Research Article - Clinical Investigation (2019) Volume 9, Issue 2

Binge eating disorder among obese/overweight in Pakistan: Under-diagnosed, undertreated and misunderstood

Corresponding Author:
Madeeha Malik
Hamdard Institute of Pharmaceutical Sciences
Hamdard University Islamabad, Pakistan
E-mail: [email protected]

Submitted: 28 January 2019; Accepted: 04 April 2019; Published online: 08 April 2019

Abstract

Introduction: Obese persons with BED have compromised functioning mostly in psycho-social aspects of Health-Related Quality of Life (HRQoL) as poor physical functioning is related to obesity. Despite the higher prevalence of BED compared with other eating disorders, lack of understanding of BED by physicians and inadequate physician-patient communication regarding BED may result in it’s under diagnosis.

Objective: The objective of the study was to assess binge eating disorder among overweight/obese in two major cities of Pakistan.

Method: A descriptive cross-sectional study design was used. A pre-validated data collection tool Binge Eating Disorder Screener-7 (BEDS-7) was distributed to a sample of 382 obese/overweight individuals. Binge Eating Disorder Screener-7 (BEDS-7) questionnaires is comprised of seven questions that directly evaluate the patient’s eating patterns and behaviors for binge eating disorder. Convenient sampling technique was used to select the respondents. After data collection, the data was cleaned, coded and entered in SPSS version-21. Chi-square test (p ≥ 0.05) was performed to find out the association between different variables.

Results: The results revealed that nearly half of the respondents of the overweight/obese had an eating disorder among them. Out of the total sample 35.1% (n=134) respondent, agreed that they had episodes of excessive overeating during the last 3 months. The results highlighted that 64.9% (n=248) had no binge eating disorder while 15.7% (n=60) of the respondents had moderate binge eating disorder and 14.9% (n=57) had severe binge eating disorder.

Conclusion: The current study concluded that moderate binge eating disorder was seen among most of the obese individuals but BED in most of the cases goes undiagnosed. Binge eating disorder was more common among students and non-smokers. Early detection and evidence-based treatment strategies can help the patients to recover on initial stages and prevent from a further complication of binge eating disorder.

Keywords

Binge eating disorder, Obese, Overweight, Occurrence, Pakistan

Introduction

Binge Eating Disorder (BED) is characterized by regular episodes of binge eating. An individual with Binge Eating Disorder (BED) has compensatory behaviors, such as self-induced vomiting or doing over-exercising after binge eating. This disorder involves two key features; firstly, eating a very large amount of food within a relatively short period of time e.g. within two hours and secondly, loss of control while eating e.g. feeling unable to stop oneself from eating [1]. Despite the higher prevalence of BED compared with other eating disorders, lack of understanding of BED by physicians and inadequate physician-patient communication regarding BED may result in its under-diagnosis [2]. Obese persons with BED have compromised functioning mostly in psycho-social aspects of Health-Related Quality of Life (HRQoL) as poor physical functioning is related to obesity [3]. Beside this eating disorder also influences the mental health of the patients and they seek for treatment interventions focusing on improving mental health domain of HRQoL [4]. Physical activity has been reported as an important treatment target for individuals with BED [5].

Pakistan has been ranked 9th among 188 countries facing obesity challenge around the globe [6]. Onequarter of the Pakistani population has been classified as overweight/obese with alarming prevalence among women and youth [7]. The BDNF rs6265, in the presence of obesity, has been reported to be associated with elevated risk of anomalous metabolic, behavioral and physical traits and obesity-related co-morbidities in Pakistani population [8]. Risk of developing eating disorders indicating females more prone than males has been reported in Pakistan. Most of the eating disorders in Pakistan go undiagnosed. Though, early diagnosis and assessment of eating disorder can provide chances for improved treatment and recovery [9]. However, it will be challenging for the healthcare system of Pakistan for providing eating disorder treatment services with the current infrastructure, facilities, and human resources in the future. Global statistics show a high prevalence of obesity in Pakistan but unfortunately, strategies to control and tackle it are not integrated into the annual healthcare plans [8]. Thus, the general objective of the study was to assess binge eating disorder among overweight/ obese in two major cities of Pakistan. The study findings provide baseline data regarding the current prevalence of binge eating disorder. It will help relevant stakeholders to design effective strategies to evade the incidence of eating disorders as well as improve diagnosis of such disorders, especially among obese/overweight people.

Methodology

The descriptive cross-sectional study design was used to assess binge eating disorder among overweight/ obese in relation to BMI in two major cities of Pakistan. Research approval for the current study was obtained from the Ethical Committee of Hamdard University (Ref. No. HU/DRA/2017/554). Beside this approval was taken from Medical Supretendent of hospitals (OPDs), owner of clinics, fitness centers, and community pharmacies. Written/verbal consent was taken from every respondent. Likewise, the respondents were guaranteed for the secrecy of information. Study sites for this research included OPDs of different health care facilities, community pharmacies, fitness centers and obesity clinics located in twin cities of Pakistan. Study respondents included adults having BMI ≥ 25 or ≥ 30 and categorized as overweight or obese persons respectively, between 18-65 years old; both genders (male vs. female) and who could easily read and write. While a person with physical limitations; bodybuilders; pregnant ladies and those on treatment for a psychological disorder were excluded.

A sample size of the study population was calculated with the help of Raosoft® sample size calculator which came to be 382 to achieve a 95% confidence interval with a 5% margin of error. Convenience sampling technique was used to select the respondents. Data was collected directly from the respondents at their respective facility. A pre-validated data collection tool Binge Eating Disorder Screener-7 (BEDS-7) was used. Binge Eating Disorder Screener-7 (BEDS-7) questionnaires is comprised of seven questions that directly evaluate the patient’s eating patterns and behaviors for binge eating disorder. It is proposed for the screening of BED patients only. The first question is related to the eating pattern while remaining all questions are related to eating behavior. BEDS- 7 scores are weighted sums of only the last five questions. The composite scores range from 0-20 with 0-5 indicating mild disorder; 6-10 moderate; 11-15 severe and 16-20 extreme. Pilot testing was conducted at 10% of the sample size to test the reliability of the tool. The value of Cronbach’s alpha was 0.82 which was satisfactory and considering that 0.68 is the acceptable cut off value. The questionnaires were self-administered to the respondents and collected back on the same day to avoid any biases. After data collection, the data was cleaned, coded and entered in SPSS version-21. Descriptive statistics comprising frequency and percentages were calculated. Chisquare test (p ≥ 0.05) was performed to find out the association between different variables.

Results

Out of 382 respondents, 63.6% (n=243) were males while 36.4% (n=139) were females. Likewise, 43.2% (n=165) were having an undergraduate qualification and were students. Of the total respondents, 52.9% (n=202) were overweight while 47.1% (n=180) were obese. On the other hand, 31.9% (n=122) of the total respondents had a family history of overweight/ obesity while 68.1% (n=260) had no family history of overweight/obesity. Of the total respondents, 47.9% (n=183) were taking carbohydrates and 32.7% (n=125) were taking proteins as weekly major diet portion in their daily lifestyle. A detailed description of demographic characteristics is given in (Table 1).

Indicator Total n (%)
Age
18-30 Y 253 (66.2)
30-40 Y 85 (22.3)
40-50 Y 24 (6.3)
>50 Y 20 (5.2)
Gender
Male 243 (63.6)
Female 139 (36.4)
Marital status
Married 143 (37.4)
Unmarried 239 (62.6)
Qualification
Matriculation 46 (12.0)
Intermediate 63 (16.5)
Under graduate 165 (43.2)
Post graduate 108 (28.3)
Occupation
Govt-employee 37 (9.7)
Private employee 92 (24.1)
Self-employee 35 (9.2)
Un-employee 52 (13.6)
Student 166 (43.5)
Residency
Urban 293 (76.7)
Rural 89 (23.3)
BMI
Overweight (25-29 kg/m2) 202 (52.9)
Obese (30 and above kg/m2) 180 (47.1)
Previously on any diet plan
Yes 53 (13.9)
No 329 (86.1)
Regularly walk and exercise
Yes 103 (27.0)
No 279 (73.0)
Using anti-obesity drug
Yes 7 (1.8)
No 375 (98.2)
Any disease present
Yes 61 (16.0)
No 321 (84.0)
Overweight/Obesity in family
Yes 122 (31.9)
No 260 (68.1)
Smoking habit
Yes 75 (19.6)
No 307 (80.4)
Weekly major diet portion
Carbohydrates 183 (47.9)
Proteins 125 (32.7)
Fats 74 (19.4)

Table 1. Demographic characteristics of respondents

The results revealed that nearly half of the respondents of the overweight/obese had an eating disorder among them. Out of the total sample 35.1% (n=134) respondent, agreed that they had episodes of excessive overeating during the last 3 months (Table 2).

Indicator n (%)
During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)? Yes 134 (35.1)
No 248 (64.9)

Table 2. Assessment of binge eating disorder among overweight/obese

Of the total respondents having binge eating disorder, 12% (n=46) often had no control on overeating and 12.8% (n=49) sometimes continued eating though they were not hungry. It was also reported that 12.3% (n=47) never felt disgusted with their self or guilty afterward of overeating and 22.5% (n=86) never make their self-vomit, that is a means to control their body shape/weight (Table 3).

Indicator n (%)
During your episodes of excessive overeating, how
often did you feel like you had no control over your
eating (e.g., not being able to stop eating, feel compelled
to eat, or going back and forth for more food)?
Never 28 (7.3)
Sometimes 46 (12.0)
Often 46 (12.0)
Always 14 (3.7)
During your episodes of excessive overeating, how
often did you continue eating even though you were not
hungry?
Never 23 (6.0)
Sometimes 49 (12.8)
Often 48 (12.6)
Always 14 (3.7)
During your episodes of excessive overeating, how
often were you embarrassed by how much you ate?
Never 47 (12.3)
Sometimes 36 (9.4)
Often 39 (10.2)
Always 12 (3.1)
During your episodes of excessive overeating, how
often did you feel disgusted with yourself or guilty
afterward?
Never 47 (12.3)
Sometimes 33 (8.6)
Often 33 (8.6)
Always 21 (5.5)
During the last 3 months, how often did you make
yourself vomit as a means to control your weight or
shape?
Never 86 (22.5)
Sometimes 21 (5.5)
Often 17 (4.5)
Always 10 (2.6)

Table 3. Assessment of severity of binge eating disorder among overweight/obese

The results highlighted that 64.9% (n=248) had no binge eating disorder while 15.7% (n=60) of the respondents had moderate binge eating disorder and 14.9% (n=57) had severe binge eating disorder (Table 4).

Indicator n (%)
No disorder 248 (64.9)
Mild 6 (1.6)
Moderate 60 (15.7)
Severe 57 (14.9)
Extreme 11 (2.9)

Table 4. Interpretation of binge eating disorder among overweight/obese

Results indicated a significant association (p=0.001) was reported between respondents of different occupations as 6.3% (n=24) students had moderate binge eating disorder. Moreover, a significant association (p=0.027) was found among respondents having no smoking habit as 11.8% (n=45) reported moderate binge eating disorder (Table 5).

Variable No disorder Mild disorder Moderate disorder Severe disorder Extreme disorder p-value
n (%) n (%) n (%) n (%) n (%)
Age
18-30 Y 168 (44.0) 2 (0.5) 41 (10.7) 37 (9.7) 5 (1.3) 0.935
30-40 Y 49 (12.8) 4 (1.0) 14 (3.7) 14 (3.7) 4 (1.0)
40-50 Y 16 (4.2) 0 (0.0) 2 (0.5) 4 (1.0) 2 (0.5)
>50 Y 15 (3.9) 0 (0.0) 3 (0.8) 2 (0.5) 0 (0.0)
Gender
Male 153 (40.1) 3 (0.8) 37 (9.7) 40 (10.5) 10 (2.6) 0.097
Female 95 (24.9) 3 (0.8) 23 (6.0) 17 (4.5) 1 (0.3)
Marital status
Married 93 (24.3) 4 (1.0) 19 (5.0) 22 (5.8) 5 (1.3) 0.977
Unmarried 155 (40.6) 2 (0.5) 41 (10.7) 35 (9.2) 6 (1.6)
Qualification
Matriculation 27 (7.1) 0 (0.0) 6 (1.6) 11 (2.9) 2 (0.5) 0.428
Intermediate 44 (11.5) 2 (0.5) 9 (2.4) 7 (1.8) 1 (0.3)
Under graduate 106 (27.7) 3 (0.8) 23 (6.0) 28 (7.3) 5 (1.3)
Post graduate 71 (18.6) 1 (0.3) 22 (5.8) 11 (2.9) 3 (0.8)
Occupation
Govt-employee 19 (5.0) 0 (0.0) 4 (1.0) 13 (3.4) 1 (0.3) 0.001
Private employee 53 (13.9) 2 (0.5) 22 (5.8) 11 (2.9) 4 (1.0)
Self-employee 19 (5.0) 0 (0.0) 5 (1.3) 9 (2.5) 2 (0.5)
Un-employee 37 (9.7) 2 (0.5) 5 (1.3) 7 (1.8) 1 (0.3)
Student 120 (31.4) 2 (0.5) 24 (6.3) 17 (4.5) 3 (0.8)
Residency
Urban 190 (49.7) 0 (0.0) 48 (12.6) 46 (12.0) 9 (2.5) 0.427
Rural 58 (15.2) 6 (1.6) 12 (3.1) 11 (2.9) 2 (0.5)
BMI
Overweight 123 (32.2) 5 (1.3) 4 (1.0) 27 (7.1) 7 (1.8) 0.276
Obese 125 (32.7) 1 (0.3) 20 (5.2) 30 (7.9) 4 (1.0)
Previously on any diet plan
Yes 30 (7.9) 1 (0.3) 14 (3.7) 8 (2.1) 0 (0.0) 0.513
No 218 (57.1) 5 (1.3) 46 (12.0) 49 (12.8) 11 (2.9)
Regularly walk and exercise
Yes 71 (18.6) 0 (0.0) 17 (4.5) 12 (3.1) 3 (0.8) 0.373
No 177 (46.3) 6 (1.6) 43 (11.3) 45 (11.8) 8 (2.1)
Using anti-obesity drug
Yes 6 (1.6) 0 (0.0) 1 (0.3) 0 (0.0) 0 (0.0) 0.208
No 242 (63.4) 6 (1.6) 59 (15.4) 57 (14.9) 11 (2.9)
Any family history of overweight/obese
Yes 75 (19.6) 2 (0.5) 24 (6.3) 18 (4.7) 3 (0.8) 0.545
No 173 (45.3) 4 (1.0) 36 (9.4) 39 (10.2) 8 (2.1)
Smoking habit
Yes 39 (10.2) 3 (0.8) 15 (3.9) 16 (4.2) 2 (0.5) 0.027
No 209 (54.7) 3 (0.8) 45 (11.8) 41 (10.7) 9 (2.5)
Weekly diet pattern having major portion
Carbohydrates 115 (30.1) 3 (0.8) 31 (8.1) 28 (7.3) 6 (1.6) 0.745
Proteins 93 (24.3) 2 (0.5) 11 (2.9) 14 (3.7) 5 (1.3)
Fats 40 (10.5) 1 (0.3) 18 (4.7) 15 (3.9) 0 (0.0)

Table 5. Impact of demographic characteristics on severity of binge eating disorder

Discussion

Binge Eating Disorder is the most common eating disorder found in obese people. The prevalence of BED ranges from approximately 0.3 to 7% in community samples to between 9% and 30% in obesity clinics [9]. The results of the present study showed that the prevalence of binge eating disorder was less among obese/overweight people in twin cities of Pakistan. The respondents suffering from binge eating disorder had no control of overeating and continue eating even if they were not hungry. The disorder was seen common among both genders. Similar findings were reported from a study conducted in USA which also indicated that BED possesses unique characteristics including loss of control on overeating and feel of guilt and shame, which do not more often happen with overeating. BED prevails among both gender frequently associated with overweight [10].

BED represents a public health problem equally important as bulimia nervosa. However, BED remains underdiagnosed in the majority of the patients. This highlight the clinical importance of questioning patients about eating problems even when not included among presenting complaints [11]. The results of the present study reported that most of the respondents had moderate binge eating disorder. The disorder was most commonly observed among students. Similar findings were reported from another study which reported a high prevalence of BED among students. The study also highlighted the need for assessment of self-esteem, child abuse and neglect, and family functions in detail as they are risk factors for EDs and affect the course of treatment [12]. Smoking has been reported as an appetite and weight control method in eating disorders. Smoking in individuals with eating disorders could be motivated more by desires for weight control than nicotine dependence [13]. The results of the present study showed that moderate binge eating disorder was more commonly seen among nonsmokers. In contrary to the current study findings smoking history or status was not associated with eating disorder psychopathology in BED but was significantly associated with depressive symptoms in participants with BED [14,15].

Conclusion

The current study concluded that the occurrence of binge eating disorder is less among obese/overweight people in twin cities of Pakistan. Although, moderate binge eating disorder was seen among most of the obese individual’s BED in most of the cases goes misunderstood, undiagnosed and untreated. Binge eating disorder was more common among students and non-smokers. Early detection and evidencebased treatment strategies can help the patients to recover on initial stages and prevent from a further complication of binge eating disorder. Thus, interventions focused on the psychopathology associated with BED could reduce the influence of emotional nods on binge eating.

References