED) who have not vomited and have illness duration of < 4 years, it is important for therapists to identify these patients’ attitude towards self -induced vomiting for the evaluation of their ASD traits and to perform an early intervention before the condition becomes chronic. To the best of our knowledge, this is the first study to compare the predisposition for ASD by ED subtype and the presence or absence of self-induced vomiting.

This study had some limitations. Of note, the sample size was small, there were differences in the number of participants in each subtype. There were no data for healthy subjects to compare patient data with standard values. Besides the above, there was a large age spread. In general, it is known that AN-R is much more common in the younger ages, and self-induced vomiting usually appear later on in adolescence/young adulthood. The differences of subjects’ age, BMI and illness duration may always be a confounder and should be controlled it with bigger sample size.

Symptoms of depression and anxiety disorders, irritability, emotional lability and obsessional features are frequent accompaniments in ED. Typically, these features worsen with weight loss and improve with weight regain [ 3 ]. Interest in the outside world also declines as patients become underweight, with the result that most patients become socially withdrawn and isolated. Since we did not measure anxiety or depression in this study, it is unclear how these were associated with ED and AQ scores. Since ED has a high incidence of anxiety and depression, it should be added to the evaluation index in the future study. There are still problems to be examined in the future regarding coexistence of autism trait and measurement of individual differences.

This study used only the AQ for evaluation of ASD traits. We should have used the AQ-10 in addition to the AQ because a few adolescent patients were included in our study. These are good tools for assessing the presence or absence of ASD traits in a busy clinical setting. However, the AQ is a self-completed scale and is not used to diagnose ASD. Using the Autism Diagnostic Observation Schedule (ADOS) or the Autism Diagnostic Interview (ADI) for ASD evaluation, excluding patients with extremely low body weights, and including control subjects in a larger overall sample should be done in future research [ 9 , 21 ]. A future issue is to determine the clinical usefulness of using the ASD evaluation tool, which is called the gold standard such as ADOS and ADI, for ED patients whose ASD characteristics are considered to be a factor for maintaining the symptoms.

Our results suggest that when body weight is above normal, patients with EDs without self-induced vomiting might have a higher ASD trait than those with it. In addition, when patients with EDs are divided by illness duration, among those with shorter illness duration (< 4 years), those without self-induced vomiting might have a higher ASD trait than those with it, and the difference of ASD trait between patients who do and do not vomit could be smaller among those with longer illness duration (≥4 years).

Given these results and considering that the prevalence of higher ASD tendencies in adults with EDs might contribute to the significant treatment resistance to conventional therapies [ 23 ], it is important for therapists to determine patients’ ASD trait from an early stage and to be flexible in designing treatments that are individually tailored for each patient. This study, which investigated the association between ASD traits and self-induced vomiting, could provide helpful points for future clinical research.

Abbreviations

the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Eating disorders

Anorexia nervosa

Bulimia nervosa

Binge eating disorder

restricting type of AN

binge eating with self-induced vomiting type

• Autism spectrum disorder

Body Mass Index

Eating Disorder Examination Questionnaire

Autism-Spectrum Quotient

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Acknowledgements

The study was supported by Japan Society for the Promotion of Science (JSPS). The authors thank our research nurses Hiroko Suwabe and Hiroe Ota for all their support during this study.

Funding for this study was provided by JSPS KAKENHI Grant Numbers 17H00039. JSPS had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript or the decision to submit the paper for publication.

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Research Center for Child Mental Development, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan

Noriko Numata, Akiko Nakagawa, Daisuke Matsuzawa & Eiji Shimizu

Department for School of Human and Social Sciences, Fukuoka Prefectural University, Fukuoka, Japan

Kazuko Yoshioka

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

Kayoko Isomura

Department of Cognitive Behavioral Physiology, Graduate School of Medicine, Chiba University, Chiba, Japan

Rikukage Setsu & Eiji Shimizu

Koutokukai Sato Hospital, Yamagata, Japan

Rikukage Setsu

Department of Psychiatry, Graduate School of Medicine, International University of Health and Welfare, Chiba, Japan

Michiko Nakazato

Department of Psychiatry, Graduate School of Medicine, Chiba University, Chiba, Japan

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Author NN designed the study and collected data. Authors RS and MN provided summaries of previous research studies. Authors KI, KY and DM conducted the statistical analysis. ES and AN supervised the study. All authors contributed to and have approved the final manuscript.

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Correspondence to Noriko Numata .

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All procedures in the current study were in accordance with the ethical standards of the institutional research committee, Chiba University Graduate School of Medicine approved the study (no. 3431). The study was conducted in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. In case that the patient was a minor under the age of 18, an informed consent was obtained from their patient/caregiver. In addition, the patients (adults) with ‘ASD’ were able to give informed consent on their own (because of the severity of the disease).

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The authors do not have any competing interests to report.

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Numata, N., Nakagawa, A., Yoshioka, K. et al. Associations between autism spectrum disorder and eating disorders with and without self-induced vomiting: an empirical study. J Eat Disord 9 , 5 (2021). https://doi.org/10.1186/s40337-020-00359-4

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DOI : https://doi.org/10.1186/s40337-020-00359-4

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