Binge-eating disorder and obesity - A combined treatment approach

Ms. A. was a 38-year-old, unmarried, black personnel manager who presented for long-standing obesity and binge eating since age 11 years. At a height of 1.62 m, she weighed 131.4 kg (body mass index [BMI], 39.7), having gained about 36 kg over the past year in the context of increased binge eating. On presentation, she was binge eating large amounts of dinner, dessert, and snack foods nearly every day, usually in the evening. In addition to her diagnoses of binge-eating disorder and obesity, both of which caused Ms. A. great distress, she also suffered from a major depressive episode of 1.5 years' duration that had improved somewhat in recent months. Although Ms. A. functioned well in her friendships and at her job, she was not dating and avoided wearing shorts or swimsuits, even at the cost of missing out on otherwise enjoyable activities. Ms. A.'s medical history was significant for hypertension, which was controlled with medication. An examination of Ms. A.'s past history revealed that she believed she had been singled out in her family from an early age as the "chubby" daughter and was treated differently from her siblings at meals and snacks. She was enrolled in her first weight-loss program at age 11 or 12 years, and her binge eating began shortly thereafter. She began to cycle through periods of weight loss of 11.25 to 40.5 kg while participating in weight-loss programs or strict diets alternating with periods of uncontrolled binge eating and overeating of "fast food," during which she regained her lost weight. In fact, Ms. A. reported that her weight had rarely been stable and was always either on the upswing or on the downswing. The case of Ms. A., which has been described in greater detail elsewhere,(10) illustrates some of the difficulties in working with patients who suffer from obesity and binge-eating disorder (BED). On one hand, Ms. A's obesity was causing her a tremendous amount of subjective distress, interfering with her participation in pleasurable activities, and quite probably was an important contributor to her hypertension, one of the most common of the comorbid disorders associated with obesity.(8) On the other hand, Ms. A's many attempts to manage her obesity through conventional means had led only to a demoralizing cycle of weight loss and regain, periods of uncontrolled binge eating, and continued preoccupation with weight and appearance. Based on her history, it seems likely that Ms. A's ongoing weight-related distress and periodic attempts to rescue her self-esteem by short-term unsustainable weight loss may have contributed importantly to the maintenance if not the onset of her BED.