Eating disorders (EDs) are psychiatric disturbances characterized by abnormal or disturbed eating behaviors that are associated with medical and psychological complications. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) currently classifies eating disorders into three primary disorders: anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) [1].
BED is defined as recurrent ingestion of an unusually large amount of food in a discrete period of time (e.g., a 2 h period). The DSM-5 diagnostic criteria for BED include a lack of control over the urge to overeat, a minimum of one episode of binge eating per week for three consecutive months, and feelings of marked distress and guilt. Furthermore, three or more characteristics are associated with BED: (i) eating rapidly, (ii) eating when not hungry, (iii) eating until uncomfortably full, (iv) eating in secrecy; to avoid being embarrassed, and (v) negative emotions after overeating. The severity of the disorder, which is determined by the number of episodes per week, has 4 classes: mild, moderate, severe and extreme. Unlike AN and BN, BED individuals are not concerned with their body image as a core or mandatory diagnostic criterion, but it may be present and not followed by compensatory actions [1,2,3].
BED peaks in later adolescence and young adulthood [4]. According to some prospective studies, uncontrolled eating with bingeing nature during childhood, whether objective or subjective, predicts later development of BED and may lead to excess weight gain and metabolic dysfunction in susceptible youth [5].
BED has the highest prevalence of all EDs [6]. A study was conducted on Saudi women to measure abnormal binge eating attitudes reported a prevalence of BED of 18.1% [7]. Additionally, in Palestine, a study aimed at measuring the prevalence of BED among female college students showed that 50% of the participants had binge eating symptoms [8].
BED is known to be more prevalent in women than in men [9]. Low self-esteem linked with body image is a well-established risk factor predicting the potentiality of BED in women than in men [10]. In particular, the likelihood of women having body image dissatisfaction, low self-esteem and perfectionism is higher than that of males. Constant worries and excessive concerns about error occurrence may induce binge eating behavior [11].
Since the discovery of oil, a substantial sociocultural revolution has taken place in the Arabian Gulf countries, resulting in new dietary habits which in turn are believed to be the reason behind the gradual increase in noncommunicable diseases, including EDs. Moreover, Western cultural exposure, especially through social media platforms, sets specific criteria for an ideal body image that displays a greater risk for psychiatric disorders, such as EDs [12]. It is believed that cultural factors attribute to the increased risk of EDs, e.g., peer and familial pressure regarding an individual’s physical appearance [8].
The association between BED and obesity has become more pronounced: the prevalence of BED was found to increase with the degree of obesity [13]. BED is repeatedly linked to considerable weight gain, and it is thought to result from both uncontrolled compulsive eating and binge eating without compensatory behaviors [14], predisposing individuals with BED to obesity and its physical and psychological health problems. In two studies, Latinos with a Body Mass Index (BMI) greater than 40 and Asian Americans with a BMI greater than 30 were found to have a significantly higher lifetime risk of BED [15].
Studies focusing on obesity and BED were carried out in the Kingdom of Saudi Arabia. One study included women receiving treatments for obesity, and 19%-69% had binge eating episodes. Another study was carried out with a sample classified according to each candidate’s BMI and obesity stage; of all the participants with binge eating symptoms, 23.5% were severely obese and 19.2% were mild to moderately obese [7]. Consequently, obese participants showed increased appetite and abnormal eating attitudes under emotional conditions and stress that were in relation to their symptoms of BED.
BED appears to be preceded by multiple mental, physical, and social risk factors that are widely shared with other EDs [4]. Formal genetic studies indicated that familial and genetic factors were risk factors for BED [15]. A review of the BED literature in the clinical setting showed that approximately 30–80% of individuals who binge eat have lifetime comorbid anxiety or mood disorders. Furthermore, BED significantly raises the risk of developing major depression, bipolar disorder, substance abuse and obsessive–compulsive disorder [16]. Compared to people who are not experiencing EDs, individuals with BED specifically are at higher risk of developing some psychological impairments that could be related to autonomy, environmental mastery, self-esteem and emotional regulation [8]. According to a systematic review of the literature, a significant relationship between BED and depression was found in 10 of 14 studies [17]. Depression is considered both a risk factor for BED and a potential cause [4]. The association between the severity of depressive symptoms and the likelihood of responding to group cognitive behavioral therapy among people with BED has been studied, and the results showed that participants with mild or no depressive symptoms were more likely to respond to therapy than those with severe depressive symptoms [18]. Another study conducted in South Korea on the relationship between BED and depressive symptoms showed that nurses with BED were 1.8 times more likely to have more severe depressive symptoms [19]. This emphasizes that depressive symptoms are considered risk factors for BED and vice versa. To further prove this, a study designed to evaluate the bidirectional association between depressive symptoms and eating disorders in early adolescence was carried out and showed that there was a reciprocal association between binge eating and depressive symptoms [20]. Moreover, another study of women enrolled in weight loss programs showed that participants with BED tended to suffer from more severe depression than those who did not have BED [21]. The same study also concluded that participants with higher BED scores showed more severe depressive symptoms [21].
Anxiety disorders are found in 30–80% of people who have BED [8]. A study conducted in Brazil showed a direct relationship between anxiety and BED symptoms. The same study showed that individuals with anxiety were more likely to develop severe BED symptoms [22]. Another study aimed to examine the relationship between insomnia symptoms and BED in people with an underlying psychiatric condition and showed that the severity of insomnia in patients with BED was significantly higher than that in patients with no history of eating disorders [23]. A study found that BED and BN had moderate/marked functional impairment in work/school, social and family life. Moreover, individuals with BED and BN had significantly high number of days lost from work/school as well as underproductive days at work or school [24].
Furthermore, a study was carried out in a population of patients with diabetes to measure the prevalence rate of overeating symptoms, subclinical binge eating (SBE) and clinical binge eating (CBE) and their association with quality of life, anxiety, depression, HbA1c levels and BMI. The prevalence rates of overeating symptoms, SBE and CBE were 8.4%, 18% and 7.9% respectively. Youth with CBE symptoms scored had the highest scores for anxiety and depression symptoms [25].
BED is associated with a range of medical complications identified in representative community samples. For example, people with BED are at higher risk of developing hypertension along with diabetes mellitus type 2 (DM-2). Moreover, people with BED are more likely to develop metabolic syndrome and dyslipidemia than people who do not suffer from any ED [16]. In a study that examined lifetime medical correlates of eating disorders (AN, BN, and BED), individuals with BED had higher lifetime prevalence of many medical conditions (e.g., diabetes mellitus, hypertension, high cholesterol, high triglyceride, arthritis, sleep problems, and bowel problems) compared to AN and BN groups [26]. Another study displayed a significant association of BED with asthma, arthritis, spine problems, chronic headache, chronic muscle pain, and gastroesophageal reflux independent of individuals body weight [24].
Multiple treatment interventions have been explored for the treatment of BED with varying degrees of support. Cognitive behavior therapy (CBT) and CBT-guided self-help are the two treatment modalities that have shown the best efficacy in terms of the reduction in the frequency of binge eating. However, other proposed options including interpersonal psychotherapy (IPT), selective serotonin reuptake inhibitors (SSRIs), and lisdexamfetamine, have received modest support [27].
Physicians and healthcare professionals show reluctance to diagnose BED despite it being the most common ED [28]. Underestimation of undiagnosed or untreated BED is noticed more in patients who have other associated medical conditions, such as DM-2, metabolic syndrome, and some mental disorders, such as depression or anxiety [16].
The aim of this study was to estimate the prevalence and associated factors of BED in the Kingdom of Bahrain. Moreover, conducting a study in the Middle East, a region where studies of EDs in general are scarce, would be scientifically valuable. The findings of the present study will address this neglected topic and will draw more attention from the public health and primary healthcare authorities in Bahrain to the importance of eating disorders in general and BED in particular to establish screening programs and raise awareness among the population.
