THE MOST COMMON CONDITION YOU'RE NOT DIAGNOSING: BINGE- EATING DISORDER Learning Objectives

•Identify the presenting symptoms and risk factors for binge-eating disorder

•Incorporate both psychotherapy and pharmacotherapy into the management of patients with binge-eating disorder Prevalence of Binge-Eating Disorder (BED)

Most prevalent eating disorder, with lifetime prevalence of 0.85%

More common in females than males (~3:1)

Median age of onset is 21.1 years old

Udo T, Grilo CM. Biol Psychiatry 2018;84(5):345-54. DSM History for Diagnosing BED

1980 1980s 1987 1994 2000-2004 2013 Binge behavior Concept of “Bulimia” was “Eating EDNOS was BED was was included as purging and replaced by Disorder Not the most recognized as a component of non-purging “Bulimia Otherwise common autonomous the DSM-III bulimia was Nervosa” in Specified” diagnosis for eating disorder diagnostic refined DSM-III-R; (EDNOS) was eating in DSM-5 criteria for criteria now the option for disorders; bulimia; criteria required both diagnosing diagnosis did not require binge eating BED in DSM-IV captured BED engaging in and primarily compensatory compensatory behaviors behaviors

DSM=Diagnostic and Statistical Manual of Mental Disorders

Citrome L. CNS Spectr 2015;20(Suppl 1):44-51. DSM-5 Binge-Eating Disorder Diagnostic Criteria

Recurrent episodes of binge The binge-eating episodes are associated with 3 (or more) of eating. An episode is the following: characterized by both of the 1. Eating much more rapidly than normal following: 2. Eating until feeling uncomfortably full 1. Eating more than most people 3. Eating large amounts of food when not physically hungry A in a discrete period of time B 4. Eating alone because of feeling embarrassed by how much 2. A sense of lack of control one is eating overeating during the episode 5. Feeling disgust with self, depressed, or very guilty afterward

Marked distress regarding binge The binge eating occurs, on average, at least once a week for 3 C eating is present D months The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in E bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or nervosa Mild: 1–3 weekly binge episodes (39.7%) Severe: 8–13 weekly binge episodes (10%) Moderate: 4–7 weekly binge episodes (47.4%) Extreme: >14 weekly binge episodes (3%) Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Association; 2013; Grilo CM et al. Behav Res Ther 2015;71:110-4. Important Non-Diagnostic Features of BED

•Overvaluation (i.e., undue importance to the point of defining self-worth) of body shape and weight •Reported by ~50% of BED patients •Associated with severity of eating pathology and psychological distress •Has negative prognostic significance •Obesity is common (36–56%)

Kornstein SG. J Clin Psychiatry 2017;78(Suppl 1):3-8; Coffino JA et al. Obesity (Silver Spring) 2019;27(8):1367-71; Udo T, Grilo CM. Biol Psychiatry 2018;84(5):345-54; Hudson JI et al. Biol Psychiatry 2007;61(3):348-58; Kessler RC et al. Biol Psychiatry 2013;73(9):904-14. A Significant Public Health Concern

•Frequently comorbid with psychiatric disorders •Increased risk of comorbid medical (i.e., metabolic) conditions •Lower quality of life and social functioning •Higher mortality rates •Elevated risk of suicide

Kornstein SG et al. Prim Care Companion CNS Disord 2016;18(3):10.4088/PCC.15r01905; Perez M, Warren CS. Obesity (Silver Spring) 2012;20(4):879-85; Suokas JT et al. Psychiatry Res 2013;210(3):1101-6; Udo T et al. BMC Med 2019;17(1):120. Lifetime Psychiatric Comorbidities of BED

100

90 93.8% 80 69.9 ≥1 lifetime 70 67.7 59.0 comorbidity 60 56.0 50 40 31.6 30 Comorbidity (%) 20

2.3 Any Lifetime Psychiatric Mean total # 10 lifetime 0 comorbidities Mood Posttraumatic Substance use Personality or disorders disorders stress disorder disorders conduct disorders

Udo T, Grilo CM. Int J Eat Disord 2019;52(1):42-50. Medical Comorbidities of BED

BED Somatic Comorbidities (Adjusted Odds Ratioa) Diabetes (1.59)* Hypertension (1.44)* High cholesterol (1.43)* High triglycerides (1.54)* a Adjusting for sociodemographic variables (age, The mean total number of chronic sex, race/ethnicity, educational level) and somatic conditions in BED (2.3 ± psychiatric comorbidities (any mood disorders, any substance use disorder, any personality/ 0.18) is greater than the number conduct disorders, and posttraumatic stress in controls with no specific eating disorder). *p<0.05. disorder (1.4 ± 0.02, p<0.05)

Udo T, Grilo CM. Int J Eat Disord 2019;52(1):42-50. BED May Confer Risk of Metabolic Syndrome Over and Above Obesity Alone

Individuals with BED also reported significantly higher 5-year incidence of dyslipidemia (hazard ratio [HR]=2.2) and ≥2 metabolic syndrome components (HR=2.4) than control individuals

The 5-year incidences of hypertension and type 2 diabetes were not significantly different by group

Findings from 134 overweight/obese adults with BED and 134 overweight/obese adults with no history of eating disorders interviewed at 2.5 and 5 years of follow-up. Analyses were adjusted for age, sex, baseline body mass index (BMI), and interval BMI change. Hudson JI et al. Am J Clin Nutr 2010;91(6):1568-73. Patients With BED Have Unfavorable Inflammatory Profile Over and Above Obesity

Non-BED Obese BED Obese P-value adjusted for Mean (standard deviation) Mean (standard deviation) body mass index Glycated hemoglobin (%) 5.5 (0.6) 5.8 (0.7) 0.001 Uric acid (mg/dL) 5.3 (1.3) 11.1 (24.7) 0.05 Erythrocyte sedimentation 11.8 (10.6) 23.0 (13.3) <0.001 rate (mm/h) High-sensitive C-reactive 4.2 (4.9) 7.9 (7.3) <0.001 protein (mg/L) White blood cells (x103/µL) 6848.5 (1737.3) 7923.5 (2094.2) <0.001 Fasting insulin (µU/mL) 20.4 (11.4) 40.0 (53.0) 0.01 Homeostasis model 4.9 (3.1) 11.6 (22.7) 0.01 assessment index Visceral adiposity index 131.8 (89.1) 231.8 (164.9) 0.01 Results from a cross-sectional study of 115 white obese (body mass index > 30) patients (BED=30; non- BED=85) seeking weight reduction. Sucurro E et al. Medicine (Baltimore) 2015;94(52):e2098. Calorie and Macronutrient Consumption in BED With Obesity

• Obese individuals with BED consume more calories than obese individuals without BED when asked to binge eat and when asked to eat a normal (i.e., non-binge) meal in the laboratory

• Obese individuals with and without BED have comparable energy expenditure

Macronutrient Intake During Laboratory Overeating Episode 1400 1200 *** 1000 * 800 BED Obese 600 Non-BED Obese 400 # *** p<0.001 200 ESTIMATED KCAL ESTIMATED * p<0.05 0 # Carbohydrates Fat Protein p=0.06

Bartholome LT et al. Eur J Nutr 2013;52(1):193-202; Raymond NC et al. Obesity (Silver Spring) 2012;20(4):765-72; Raymond NC et al. Int J Eat Disord 2007;40(1):67-71; Guss JL et al. Obes Res 2002;10(10):1021-9. BED Dysregulation in the Peripheral and Central Signals Controlling Feeding • BED patients who are lean or obese demonstrate dysfunction in the ghrelin signaling system • Larger gastric capacity in BED may further reduce satiety signals (i.e., leptin, CCK, GLP- 1, and PYY3-36) and contribute to overeating • Leptin, adiponectin, and insulin may also be dysregulated in BED

αMSH=alpha-melanocyte stimulating hormone; AgRP: agouti gene-related peptide; CCK: cholecystokinin; GI: gastrointestinal; GLP: glucagon-like peptide; NPY: neuropeptide Y; POMC: pro-opiomelanocortin; PYY: peptide YY. Geliebter A et al. Am J Lifestyle Med 2008;2(4):305-14; Hellström PM et al. Br J Nutr 2004;92(Suppl 1):S47-57; Monteleone P et al. Psychoneuroendocrinology 2005;30(3):243-50; Khalil RB, Hachem C. Eat Weight Disord 2014;19(1):3-10; Ilyas A et al. Mol Cell Endocrinol 2019;497:110307. Identifying BED BED Risk Factors

•Family history of BED •Childhood obesity •Familial eating problems •Parent with mood or substance use disorder •Trauma and stressful life events •Family discord, high parental demands or parental perfectionism, and parental separation

Hudson IJ et al. Arch Gen Psychiatry 2006;63(3):313-9; Striegel-Moore RH et al. Int J Eat Disord 2005;37(1):11-8; Blomquist KK et al. Compr Psychiatry 2011;52(6):693-700; Pike KM et al. Psychiatry Res 2006;142(1):19-29; Degortes D et al. Eur Eat Disord Rev 2014;22(5):378-82. Recognition of BED

•Perform clinical assessment • Ask about eating habits, not just appetite and weight •Use screening tools, especially for… • Patients who are reluctant to discuss eating habits • Overweight/obese patients seeking treatment for weight loss • Patients with mood or anxiety disorders • Patients with substance abuse or impulse-control issues

Kornstein SG et al. Prim Care Companion CNS Disord 2016;18(3):10.4088/PCC.15r01905. Diagnostic Questions to Identify BED

Do you think you eat more food than the average person your age?

Do any other members of your family have eating problems?

Have you felt like some of your eating has seemed out of control?

Have you had any concerns about your eating behaviors or your relationship with food?

Are there times when you eat in secret?

Does your weight fluctuate?

Do you eat more when you are stressed or anxious?

Citrome L. J Clin Psychiatry 2017;78(Suppl 1):9-13; Kornstein SG et al. Prim Care Companion CNS Disord 2016;18(3):10.4088/PCC.15r01905. Screening Tools for BED

Specific Binge-Eating Disorder Screener-7 (BEDS-7)

to BED Yale-Brown Obsessive-Compulsive Scale Modified for Binge Eating (YBOCS-BE)

Binge-Eating Scale (BES)

Eating Disorder Examination (EDE) Not Eating Disorder Examination Questionnaire (EDE-Q) Specific SCOFF Questionnaire Eating Disorder Screen for Primary Care (ESP) to BED Eating Loss of Control Scale (ELOCS) Questionnaire on Eating and Weight Patterns (QEWP-5) Eating Disorder Assessment for DSM-5 (EDA-5)

Herman BK et al. Prim Care Companion CNS Disord 2016;18(2):10.4088/PCC.15m01896; Deal LS et al. Int J Eat Disord 2015;48(7):994-1004; Gormally J et al. Addict Behav 1982;7(1):47-55; Morgan JF et al. BMJ 1999;319(7223):1467-8; Fairburn CG, Beglin SJ. Int J Eat Disord 1994;16(4):363-70; Cotton MA et al. J Gen Intern Med 2003;18(1):53-6; Blomquist KK et al. Psychol Assess 2014;26(1):77-89; Yanovski SZ et al. Int J Eat Disord 2015;48(3):259-61; Sysko R et al. Int J Eat Disord 2015;48(5):452-63. Differential Diagnosis

•Distinguish from other eating disorders • Compensatory behaviors (e.g., purging, laxative use, excessive exercise, or fasting) suggest bulimia nervosa • Compensatory behaviors with severe underweight may indicate anorexia nervosa • Later age of onset and longer episode duration than anorexia and bulimia nervosa

•Distinguish from other mental illnesses (e.g., depressive and bipolar disorders, borderline personality disorder)

Citrome L. CNS Spectr 2019;24(S1):4-13; Udo T, Grilo CM. Biol Psychiatry 2018;84(5):345-54. Barriers to Diagnosis

Poor Lack of Communication Awareness

Patient shame about Patient is unaware BED-related symptoms are a behaviors, particularly medical problem among overweight

Perceived and actual Lack of clinician weight stigmatization familiarity with BED from clinician

Kornstein SG. J Clin Psychiatry 2017;78(Suppl 1):3-8; Citrome L. J Clin Psychiatry 2017;78(Suppl 1):9-13. Miscommunication Between Physicians and Patients

• Among obese treatment-seeking adults, weight-based stigmatization from doctors uniquely predicts psychological distress, which may mediate binge eating behavior • In physician-patient (suspected or diagnosed BED) conversations: • Psychiatrists tend to focus more on symptoms related to weight and ask about the type of food consumed more often than diagnostic criterion related to quantity of food consumed • Patients tend to focus on the relationship between feelings, coping strategies, and compulsion to binge eat

• Focus should be directed to BED diagnostic criteria, assessment of patients’ emotions and sense of lack of control, and relationships between body weight and BED

Ashmore JA et al. Eat Behav 2008;9(2):203-9; Kornstein SG et al. Postgrad Med 2015;127(7):661-70. Managing BED Current Status of BED Treatments

•Many patients with BED remain undiagnosed and, if managed at all, have received delayed treatment or inadequate treatment

•Available treatments reduce binge eating and depressive symptoms to various degrees • Lisdexamfetamine has also demonstrated efficacy in reducing weight

Linardon J. Int J Eat Disord 2018;51(8):785-97; De Zwaan M et al. Trials 2012;13:220; Vocks S et al. Int J Eat Disord 2010;43(4):205-17; Ghaderi A et al. PeerJ 2018;6:e5113. Overweight/Obesity: To Treat or Not to Treat?

• As of 2017, only clinical guidelines from United States and Australia/New Zealand explicitly recommend weight management for the treatment of BED

• United States: nutritional counseling, behavioral weight-control programs, orlistat (anti-obesity medication)

• Australia/New Zealand: orlistat

• Clinical guidelines from Germany, Netherlands, Spain, United Kingdom, and the World Federation of Societies of Biological Psychiatry made no recommendation regarding weight management

Hilbert A et al. Curr Opin Psychiatry 2017;30(6):423-37. Treatment Goals

The main goal of BED treatment is to reduce binge-eating behavior and thereby reduce the risk of medical and psychiatric complications

Address When emotional Decrease binge- Treat comorbid appropriate, issues, such as eating behavior psychopathology address weight shame, guilt, and concerns low self-esteem

Kornstein SG. J Clin Psychiatry 2017;78(Suppl 1):3-8. Best Evidence-Based Treatments for BED Remission or Reducing Binge Eating Frequency

•Cognitive behavioral therapy (CBT)-based treatments (psychotherapy or guided self-help; individual or group) •Interpersonal therapy (IPT) •Selective serotonin reuptake inhibitor (SSRI) •Lisdexamfetamine (LDX)

Ghaderi A et al. Peer J 2018;6:e5113; Vocks S et al. Int J Eat Disord 2010;43(3):205-17; Grilo CM. J Clin Psychiatry 2017;78(Suppl 1):20-24; Linardon J. Int J Eat Disord 2018;51(8):785-97; Peat CM et al. Eur Eat Disord Rev 2017;25(5):317-28; Brownley KA et al. Ann Intern Med 2016;165(6):409-20; Hilbert A et al. J Consult Clin Psychol 2019;87(1):91-105. Greater Efficacy of CBT-Based Psychotherapy and Structured Self-Help Than Pharmacotherapy

Mean Effect Size (Hedges’ d) Compared to Control Condition Binge frequency 1.6 Binge eating 1.4 abstinence Body weight 1.2 Days with binges 1 0.8 Mean odds ratio for 0.6 0.4 psychotherapy, 0.2 structured self-help and Depressive 0 pharmacotherapy were -0.2 Restraint symptoms significantly greater than Psychotherapy control conditions Structured self-help • Psychotherapy > * Pharmacotherapy pharmacotherapy • Self-help > Shape concern * * Eating concern p<.05 versus control pharmacotherapy

*p<.05 versus pharmacotherapy Weight concern N=864 (15 randomized clinical trials)

Vocks S et al. Int J Eat Disord 2010;43(4):205-17. Greater Efficacy of CBT Than Pharmacotherapy in the Longer Term

Therapist-Led CBT vs. Pharmacotherapy Remission rates Binge frequency Cognitive symptoms Follow-up Odds Ratio Hedges’ g Hedges’ g p p p Point [95% CI] [95% CI] [95% CI] Short-term 8.66 .11 .92 .051 .689 .007 (<12 months) [.98, 76.11] [-.41, .63] [.25, 1.59] Long-term 14.44 1.15 .99 .015 .266 <.001 (≥12 months) [1.69, 122.97] [ -.88, 3.20] [.51, 1.48] Results from meta-analysis of randomized controlled trials including patients with BED (31 studies) or mostly patients with BED (4 studies)

Linardon J et al. J Consult Clin Psychol 2017;85(11):1080-94. Equivalent BED Short- and Long-Term Recovery Rates for CBT and IPT

Abstinence from Binge Eating 100 N.S. 90 N.S. 80 70 60 50 Cognitive Behavioral Therapy 40 Interpersonal Therapy PERCENT 30 20 10 0 Post-treatment Month 12 Data from adults with BED randomly assigned to CBT or IPT treatment (20 90-minute weekly group sessions and 3 individual sessions) who were assessed post-treatment (n=158) and up to 12 months of follow up (n=133).

Wilfley DE et al. Arch Gen Psychiatry 2002;59(8):713-21. Greater Efficacy of SSRIs and Lisdexamfetamine Than Placebo

Binge Eating Depression Remission Body Mass Index Frequency Symptoms (6 studies, n=264) (5 studies, n=237) (6 studies, n=257) (4 studies, n=148) SSRI>Placebo SSRI>Placebo SSRI=Placebo SSRI=Placebo RD=0.15 SMD=-0.45 SMD=0.01 SMD=-0.16 p=0.02 p=0.02 p=0.97 p=0.33

Binge Eating Remission Body Mass Index Frequency (3 studies, n=850) (3 studies, n=852) (3 studies, n=849) SSRI=selective serotonin reuptake inhibitor LDX>Placebo LDX>Placebo LDX>Placebo LDX=lisdexamfetamine RD=0.25 SMD=-0.76 SMD=-5.23 RD=risk difference p<0.001 p<0.001 p<0.001 SMD=standard mean difference

Results from meta-analysis of randomized clinical trials with low or moderate risk of bias.

Ghaderi A et al. PeerJ 2018;6:e5113. Lisdexamfetamine

• FDA approval in 2015 for treatment of moderate-to-severe BED • Pro-drug of D- • Mechanism of action is thought to involve dopamine and norepinephrine reuptake blockage in post-synaptic receptors • May regulate reward mechanisms directly linked to food choice and eating behaviors • Evidence for reducing binge eating, binge days, and weight • Most common side effects are dry mouth, decreased appetite, , and headache

McElroy SL et al. JAMA Psychiatry 2015;72(3):235-46; McElroy SL et al. Neuropsychopharmacology 2016;41(5):1251-60. Long-Term (12-Month) Safety and Tolerability of Lisdexamfetamine (LDX)

Serious TEAEs Most TEAEs were of mild to moderate 2.8% intensity and did not lead to treatment discontinuation TEAEs related to LDX The most commonly reported TEAEs 64.9% were dry mouth (27.2%), headache (13.2%), insomnia (12.4%), and upper 84.5% TEAEs leading to treatment discontinuation respiratory tract infection (11.4%) Any TEAEs 9.0% Safety and tolerability profile consistent Severe TEAEs with short-term LDX studies in adults with 7.0% BED and long-term studies in adults with other indications (i.e., ADHD) TEAE=treatment emergent adverse event

Data from 12-month, open-label extension study of adults with BED (N=599; 87% women; 76.8% white; >90% overweight or obese) administered LDX (50 or 70 mg/day).

Gasior M et al. J Clin Pharmacol 2017;37(3):315-22. Off-Label Pharmacological Agents for BED (1/2)

Evidence of weight Evidence of binge Evidence of binge Drug Drug Class Studies reduction eating reduction day reduction SSRI 2 RCTs No No Yes (1/2 studies) SSRI 2 RCTs Yes (1/2 studies) No Yes (1/2 studies) 2 RCTs, SSRI Yes (2/3 studies) Yes (3/3 studies) No 1 open-label SSRI 1 RCT Yes Yes Yes SSRI 1 RCT Yes No Yes TCA 1 RCT Yes Yes No NRI 1 RCT Yes Yes Yes SNRI 1 study# Yes No No SNRI 1 RCT No No No NDRI 1 RCT No No No SSRI=selective serotonin reuptake inhibitor; TCA=tricyclic ; NRI=norepinephrine reuptake inhibitor; SNRI=serotonin-norepinephrine reuptake inhibitor; NDRI=norepinephrine-dopamine reuptake inhibitor; RCT=randomized clinical trial; # retrospective study.

Amodeo G et al. Expert Opin Pharmacother 2019;20(6):679-90. Off-Label Pharmacological Agents for BED (2/2)

Evidence of weight Evidence of binge Evidence of binge Drug Drug Class Studies reduction eating reduction day reduction Topiramate Anticonvulsant 2 RCTs Yes (2/2 studies) Yes (2/2 studies) Yes (1/2 studies) Lamotrigine Anticonvulsant 1 RCT No No No Zonisamide Anticonvulsant 1 RCT Yes Yes No Baclofen Anti-craving 1 RCT No Yes No Samidorphan Anti-craving 1 RCT No No No Acamprosate Anti-craving 1 RCT Yes No Yes Naltrexone Anti-craving 2 RCTs Yes (1/2 studies)* No No ^ Anti-obesity 3 RCTs Yes (3/3 studies) Yes (2/3 studies) Yes (2/3 studies) Orlistat Anti-obesity 1 RCT Yes No No D-fenfluramine Anti-obesity 1 RCT No Yes No RCT=randomized clinical trial. ^ Withdrawn from the market due to safety issues. * Versus bupropion.

Amodeo G et al. Expert Opin Pharmacother 2019;20(6):679-90. Dasotraline: Emerging Treatment for BED

• Dasotraline is a long-acting dopamine-norepinephrine reuptake inhibitor • Low abuse potential due to slow absorption and a long elimination half-life that results in stable plasma concentrations over 24 hours • Most common adverse events (≥10%) include insomnia, dry mouth, headache, decreased appetite, decreased weight, anxiety, and • The percent of BED patients with weight reduction of ≥5% and ≥7% following treatment with dasotraline is approximately 31% and 18%, respectively • Weight loss with dasotraline is approximately 3-6 kg in patients with BED Koblan KS et al. Drug Alcohol Depend 2016;159:26-34; McElroy SL et al. J Clin Psychiatry 2020;81(5):19m13068; Grilo CM et al. CNS Spectr 2020; Epub ahead of print. Dasotraline Reduces Binge Eating Days

Results from randomized, double-blind trial of dasotraline (4-8 mg/day) or placebo treatment for 12 weeks in adult patients (18-55 years) with moderate-to-severe BED

McElroy SL et al. J Clin Psychiatry 2020;81(5):19m13068; Dasotraline Reduces Eating Disorder Psychopathology

0 -0.2 -0.4 -0.6 -0.8 -1 Effect size: 0.49 QM QM ScoreGlobal - -1.2 Effect size: 0.59 LeastSquare Mean

EDE -1.4 * -1.6 * Dasotraline 4 mg (N=161) Dasotraline 6 mg (N=162) Placebo (N=162)

EDE-QM: Eating Disorder Examination Questionnaire, modified *p<0.001 compared to placebo

Results from randomized, double-blind trial of dasotraline (4 or 6 mg/day) or placebo treatment for 12 weeks in adult patients (18-55 years) with moderate-to-severe BED

Grilo CM et al. CNS Spectr 2020; Epub ahead of print. BED May Have Overlapping Features With Food Addiction Among Patients With Obesity

• Food addiction is a contentious construct due to lack Symptoms of Food of high-quality evidence in humans Addiction • Much time spent obtaining • Prevalence and severity of BED and food addiction trigger foods symptoms increase across weight categories • Feelings of withdrawal when off trigger foods • BED and food addiction symptoms are highly • Continued use despite correlated (r=0.76, p<0.001) knowledge of adverse consequences • Exact overlap between BED and food addiction is • Important activities reduced or given up unclear • Repeated unsuccessful attempts to quit • Subset of binge eaters with food addiction may • Taken in larger quantities or represent a more impaired group longer periods than intended

Meule A, Gearhardt AN. Curr Addict Rep 2014;1:193-204; Burrows T et al. Behav Sci (Basel) 2017;7(3):54. Foods With High Glycemic Index Create Rapid Shifts in Metabolic Fuels That May Lead to Food Addiction

Lennerz B, Lennerz JK. Clin Chem 2018;64(1):64-71; Adams RC et al. Nutrients 2019;11(9):2086; Gardner A et al. In: Labster Virtual Lab Experiments: Basic Biochemistry. Springer Spektrum, Berlin, Heidelberg, 2019. Ketogenic Diet for Obese BED Patients With Food Addiction Symptoms Seeking Weight Loss

Case series of obese patients with BED and food addiction symptoms being treated with low-carbohydrate (<30 g/day) ketogenic diets for ≥ 6 months

• 54-year-old African American • 34-year-old Caucasian man • 62-year-old Caucasian woman woman • After 6 months of diet, reported no • After 9 months of treatment • After 6 months of diet, reported no binge episodes, food addiction reported only 1 binge episode, more binge eating, continued symptoms were almost completely reduction in food addiction obsessive thoughts over food that resolved, and lost 20.4 kg symptoms and lost 10.9 kg she could resist, and lost 18.1 kg • Sustained diet and improvements on • Maintained diet and weight loss at binge eating and food addiction 12 months symptoms at 13 months

Carmen M et al. J Eat Disord 2020;8:2. Treating Addiction With Repetitive Transcranial Magnetic Stimulation (rTMS)

p=0.004

Findings from meta-analysis of randomized controlled trials and controlled clinical trials (18 studies; n=425) examining effect of high-frequency rTMS to dorsolateral prefrontal cortex in individuals with addiction, eating disorders, or obesity.

Song S et al. Brain Stimul 2019;12(3):606-18. Summary

•BED is the most common eating disorder and is characterized by high rates of psychiatric and metabolic comorbidities •Barriers to diagnosis include poor communication and lack of awareness from patients and clinicians •BED treatment should be focused on reducing binge-eating behavior and thereby reducing the risk of medical and psychiatric complications •Best evidence-based treatments include CBT, IPT, SSRIs, and lisdexamfetamine Posttest Question 1

Lilly is a 26-year-old woman who reports a sense of lack of control over her eating and a deep sense of guilt following bouts of overeating. She avoids eating around other people because she is embarrassed about the amount of food she eats and how rapidly she consumes it. Lilly reports this behavior and her feelings about it occur at least once a week and have persisted for at least half a year.

What additional information is required for a diagnosis of binge-eating disorder?

A. Her body mass index B. Her degree of concern with her body shape and weight C. Whether she engages in compensatory behaviors to avoid gaining weight D. Whether she eats when she is not physically hungry Posttest Question 2

Marcos has recently been diagnosed with moderate binge-eating disorder and is seeking treatment. Which therapy option demonstrates the best evidence regarding efficacy for treating binge-eating behaviors?

A. Behavioral weight loss therapy B. Dialectical behavior therapy C. Psychodynamic therapy D. Cognitive behavioral therapy