Binge eating disorder treatment controversies

To the Editor

The Australia and New Zealand Academy for Eating Disorders (ANZAED, 2018) draws attention to binge eating disorder (BED), a new entity in Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5). They raise two important and controversial BED treatments for discussion.

First, they report on the introduction of a new medication designed to treat BED in adults – lisdexamphetamine (LDX), a long acting once-daily inactive prodrug of dexamphetamine and the only medication authorised by the Therapeutic Goods Administration (TGA) to treat BED. As for all medications, the authors point out that it should be used judiciously; it is, however, inaccurate for them to state that LDX is ‘contraindicated’ for bulimia nervosa (BN). The LDX Product Information confirms that this is not so. While it is true that LDX is not indicated for BN according to the TGA, this is at a different level of LDX avoidance necessitated by the term ‘contraindicated’, which has much stronger clinical and medicolegal implications.

My second concern (and I thank ANZAED for raising the issue) is whether or not to tackle weight loss in overweight patients, a relevant topic as the majority of BED patients are overweight/obese. While employing weight loss techniques for overweight patients may seem like an obvious approach, critics argue that Behavioural Weight Loss (BWL) programmes have limited success, and there is concern that restricted diets may fuel future eating disorders, especially those involving rebound binge eating.

The argument goes, therefore, that it is best to avoid talk about weight loss and instead provide ‘clinical interventions that aim to inoculate individuals who are in larger bodies against effects of the stigma to which they are exposed’ (ANZAED, 2018). That is, patients should accept their overweight status, eschew negative connotations about their size and be as healthy as possible at that weight – this clinical view being known as Health At Every Size (HAES; Bacon, 2010).

When weighing the merits of the two approaches, it may be helpful to consider the corollary of HAES for patients who are significantly underweight and suffering from anorexia nervosa. As clinicians, would we abandon our efforts to help these patients to gain weight and instead use clinical interventions to help them adjust to a stigmatising world?