US Pharm. 2021;46(2):36-38.

Emotional eating refers to the tendency to overeat in response to negative emotions. Eating is used as a way to suppress or soothe emotions, such as stress, anger, fear, sadness, loneliness, or boredom. Emotional eating was first reported to be significantly related to bulimia, supporting the hypothesis that emotion is a factor in overeating in bulimic patients.¹ Major life events or, more commonly, the hassles of daily life can trigger negative emotions that lead to emotional eating and disrupt weight-loss efforts. Emotional eating contributes to binge eating episodes, and persons with binge eating disorder (BED) have a significantly greater tendency to eat in response to negative circumstances.¹

This column will briefly distinguish between binge eating and emotional eating and will discuss signs and symptoms, causes, and current medical and psychological treatments.

BINGE EATING

BED is the most common eating disorder in the United States, with a lifetime prevalence of approximately 3.5% in adult women, 2.0% in adult men, and 1.6% in adolescents. BED is characterized by the consumption of a very large amount of food in a relatively short period of time, and often the individual eats so fast that he or she is not aware of what is being eaten or how it tastes. While binging, a person feels out of control and is unable to stop eating even though he or she likely wants to stop.² Persons with BED usually eat even when they are not hungry, and often to the point of feeling uncomfortably full, nauseated, or sick. Those who binge are typically unhappy about their behavior, and most episodes occur alone in a private setting, such as a bedroom, office, or automobile.²

The causes of BED are unknown, but genetics, biological factors, long-term dieting, and psychological issues increase the risk. Although people of any age can suffer from BED, the condition is most prevalent in the late teen years to early 20s. A number of factors increase the risk of developing BED.^2,3

Family Background: Individuals may have an eating disorder if their parents or siblings have (or had) an eating disorder. This indicates that genes enhance the risk of eating-disorder development.^2,3

Dieting: Dieting or restricting calories during the day may trigger an urge to binge eat, especially if the person suffers from depression. Many people with BED have a history of long-time dieting.^2,3

Psychological Issues: Triggers for binging include stress, poor body image, and the availability of preferred binge foods. Unfortunately, many people with BED have negative feelings about themselves, including their accomplishments and skills.^2,3

EMOTIONAL EATING

Emotional eating is the tendency to respond to stressful and difficult feelings by eating, even in the absence of physical hunger. Emotional eating or emotional hunger often manifests as a craving for high-caloric or high-carbohydrate foods with minimal nutritional value. These foods, often referred to as comfort foods, include ice cream, cookies, chocolate, chips, french fries, and pizza, among others. About 40% of people tend to eat more when exposed to stress, 20% experience no change, and 40% eat less. Consequently, stress is associated with both weight gain and weight loss.^2,4 Whereas emotional eating can be a symptom of atypical depression, persons without clinical depression may engage in this behavior in response to temporary negative feelings or chronic stress.²

The primary difference between emotional eating and binge eating is in the amount of food consumed. By definition, binge eating refers to eating to a highly uncomfortably full point, whereas emotional eating may involve lower caloric consumption or irregular meal volumes. Emotional eating may also be part of an emotional disorder, such as depression, bulimia, or other mental illnesses.^2,4

Emotional eating is thought to result from a number of factors rather than a single cause. Some research shows that girls and women are at higher risk for emotional eating and therefore at higher risk for eating disorders. However, other research indicates that, in some populations, men are more likely to eat in response to feelings of depression or anger and women are more likely to eat excessively in response to failure of a diet.⁴

The pathophysiology of emotional eating is insufficiently known. Glucagon-like peptide 1 (GLP-1), a postprandial hormone, plays a role in feeding behavior by signaling satiety in the brain. GLP-1 receptor agonists, which are used to treat type 2 diabetes, promote weight loss. Many studies have investigated the association between emotional eating and responses to food cues in brain areas involved in satiety, as well as GLP-1 receptor agonist–induced effects on these brain responses.⁵

Cortisol’s Role

Cortisol has been termed “the stress hormone” because excess cortisol is secreted during times of physical or psychological stress, and the normal pattern of cortisol secretion (with levels highest in the early morning and lowest at night) can be altered. This disruption of cortisol secretion not only can promote weight gain, but also can influence where on the body excess fat develops. Some studies have shown that stress and elevated cortisol tend to cause fat deposition in the abdominal area. This fat deposition is strongly correlated with the development of cardiovascular disease, including heart attacks and strokes.⁶

Part of the stress response often includes increased appetite to supply the body with the fuel it needs for the fight-or-flight response, resulting in cravings for so-called comfort foods. People who have been subjected to chronic rather than short-term stress (e.g., job, school, or family stress or exposure to crime or abuse) are at risk for having a chronically high cortisol level, which contributes to the development of chronic emotional-eating patterns.⁶

TREATMENT

The goals for treatment of BED are to reduce eating binges and to achieve healthy eating habits. Because binge eating can correlate with negative emotions, treatment may also address any other mental-health issues, such as depression.^3,4,7

Psychotherapy

Whether in individual or group sessions, psychotherapy can help teach patients how to exchange unhealthy habits for healthy ones and reduce binging episodes.^3,4,7 Psychotherapy is first-line treatment and includes three major types.

Cognitive Behavioral Therapy (CBT): CBT may help patients cope better with the factors that can trigger binge eating episodes, such as negative feelings about their body or depressed mood. CBT can also lead to an improved sense of control over behavior and can help regulate eating patterns.^3,4,7

Interpersonal Psychotherapy: This form of therapy is a reasonable alternative to CBT as first-line treatment for BED. According to the theoretical foundation of interpersonal psychotherapy, binge eating results from an unresolved problem in at least one of four possible areas: grief, interpersonal-role dispute, role transition, and interpersonal deficit. Interpersonal psychotherapy focuses on relationships with other people, with the goal of improving interpersonal skills (how the patient relates to others, including family, friends, and coworkers). This may help reduce binge eating that is triggered by problematic relationships and unhealthy communication skills.^3,4,7

Dialectical Behavioral Psychotherapy: Dialectical behavior therapy consists of teaching skills for management of problematic behaviors, such as binge eating, that are associated with emotional dysregulation. This type of therapy includes protocols for managing therapy-disrupting behavior and more severely affected patients who exhibit self-injurious and life-threatening behavior. Dialectical behavior therapy promotes skills related to mindful eating, emotional regulation, and the management of unpleasant or painful circumstances and feelings associated with binge eating.^3,4,7

Medications

Although medication is useful for treating BED, it is generally regarded as less efficacious than psychotherapy; therefore, most patients may prefer psychotherapy. However, pharmacotherapy may be less time-consuming or less expensive. On that basis, it is reasonable to employ pharmacotherapy as first-line treatment for patients who prefer medication and decline psychotherapy, as well as for those who do not have access to psychotherapy. It should be noted that although the following agents can be helpful in controlling binge or emotional eating episodes, they may not have much impact on weight reduction.^4,8

Lisdexamfetamine Dimesylate (Vyvanse): Vyvanse, which is used to treat attention-deficit/hyperactivity disorder, is the first FDA-approved drug for treatment of moderate-to-severe BED in adults. This stimulant can be habit-forming and abused. Common side effects include dry mouth and insomnia, but more serious side effects can occur.^4,8 In adults and adolescents aged 18 years or older, the initial dosage is 30 mg once daily in the morning; it may be titrated in 20-mg increments at weekly intervals to a target dosage of 50 mg to 70 mg once daily (maximum, 70 mg/day). The drug should be discontinued if binge eating does not improve.^4,8

Topiramate (Topamax): This anticonvulsant has been found to reduce binge eating episodes. However, because side effects such as dizziness, nervousness, sleepiness, and trouble concentrating can occur, patients should discuss the risks and benefits with their healthcare provider.^4,8 The initial dosage is 25 mg once daily, followed by a gradual increase in progressively larger increments of 25 mg to 100 mg at intervals of 1 week or longer based on response and tolerability, to a maximum of 400 mg per day.^4,8

Antidepressants: Selective serotonin reuptake inhibitors (e.g., fluoxetine and sertraline) are used to treat binge eating because of their efficacy and tolerability. Dosing is comparable or greater than that usually used for unipolar major depression, and titration intervals are comparable.^4,8

Weight-Loss Programs

Many people with BED have a history of failed attempts to lose weight on their own. However, weight-loss programs typically are not recommended until the BED is treated because dieting may trigger more binge eating episodes, making weight loss more difficult. Weight-loss programs, when deemed appropriate, are generally used under medical supervision to ensure that nutritional requirements are met. Weight-loss programs that address binge triggers can be especially helpful in patients also receiving CBT.^2,7

REFERENCES

1. Brownley KA, Berkman ND, Peat CM, et al. Binge-eating disorder in adults: a systematic review and meta-analysis. Ann Intern Med. 2016;165:409-420.
2. Binge-eating disorder. www.mayoclinic.org/diseases-conditions/binge-eating-disorder/symptoms-causes/syc-20353627. Accessed January 21, 2021.
3. Wilson GT, Wilfley DE, Agras WS, Bryson SW. Psychological treatments of binge eating disorder. Arch Gen Psychiatry. 2010;67:94-101.
4. Sysko R, Devlin M. Binge eating disorder in adults: overview of treatment. UpToDate. Waltham, MA: UpToDate; 2020. www.uptodate.com. Accessed January 21, 2021.
5. Da Porto A, Casarsa V, Colussi G, et al. Dulaglutide reduces binge episodes in type 2 diabetic patients with binge eating disorder: a pilot study. Diabetes Metab Syndr. 2020;14:289-292.
6. Lee DY, Kim E, Choi MH. Technical and clinical aspects of cortisol as a biochemical marker of chronic stress. BMB Rep. 2015;48:209-216.
7. Kass AE, Kolko RP, Wilfley DE. Psychological treatments for eating disorders. Curr Opin Psychiatry. 2013;26:549-555.
8. Brownley KA, Peat CM, La Via M, Bulik CM. Pharmacological approaches to the management of binge eating disorder. Drugs. 2015;75:9-32.

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