Clarify and Conceptualize Binge Eating in Children
A better understanding of what constitutes binge eating among youths may produce more consistent findings across studies and help target children in need of intervention for overweight or more severe eating disturbance.
Researchers typically base measures that assess disturbed eating patterns upon adult versions that contain probes relevant to adults with binge eating but not necessarily to children. In particular, the construct and experience of “loss of control” requires further investigation, particularly given that some children may not understand the concept, nor may they comfortably admit to feeling “out of control” or “unable to stop” once having started eating. As such, exploratory research is required to capture the qualitative aspects of aberrant eating episodes described by children.
Analyzing a number of behavioral, physical, and emotional variables potentially surrounding aberrant eating episodes has been suggested as one method to elucidate eating patterns among overweight individuals (Tanofsky-Kraff & Yanovski, 2004). Such methods may be especially germane to studying children’s eating episodes and may provide a child-specific phenotype that is reflective of adult binge eating.
Research should also focus on the importance of the criterion of a “large amount of food given the context” to describe binge episodes in children.
Some data already suggest that the experience of LOC among youths, as opposed to episode size, may be the more salient factor associated with emotional distress and body composition (Morgan et al., 2002; Tanofsky-Kraff et al., 2004, 2005).
Furthermore, because nutritional needs change in growing children, quantifying whether a given amount of food is unambiguously large given the age and sex of a child as well as the context of the eating episode is not only challenging but often disputable. In taking a conservative approach such as that required in administering the EDE (Fairburn & Cooper, 1993), if an amount of food described during an episode is not unambiguously large, researchers will often code the amount as “not large.” Therefore, the quantity of food that constitutes “binge” episodes in children is often not much larger than an amount of food considered “not unambiguously large.”
In a 2003 review of the literature on binge eating in children and adolescents, Marcus and Kalarchian proposed provisional BED research criteria for children 14 years and younger (Table 4.2).
Table 4.2. Provisional Research Criteria for Diagnosing Binge Eating Disorder in Children (Marcus & Kalarchian, 2003)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Food seeking in absence of hunger (e.g., after a full meal).
2. A sense of lack of control over eating (e.g., endorse that, “When I start to eat, I just can’t stop”).
B. Binge episodes are associated with one or more of the following:
1. Food seeking in response to negative affect (e.g., sadness, boredom, restlessness).
2. Food seeking as a reward.
3. Sneaking or hiding food.
C. Symptoms persist over a period of three months.
D. Eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Supporting some data among child samples (Morgan et al., 2002; Tanofsky-Kraff et al., 2004), criterion A1 of their proposed diagnosis removes the requirement of a “large amount of food” being ingested in the definition of a binge, but the experience of LOC is retained. Inclusion of a new requirement of eating “in absence of hunger” (criterion A1) has been suggested as a potentially significant construct in body weight among young children (Faith et al., 2006; Fisher & Birch, 2002).
Using a feeding paradigm, Fisher and Birch examined eating in the absence of hunger among 5-year-old girls at baseline and again two years later. Not only was eating in the absence of hunger a stable trait among girls over time, but girls who ate in the absence of hunger were significantly more likely to be overweight than girls who did not eat in the absence of hunger. Of criterion B, the first symptom, “food seeking in response to negative affect,” has been studied in young children.
Among 5-year-old girls, Carper and colleagues reported evidence of emotional disinhibition of eating in 25% of the sample (Carper, Orlet Fisher, & Birch, 2000). In Stice and colleagues’ study of the emergence of eating disturbance during the first five years of life (Stice, Agras et al. 1999), criterion B3, “sneaking or hiding food,” was examined. Secretive eating was assessed based upon mothers’ responses to the question “Does your child hide any favorite food in his/her room or elsewhere in the house?” During the five-year period, 18.1% of children experienced the emergence of secretive eating.
Furthermore, heightened maternal disinhibition, hunger, body dissatisfaction, and bulimic symptoms as well as elevated maternal BMI and paternal history of overweight were predictors of an increased hazard for the emergence of secretive eating (Stice, Agras et al., 1999). Finally, two recent studies report that loss of control and binge eating are associated with eating in response to negative emotions during middle childhood and adolescence (Goossens et al., 2007; Tanofsky-Kraff et al., 2007). Further data is required to assess the significance and impact of emotional and secretive eating as well as criterion B2, “food seeking as a reward” during childhood.
Only one study has tested Marcus and Kalarchian’s provisional criteria (Shapiro, Hammer, Woolson, & Bullik, 2007). A brief measure designed specifically to assess the proposed criteria was administered to 55 children (aged 5-13 years) seeking weight loss treatment. The authors diagnosed 30% of the sample with BED. Since similar rates of BED are reported in treatment seeking adults (Spitzer et al., 1991; Spitzer, Yanovski, & Wadden et al. 1993), these preliminary findings may suggest that Marcus and Kalarchian’s provisional criteria for BED are more suitable for children with binge eating problems than those proposed in the DSM-IV-TR (APA, 2000).
In summary, researchers should continue to think broadly in creating novel methods to capture the construct of aberrant eating in young children.
Uniformed Services University of the Health Sciences and National Institute of Child Health and Human Development, Bethesda, MD 20892.
This research was supported by the Intramural Research Program of the NIH, grant ZO1-HD-00641 (NICHD, NIH) to Dr. J. Yanovski.