Working with patients who struggle with obesity, I see how often excess weight and disordered eating overlap. The two get treated as separate problems, sometimes as opposites. Plenty of people live at the intersection, and ignoring that connection makes treatment less effective and occasionally harmful.

Eating disorders are psychiatric conditions in which eating patterns or related behaviors disrupt health or functioning (APA, DSM-5-TR, 2022). They affect people across all ages, genders, and body sizes. The DSM-5-TR describes anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant or restrictive food intake disorder, and others. Each has distinct features. All carry real medical and psychological risk.

Binge eating disorder matters most in this conversation. It is the most common eating disorder in the United States. Patients describe episodes of eating large amounts with a loss of control, followed by guilt, shame, or depression, without the vomiting or other compensatory behaviors seen in bulimia. Lifetime prevalence runs around 0.85% of U.S. adults, with 12-month prevalence near 0.44% (Udo & Grilo, Biol Psychiatry, 2018; Hudson et al., Arch Gen Psychiatry, 2007). Among patients seeking behavioral weight loss treatment, roughly one in ten meet criteria (Chao et al., Obesity, 2017). Among adults presenting for bariatric surgery, meta-analytic estimates using DSM-5 criteria put it near 14% (Hilbert et al., Int J Eat Disord, 2020).

Why does this matter? Untreated binge eating disorder makes weight loss programs harder to sustain. Patients drop out more often, regain faster, and carry higher rates of depression, anxiety, and substance use. The metabolic toll shows up as more diabetes and hypertension. Identifying it early lets us adapt care, often by starting with cognitive behavioral therapy or another evidence-based treatment before any weight loss effort.

Eating disorders leave physical findings, and a fair number of them are visible on a video call. Dry skin, thinning hair, and the fine body hair of anorexia are all things a patient can show on camera. Parotid enlargement in bulimia is visible. Dental enamel erosion isn’t, and neither are the electrolyte abnormalities that matter most, which is where labs and a low threshold for in-person referral come in. Severe cases can develop life-threatening arrhythmias. Binge eating disorder is more often associated with metabolic changes, elevated liver enzymes and worsening insulin resistance. Psychiatric comorbidity is frequent across the whole spectrum, including depression, anxiety, PTSD, and ADHD (Hilbert et al., Psychol Med, 2014).

It is a mistake to think only thin patients have eating disorders. Many patients with obesity have restrictive patterns, obsessive food thoughts, or emotional eating cycles. I have seen patients try extreme diets, binge during periods of stress, then spiral into weight cycling. Others present with nutrient deficiencies despite high calorie intake. Body size rules an eating disorder neither in nor out.

Screening is where this gets caught. The SCOFF questionnaire and the Eating Disorder Screen for Primary Care are short and practical. Even plain questions about body image, eating patterns, or feeling out of control with food will surface problems. When the psychiatric history includes depression, trauma, or substance use, suspicion should go up.

Treatment requires integration. For binge eating disorder, first-line options include cognitive behavioral therapy, interpersonal therapy, and dialectical behavior therapy (Brownley et al., Ann Intern Med, 2016; Grilo et al., Curr Obes Rep, 2023). Lisdexamfetamine, SSRIs, and topiramate help some patients. These approaches reduce binge episodes and rarely produce significant weight loss, which is worth saying to patients directly so nobody is disappointed by a treatment that is working. Obesity care gets layered in once eating behaviors stabilize. Dietitians, primary care, psychiatry, and behavioral health need to be working the same case. Heavy emphasis on BMI or food rules can backfire by reinforcing disordered thinking.

Sequencing depends on the condition. In anorexia, the priority is weight restoration and psychiatric treatment, never weight reduction. For bulimia, obesity treatment waits until binge-purge behaviors are controlled. In binge eating disorder, obesity treatment can follow once episodes are reduced and things are stable. For ARFID, individual assessment guides the approach. In every case the eating disorder comes first while symptoms are active. Starting weight loss treatment too early worsens the disorder, damages trust, and blocks recovery (Mehler et al., J Eat Disord, 2011).

Recognizing that obesity and eating disorders coexist changes how we practice. It moves the focus from weight to whole-person health. Patients need care addressing both the physical and psychological sides, which means helping them repair their relationship with food and body while long-term medical outcomes improve.

Scott Rennie, D.O.

References:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). 2022.

2. Udo T, Grilo CM. Prevalence and Correlates of DSM-5-Defined Eating Disorders in a Nationally Representative Sample of U.S. Adults. Biol Psychiatry. 2018;84(5):345-354. https://pubmed.ncbi.nlm.nih.gov/29859631/

3. Hudson JI, et al. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2007;61(3):348-358. https://pubmed.ncbi.nlm.nih.gov/16815322/

4. Chao AM, et al. Obesity (Silver Spring). 2017;25(4):713-720.

5. Hilbert A, et al. Meta-analysis on the long-term effectiveness of psychological and medical treatments for binge-eating disorder. Int J Eat Disord. 2020;53(9):1353-1376. https://pubmed.ncbi.nlm.nih.gov/32583527/

6. Hilbert A, et al. Psychol Med. 2014;44(15):3239-3250.

7. Brownley KA, et al. Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis. Ann Intern Med. 2016;165(6):409-420. https://pubmed.ncbi.nlm.nih.gov/27367316/

8. Grilo CM, et al. Curr Obes Rep. 2023.

9. Mehler PS, et al. J Eat Disord. 2011.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.