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  <p class="title-left"><span class="bold"><a id="_idTextAnchor000"></a>Characterization of Binge-Eating Behavior in Individuals With Binge-Eating Disorder in an Adult Population in the United States</span></p>
  <p class="byline-regular">Manjiri Pawaskar, PhD<span class="superscript">a</span>; Kirk Solo, MBA<span class="superscript">b</span>; Jason Valant, BA<span class="superscript">b</span>; Emily Schmitt, BA<span class="superscript">b</span>; Millicent Nwankwo, BA<span class="superscript">a</span>; and Barry K. Herman, MD, MMM<span class="superscript">c,</span><span class="asterisk">*</span></p>
  <div id="abstract"><img src="/publishingimages/new_articles/grey_side_rule.jpg" alt="Vertical divider" />
    <p class="subheads-abstract-head"><span class="semibold">ABSTRACT</span></p>
    <p class="abstract-text"><span class="bold-italic">Objective:</span> Characterize the frequency, duration, and severity of binge-eating behaviors in adults meeting <span class="italic">DSM-5</span> criteria for binge-eating disorder (BED) in a large US community sample.</p>
    <p class="abstract-text"><span class="bold-italic">Methods:</span> A representative sample of US adults from the National Health and Wellness Survey was recruited from an online panel and asked to respond to an Internet survey (conducted in October 2013) that included questions designed to assess binge-eating behaviors in relation to <span class="italic">DSM-5</span> BED diagnostic criteria.</p>
    <p class="abstract-text"><span class="bold-italic">Results:</span><span> Of 22,397 respondents, 344 self-reported meeting </span><span class="italic">DSM-5</span><span> BED criteria (BED respondents). Most BED respondents reported that binge-eating episodes had occurred for the past 7</span>−<span>12 months (61.0%), and 93.6% reported</span><span> </span>≥<span class="thinspace"> </span><span>2</span>−<span>3 binge-eating episodes/wk. All BED respondents reported that “extreme” (52.6%) or “great” (47.4%) distress levels were associated with binge-eating episodes. Among BED respondents who agreed to provide detailed binge-eating behavior data after being invited to respond to additional survey questions, 40.6% reported binge eating on average</span><span> </span><span>&gt;</span><span class="thinspace"> </span><span>1 time/d, and 59.2% reported binge eating 2</span>−<span>3 times/d. For 44.5% of BED respondents, binge-eating duration was 31</span>−<span>60 minutes. BED respondents reported that they “very often” (36.6%) or “often” (34.0%) had urges to binge eat between 7</span><span class="smallcaps">–</span><span>10 </span><span class="smallcaps">pm</span><span>. “Feeling disgusted with oneself, depressed, or guilty afterward” was the most bothersome symptom o</span><span>f b</span><span>inge eating for BED respondents (extremely bothersome: 41.9%).</span></p>
    <p class="abstract-text"><span class="bold-italic">Conclusions:</span> Binge-eating frequency among BED respondents averaged once daily. Most BED respondents exhibited binge-eating behavior for 7–12 months, often with severe symptoms. These findings highlight the disease burden of BED and have potential implications for diagnosing and treating BED.</p>
    <p class="abstract-citation"><span class="italic">Prim Care Companion CNS Disord 2016;18(5):</span><span class="doi italic">doi:10.4088/PCC.16m01965</span></p>
    <p class="abstract-copyright"><span class="italic">© Copyright 2016 Physicians Postgraduate Press, Inc.</span></p>
    <p class="front-matter first"><span class="superscript">a</span>Shire, Global Health Economics and Outcomes Research, Lexington, Massachusetts. Dr Pawaskar and Ms Nwankwo are no longer affiliated with Shire. </p>
    <p class="front-matter"><span class="superscript">b</span>Lexidyne LLC, Colorado Springs, Colorado. Ms Schmitt is no longer affiliated with Lexidyne.</p>
    <p class="front-matter"><span class="superscript">c</span>Shire, Global Medical Affairs, Lexington, Massachusetts. </p>
    <p class="front-matter"><span class="asterisk">*</span><span class="italic">Corresponding author:</span> Barry K. Herman, MD, MMM, Shire, 300 Shire Way, Lexington, MA 02421 <span class="hyperlink">(<a href="mailto:bherman@shire.com">bherman@shire.com</a>)</span>.</p>
  </div>
  <p class="drop-cap-with-body-text"><span class="bold-14pt-for-cap"><span class="bold">A</span></span><span>lthough binge-eating disorder (BED) symptomatology was documented in 1959</span><span class="htm-cite"><a href="#ref1">1</a></span><span> and clinically validated in the early 1990s,</span><span class="htm-cite"><a href="#ref2">2–4</a></span><span> BED was not formally recognized as a distinct eating disorder until the </span><span class="italic">Diagnostic and Statistical Manual of Mental Disorders</span><span>, Fifth Edition (</span><span class="italic">DSM-5</span><span>) was released in 2013.</span><span class="htm-cite"><a href="#ref5">5</a></span><span> According to </span><span class="italic">DSM-5</span><span> criteria,</span><span class="htm-cite"><a href="#ref5">5</a></span><span> BED is characterized by recurrent binge-eating episodes that are associated with a feeling o</span><span>f l</span><span>ack of control over eating and marked distress. At least 3 o</span><span>f t</span><span>he following indicators of impaired control must occur in BED: eating until uncomfortably full, eating a large amount of food when not physically hungry, eating more rapidly than usual, eating alone because of embarrassment, and feelings of disgust, guilt, or depression after binge eating. For a </span><span class="italic">DSM-5</span><span> diagnosis, binge-eating episodes must occur at least once a week for a minimum of 3 months,</span><span class="htm-cite"><a href="#ref5">5</a></span><span> which contrasts with the </span><span class="italic">DSM-IV-TR</span><span> criterion of </span>≥<span class="thinspace"> </span><span>2 times per week for</span><span> </span>≥<span class="thinspace"> </span><span>6 months.</span><span class="htm-cite"><a href="#ref6">6</a></span><span> The </span><span class="italic">DSM-IV-TR</span><span> frequency criterion was chosen to set a high diagnostic threshold in the absence of empirical support for less stringent criteria.</span><span class="htm-cite"><a href="#ref7">7</a></span><span> However, data now support less stringent </span><span class="italic">DSM-5</span><span> criteria.</span><span class="htm-cite"><a href="#ref8">8</a></span><span> Binge-eating episodes in BED must not be associated with recurrent inappropriate compensatory behaviors and must not occur exclusively during the course o</span><span>f b</span><span>ulimia nervosa or anorexia nervosa.</span><span class="htm-cite"><a href="#ref5">5</a></span><span> The </span><span class="italic">DSM-5</span><span> also describes symptom severity criteria on the basis o</span><span>f t</span><span>he number of weekly binge-eating episodes (mild: 1–3, moderate: 4–7, severe: 8–13, extreme: &gt;14), but severity can be adjusted on the basis of other symptoms and the level of functional disability.</span><span class="htm-cite"><a href="#ref5">5</a></span></p>
  <p class="body-text">Two large-scale epidemiologic studies<span class="htm-cite"><a href="#ref9">9</a>,<a href="#ref10">10</a></span> assessed BED prevalence on the basis of <span class="italic">DSM-IV-TR</span> criteria and estimated the 12-month and lifetime prevalence of BED to range from 0.8% to 1.2% and 1.9% to 2.8%, respectively. Given the less stringent <span class="italic">DSM-5</span> diagnostic binge-eating frequency criteria, individuals not meeting <span class="italic">DSM-IV-TR</span> criteria may meet <span class="italic">DSM-5</span> criteria.<span class="htm-cite"><a href="#ref11">11</a></span> Supporting this concept, the Validate Attitudes and Lifestyle Issues in Depression, ADHD and Troubles with Eating (VALIDATE) Internet survey<span class="htm-cite"><a href="#ref12">12</a></span> reported 12-month and lifetime prevalence estimates of BED to be 1.64% and 2.03%, respectively, on the basis of <span class="italic">DSM-5</span> criteria and 1.15% and 1.52%, respectively, on the basis of <span class="italic">DSM-IV-TR</span> criteria in a large, representative sample of US adults.</p>
  <p class="body-text">A fairly large body of research, which extends over more than 2 decades, has described the binge-eating characteristics of individuals meeting <span class="italic">DSM</span> diagnostic criteria for BED. Obese individuals meeting <span class="italic">DSM-IV-TR</span> BED criteria consume more calories than obese individuals without BED when asked to binge eat.<span class="htm-cite"><a href="#ref13">13–16</a></span> Obese individuals with BED also eat for a longer duration of time when asked to binge eat,<span class="htm-cite"><a href="#ref14">14</a></span> report more episodes of overeating and days of overeating,<span class="htm-cite"><a href="#ref17">17</a></span> and consume more evening meals than obese individuals without BED.<span class="htm-cite"><a href="#ref17">17</a></span> Individuals meeting <span class="italic">DSM-IV-TR</span> BED criteria are also 3.6 times more likely to experience postmeal loss of control, after controlling for affective state and caloric intake, than individuals without BED.<span class="htm-cite"><a href="#ref18">18</a></span> Of the 5 indicators of impaired control included in the diagnostic criteria for BED, eating large amounts of food when not hungry and eating alone because of embarrassment are the best predictors of a BED diagnosis.<span class="htm-cite"><a href="#ref19">19</a></span> Furthermore, individuals meeting all of the <span class="italic">DSM-IV-TR</span> criteria for BED except the marked distress criterion exhibited decreased levels of eating disorder pathology and depressive symptoms compared with individuals meeting all <span class="italic">DSM-IV-TR</span> BED criteria.<span class="htm-cite"><a href="#ref20">20</a></span></p>
  <p class="body-text">Although the binge-eating characteristics of individuals meeting <span class="italic">DSM-IV-TR</span> diagnostic criteria for BED are described in the published literature, less is known about the binge-eating characteristics of individuals meeting <span class="italic">DSM-5</span> BED diagnostic criteria. The VALIDATE study<span class="htm-cite"><a href="#ref12">12</a></span> collected detailed information on binge-eating behaviors in individuals who self-reported meeting <span class="italic">DSM-5</span> diagnostic criteria for BED to provide insight into this issue. Here, the binge-eating characteristics in adults who self-reported meeting <span class="italic">DSM-5</span> BED criteria from the large US community sample of the VALIDATE study are described.</p>
  <p class="subheads_subhead-1-left"><span class="bold">METHODS</span></p>
  <p class="subheads-subhead-2-no-space"><span class="bold">Sample and Procedures</span></p>
  <p class="body-text">Detailed information on the VALIDATE sample and procedures have been described.<span class="htm-cite"><a href="#ref12">12</a></span> In brief, from respondents to the 2012 and 2013 National Health and Wellness Survey (NHWS; n<span class="thinspace"> </span>=<span class="thinspace"> </span>71,157 from January–December 2012 and n<span class="thinspace"> </span>=<span class="thinspace"> </span>75,000 from January–September 2013), a total of 69,972 respondents were contacted to participate in the VALIDATE survey. A stratified random-sample framework ensured representation across sex, age, and ethnicity strata. The demographic profile of NHWS respondents has been shown to approximate the Current Population Survey of the US Census Bureau.<span class="htm-cite"><a href="#ref21">21</a>,<a href="#ref22">22</a></span> The VALIDATE survey was conducted over the Internet and completed between October 9 and 29, 2013. The survey included questions assessing <span class="italic">DSM-5</span> and <span class="italic">DSM-IV-TR</span> diagnostic criteria for BED, demographics, general health, self-esteem, diagnosed psychiatric disorders, and binge-eating behavior characteristics.</p>
  <div class="clinical-article">
    <div class="heading"><img src="/publishingimages/new_tocs/clinical_points.gif" alt="clinical points" /></div>
    <p class="take-home-head-clin-pts"></p>
    <ul>
      <li class="clinical-points">Binge-eating disorder (BED) is now formally recognized as a distinct eating disorder in the <span class="italic">DSM-5</span>, but limited information is available regarding the binge-eating characteristics of individuals who meet <span class="italic">DSM-5</span> BED diagnostic criteria.</li>
      <li class="clinical-points">The findings of this study indicate that binge-eating episodes in most respondents who met <span class="italic">DSM-5</span> diagnostic criteria for BED occurred at least 2−3 times each week, had occurred over the past 7−12 months, and were associated with high levels of distress.</li>
      <li class="clinical-points">The characteristics of binge-eating episodes, along with the bothersomeness of BED symptoms, underscore the disease burden of BED and have potential implications for diagnosing and treating BED in the clinical setting.</li>
    </ul>
  </div>
  <p class="subheads-subhead-2">Measures</p>
  <p class="body-text">As previously reported,<span class="htm-cite"><a href="#ref12">12</a></span> survey respondents provided self-report information related to demographic and socioeconomic status, psychiatric comorbidities, and psychological features. Respondents were also asked if they had received diagnoses of psychiatric and medical conditions. Responses to questions related to <span class="italic">DSM-5</span> or <span class="italic">DSM-IV-TR</span> BED symptom criteria were used to determine whether respondents could be considered to meet diagnostic criteria for BED. Consistent with <span class="italic">DSM</span> criteria,<span class="htm-cite"><a href="#ref5">5</a>,<a href="#ref6">6</a></span> respondents self-reporting bulimia nervosa or anorexia nervosa diagnoses were not assigned a BED diagnosis. Data relating to BED prevalence and associated comorbidities in this sample have been described.<span class="htm-cite"><a href="#ref12">12</a></span></p>
  <p class="body-text">All survey respondents were asked questions related to the frequency of binge-eating symptoms<span class="bold"> </span>in relation to <span class="italic">DSM-5</span> diagnostic criteria. A subset of respondents (BED module respondents) also answered questions that provided detailed information on the frequency, severity, and duration of binge-eating symptoms; the age at first binge-eating experience; the lifetime duration of binge eating; the bothersomeness of binge-eating features (1<span class="thinspace"> </span>=<span class="thinspace"> </span>not at all bothersome to 5<span class="thinspace"> </span>=<span class="thinspace"> </span>extremely bothersome); the timing of daily binge eating and urges to binge eat (1<span class="thinspace"> </span>=<span class="thinspace"> </span>never to 4<span class="thinspace"> </span>=<span class="thinspace"> </span>very often) across multiple daily periods (morning [8 <span class="smallcaps">am</span>–12 <span class="smallcaps">pm</span>], early afternoon [12 <span class="smallcaps">pm</span>–4 <span class="smallcaps">pm</span>], late afternoon [4 <span class="smallcaps">pm</span>–7 <span class="smallcaps">pm</span>], evening [7 <span class="smallcaps">pm</span>–10 <span class="smallcaps">pm</span>], night [after 10 <span class="smallcaps">pm]</span>); and whether binge eating was planned in advance.</p>
  <p class="subheads-subhead-2">Data Presentation</p>
  <p class="body-text">On the basis of initial survey responses, respondents were categorized as (1) BED respondents (those who self-reported meeting all <span class="italic">DSM-5</span> diagnostic criteria for BED in the past 12 months), (2) binge-eating respondents (those who self-reported eating large amounts of food [criterion A1] and feelings of loss of control [criterion A2] in the past 12 months but who did not meet the other diagnostic criteria [criteria B–E]), (3) BED subthreshold respondents (those who self-reported meeting all <span class="italic">DSM-5</span> BED diagnostic criteria in the past 12 months, except for the frequency and duration criterion [criterion D]), and (4) non-BED respondents (those who may or may not have self-reported eating large amounts of food [criterion A1]; if they did, a feeling of loss of control during the time when they ate the large amount of food [criterion A2] was not reported).</p>
  <p class="body-text">All data are reported with descriptive statistics. Categorical variables were analyzed with χ<span class="superscript">2</span> tests or 2-sided tests of equality for proportions. Continuous variables were analyzed with <span class="italic">t</span> tests with Bonferroni corrections.</p>
  <p class="subheads_subhead-1-left"><span class="bold">RESULTS</span></p>
  <p class="subheads-subhead-2-no-space"><span class="bold">Respondent Disposition and Demographics</span></p>
  <p class="body-text">A total of 22,397 respondents completed the survey within 3 weeks of being invited to participate. Among all respondents, 344 were categorized as BED respondents; 1,245 as binge-eating respondents; 371 as BED subthreshold respondents; and 20,437 as non-BED respondents. A total of 1,075 respondents (309 BED respondents, 381 binge-eating respondents, 318 BED subthreshold respondents, and 67 non-BED respondents) agreed to provide detailed information regarding binge-eating behaviors from the BED-specific module.</p>
  <p class="body-text">The BED (70.3% [242/344]) and BED subthreshold (75.2% [279/371]) respondent groups had significantly higher (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05) percentages of women than the non-BED (53.7% [10,968/20,437]) and binge-eating (55.7% [693/1,245]) respondent groups (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('t1'); return false;">Table 1</a></span>). BED respondents were significantly younger than non-BED respondents (mean<span class="thinspace"> </span>±<span class="thinspace"> </span>SD<span class="thinspace"> </span>=<span class="thinspace"> </span>46.01<span class="thinspace"> </span>±<span class="thinspace"> </span>14.32 vs 51.59<span class="thinspace"> </span>±<span class="thinspace"> </span>15.80 years, <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001) and had a significantly higher body mass index than non-BED respondents (mean<span class="thinspace"> </span>±<span class="thinspace"> </span>SD<span class="thinspace"> </span>=<span class="thinspace"> </span>33.71<span class="thinspace"> </span>±<span class="thinspace"> </span>9.36 vs 27.96<span class="thinspace"> </span>±<span class="thinspace"> </span>6.68 kg/m<span class="superscript">2</span>, <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001). Income distribution did not significantly differ across respondent groups (<span class="callout"><a href="#" onclick="createFigure('t1'); return false;">Table 1</a></span>).</p>
  <div id="figure-2"> <a href="#" onclick="createFigure('t1'); return false;"><img src="16m01965T1.gif" alt="Table 1" id="t1" border="0" /></a>
    <p class="click-to-enlarge">Click figure to enlarge</p>
  </div>
  <p class="subheads-subhead-2">BED Symptom Frequency and Duration</p>
  <p class="body-text">All BED respondents, binge-eating respondents, and BED subthreshold respondents reported consuming amounts of food that were definitely larger than most people would eat and feeling loss of control over eating. None of the non-BED respondents reported loss of control over eating; only 15.7% reported consuming amounts of food that were definitely larger than most people would eat (<span class="callout"><a href="#" onclick="createFigure('t2'); return false;">Table 2</a></span>). Significantly higher percentages of BED and BED subthreshold respondents reported eating more rapidly than usual, eating until uncomfortably full, eating when not hungry, eating alone because of embarrassment, and feelings of disgust than binge-eating respondents (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('t2'); return false;">Table 2</a></span>). A significantly higher percentage of BED respondents reported extreme distress in association with binge eating than did BED subthreshold or binge-eating respondents (both <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('t2'); return false;">Table 2</a></span>).</p>
  <div id="figure-2"> <a href="#" onclick="createFigure('t2'); return false;"><img src="16m01965T2.gif" alt="Table 2" id="t2" border="0" /></a>
    <p class="click-to-enlarge">Click figure to enlarge</p>
  </div>
  <p class="body-text">Significantly higher percentages of BED respondents reported that the duration of binge eating was between 3  and 4, 5 and 6, and 7 and 12 months than did BED subthreshold or binge-eating respondents (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('t2'); return false;">Table 2</a></span>), with the majority of BED respondents reporting a duration of 7 to 12 months. A significantly higher percentage of BED subthreshold respondents reported that the duration of binge-eating episodes was between 1 and 2 months, and significantly lower percentages of BED subthreshold respondents reported that the duration of binge-eating episodes was between 7 and 12 and ≥<span class="thinspace"> </span>3 consecutive months compared with binge-eating respondents (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05).</p>
  <p class="body-text">Significantly higher percentages of BED respondents reported frequencies of binge eating between 2 and 3, 4 and 5, and 6 and 7 days per week than did binge-eating respondents and frequencies of binge eating between 4 and 5 and 6 and 7 days per week than did BED subthreshold respondents (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('t2'); return false;">Table 2</a></span>). A significantly lower percentage of BED subthreshold respondents reported a frequency of binge eating of &lt;<span class="thinspace"> </span>1 day per week, and a significantly higher percentage reported a frequency between 2 and 3 days per week compared with binge-eating respondents (both <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('t2'); return false;">Table 2</a></span>).</p>
  <p class="subheads-subhead-2">BED Symptom Severity</p>
  <p class="body-text">Across all symptoms, significantly higher percentages of BED respondents reported severe symptoms and significantly lower percentages reported mild symptoms than did BED subthreshold or binge-eating respondents (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1</a></span>). Significantly higher percentages of BED subthreshold respondents reported that symptoms of eating large amounts of food in 2 hours and loss of control during the binge-eating episode were moderate or severe than did binge-eating respondents (both <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1</a></span>). In addition, significantly higher percentages of BED subthreshold respondents than binge-eating respondents reported that symptoms of eating until uncomfortably full, eating when not physically hungry, and feeling disgusted with oneself, depressed, or guilty afterward were severe (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1</a></span>).</p>
  <div id="figure-2"> <a href="#" onclick="createFigure('f1'); return false;"><img src="16m01965F1.gif" alt="Figure 1" id="f1" border="0" /></a>
    <p class="click-to-enlarge">Click figure to enlarge</p>
  </div>
  <p class="subheads-subhead-2">Binge-Eating Characterization in BED Module Respondents</p>
  <p class="body-text">Compared with non-BED respondents, BED respondents were significantly older when symptoms were first experienced (<span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001), and the length of time symptoms were experienced was significantly shorter (<span class="italic">P</span><span class="thinspace"> </span>=<span class="thinspace"> </span>.001, <span class="callout"><a href="#" onclick="createFigure('t1'); return false;">Table 1</a></span>). A greater percentage of BED respondents reported binge eating on average &gt;<span class="thinspace"> </span>1 time per day than did all other respondent groups (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('t1'); return false;">Table 1</a></span>). Greater percentages of BED subthreshold respondents reported binge eating on average &gt;<span class="thinspace"> </span>1 time per day than did non-BED respondents. Respondent groups did not differ statistically in regard to the mean<span class="thinspace"> </span>±<span class="thinspace"> </span>SD number of binges per day among those self-reporting &gt;<span class="thinspace"> </span>1 binge day per week. The highest mean<span class="thinspace"> </span>±<span class="thinspace"> </span>SD number of binges ever experienced in 1 week was significantly larger in BED respondents (<span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05) than in BED subthreshold or binge-eating respondents but not in non-BED respondents (<span class="callout"><a href="#" onclick="createFigure('t1'); return false;">Table 1</a></span>). Most respondents reported that binges were not planned in advance (<span class="callout"><a href="#" onclick="createFigure('t1'); return false;">Table 1</a></span>).</p>
  <p class="body-text">Among respondents who experienced &gt;<span class="thinspace"> </span>1 binge per day, the highest percentage of respondents in each group reported binge eating 2 to 3 times per day (<span class="callout"><a href="#" onclick="createFigure('f2'); return false;">Figure 2A</a></span>); there were no significant differences among respondent groups. Except for non-BED respondents, the highest percentage of respondents in each group reported that they binge ate on average 31 to 60 or 61 to 90 minutes each day (<span class="callout"><a href="#" onclick="createFigure('f2'); return false;">Figure 2B</a></span>). Significantly greater percentages of BED, binge-eating, and BED subthreshold respondents reported that they binge ate on average for 31 to 60 minutes than did non-BED respondents (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('f2'); return false;">Figure 2B</a></span>). BED respondents were least likely to report that the most binges per week ranged from 0 to 2 and most likely to report that most binges per week ranged from 5 to ≥<span class="thinspace"> </span>10 (<span class="callout"><a href="#" onclick="createFigure('f2'); return false;">Figure 2C</a></span>). Significantly lower percentages of BED, BED subthreshold, and binge-eating respondents reported that the most binges per week was 0 compared with non-BED respondents (all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, <span class="callout"><a href="#" onclick="createFigure('f2'); return false;">Figure 2C</a></span>).</p>
  <div id="figure-2"> <a href="#" onclick="createFigure('f2'); return false;"><img src="16m01965F2.gif" alt="Figure 2" id="f2" border="0" /></a>
    <p class="click-to-enlarge">Click figure to enlarge</p>
  </div>
  <p class="body-text">A majority of BED respondents reported the urge to binge eat (very often: 36.6% [126/344], often: 34.0% [117/344]) and actual binge eating (very often: 32.3% [111/344], often: 32.3% [111/344]) between 7 <span class="smallcaps">pm</span> and 10 <span class="smallcaps">pm</span> (<span class="callout"><a href="#" onclick="createFigure('f3'); return false;">Figures 3A and 3B)</a></span>. Across the entire day, BED respondents rated the urge to binge eat and actual binge eating as higher than non-BED respondents (<span class="callout"><a href="#" onclick="createFigure('f3'); return false;">Figure 3C and 3D</a></span>, all <span class="italic">P</span><span class="thinspace"> </span>≤<span class="thinspace"> </span>.003).</p>
  <div id="figure-2"> <a href="#" onclick="createFigure('f3'); return false;"><img src="16m01965F3.gif" alt="Figure 3" id="f3" border="0" /></a>
    <p class="click-to-enlarge">Click figure to enlarge</p>
  </div>
  <p class="body-text">BED respondents reported that the most bothersome symptoms of BED (“very” or “extremely” bothersome, <span class="callout"><a href="#" onclick="createFigure('f4'); return false;">Figure 4A</a></span>) included feeling disgusted after binge eating, eating until uncomfortably full, and loss of control over eating. With the exception of eating more rapidly than normal, women were more likely than men to rate symptoms as extremely bothersome; the overall ranking of bothersomeness across symptoms did not differ between sexes (<span class="callout"><a href="#" onclick="createFigure('f4'); return false;">Figure 4B</a></span>). BED respondents rated all symptoms as significantly more bothersome than did BED subthreshold or binge-eating respondents (<span class="callout"><a href="#" onclick="createFigure('f4'); return false;">Figure 4C</a></span>, all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05), with ratings of “very bothersome” or “extremely bothersome” in BED respondents ranging from 36.6% to 66.3% across symptoms. BED subthreshold respondents rated all symptoms as significantly more bothersome than binge-eating respondents (<span class="callout"><a href="#" onclick="createFigure('f4'); return false;">Figure 4C</a></span>, all <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05).</p>
  <div id="figure-2"> <a href="#" onclick="createFigure('f4'); return false;"><img src="16m01965F4.gif" alt="Figure 4" id="f4" border="0" /></a>
    <p class="click-to-enlarge">Click figure to enlarge</p>
  </div>
  <p class="subheads_subhead-1-left"><span class="bold">DISCUSSION</span></p>
  <p class="body-text">To our knowledge, this is the first epidemiology survey to characterize binge-eating behavior in a representative population of US adults who self-report meeting <span class="italic">DSM-5</span> diagnostic criteria for BED. Among most BED respondents, binge eating had occurred for the past 7 to 12 months at a rate of ≥<span class="thinspace"> </span>2 to 3 binges per week; the duration of binge eating was most often between 31 and 60 minutes. The most common time for the urge to binge and actual binge eating to occur was between 7 <span class="smallcaps">pm</span> and 10 <span class="smallcaps">pm</span> in BED respondents, with binge eating rarely being planned in advance. BED symptoms reported as most bothersome by BED respondents included feeling disgusted after binge eating, eating until uncomfortably full, and loss of control over eating, with women generally rating BED symptoms as more bothersome than men. These data underscore the burden of binge-eating disorder in this population.</p>
  <p class="body-text">This is also the first study, to our knowledge, comparing the binge-eating behavior and disease burden in individuals meeting <span class="italic">DSM-5</span> diagnostic criteria for BED, individuals who are subthreshold for BED, and non-BED individuals. These data indicate that individuals who self-report meeting <span class="italic">DSM-5</span> BED diagnostic criteria differ on numerous binge-eating dimensions from those who do not self-report meeting full <span class="italic">DSM-5</span> criteria. These differences offer further support for the <span class="italic">DSM-5</span> BED diagnostic criteria. Notably, BED respondents were more likely to report that binge eating had been occurring for ≥<span class="thinspace"> </span>3 months, binge eating occurred between 4 and 7 days per week, and BED symptoms were severe and more bothersome than BED subthreshold and binge-eating respondents. The highest number of binges per week ever experienced by BED respondents was also greater than that reported for BED subthreshold and binge-eating respondents.</p>
  <p class="body-text">BED subthreshold and binge-eating respondents differed not only from non-BED respondents, but also from each other. BED subthreshold respondents (those who self-reported meeting all <span class="italic">DSM-5</span> BED criteria except for the frequency and duration criterion) and binge-eating respondents (those who self-reported binge-eating episodes with a feeling of loss of control but did not meet the full <span class="italic">DSM-5</span> criteria) exhibited differing profiles of symptom severity, bothersomeness, and distress associated with binge eating. These differing profiles not only support the importance of the marked distress criterion for BED, but also indicate that there are quantitative differences in binge-eating behaviors among individuals who self-report meeting different BED symptom profiles.</p>
  <p class="body-text">The lack of planning associated with binge eating in BED respondents highlights the impulsive and compulsive nature of binge-eating behavior. This finding is consistent with the published literature,<span class="htm-cite"><a href="#ref23">23–31</a></span> which reports that individuals with BED exhibit more impulsive and compulsive behavior than obese individuals not diagnosed with BED. Studies<span class="htm-cite"><a href="#ref23">23–31</a></span> report that individuals with BED exhibit increased impulsivity on the Barratt Impulsiveness Scale and UPPS Impulsive Behavior Scale and impaired set-shifting reflective of perseverative and compulsive behaviors compared with non-BED obese individuals and normal-weight individuals.</p>
  <p class="body-text">Although non-BED respondents were least likely to consume large amounts of food and more likely to report shorter binge-eating episode durations, they self-reported the earliest age at first symptoms, the longest symptom duration, and the most binges ever experienced during a week. The reasons for these discrepancies are unclear. However, they may be related to respondent perceptions of what constitutes a binge. Some individuals may eat a small or moderate amount of food and perceive it as large. Evidence of such a perceptual difference in regard to binge eating has been reported<span class="htm-cite"><a href="#ref32">32</a></span> and emphasizes the need to clearly define what constitutes a binge. If true, comparisons between the non-BED and other respondent groups regarding binge-eating characteristics should be considered cautiously.</p>
  <p class="body-text">The key strengths of this study are that it used <span class="italic">DSM-5</span> diagnostic criteria for BED and consisted of a large, representative US adult population with respect to age, sex, and race/ethnicity. However, the data are based on self-report and are from an Internet-based survey, so their generalizability may be limited.</p>
  <p class="body-text">In conclusion, these data indicate that binge-eating frequency varied in BED respondents but on average occurred more than 2 or 3 days per week and had been occurring for 7 to 12 months. In BED respondents, binge-eating symptoms were often severe. Further, there were distinctions between BED respondents and respondents who did not meet all BED diagnostic criteria. BED respondents reported that symptoms were more severe and more bothersome. These data highlight the disease burden in individuals with BED and have potential implications for diagnosing and treating BED in the clinical setting.</p>
  <p class="end-matter"><span class="bold-italic">Submitted:</span> April 15, 2016; accepted August 4, 2016.</p>
  <p class="end-matter"><span class="bold-italic">Published online:</span> October 27, 2016.</p>
  <p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> <span class="semibold">Dr Pawaskar</span> is a former employee of Shire and a current employee of Merck and holds stock and/or stock options in Shire and Merck. <span class="semibold">Dr Herman</span> is an employee of Shire and holds stock and/or stock options in Shire. <span class="semibold">Messrs Solo</span> and <span class="semibold">Valant</span> are principal owners of Lexidyne. <span class="semibold">Ms Schmitt</span> is a former employee of Lexidyne. <span class="semibold">Ms Nwankwo</span> is a former consultant for Shire.</p>
  <p class="end-matter"><span class="bold-italic">Funding/support:</span> This research was funded by the sponsor, Shire Development LLC (Lexington, Massachusetts), and conducted by Kantar Health (Horsham, Pennsylvania), with additional analyses provided by Lexidyne LLC (Colorado Springs, Colorado). The sponsor also provided funding to Complete Healthcare Communications, LLC (CHC; Chadds Ford, Pennsylvania) for support in writing and editing of this manuscript. Under the direction of the authors, writing assistance was provided by Stefan Kolata, PhD (a former employee of CHC) and Craig Slawecki, PhD (a current employee of CHC). Editorial assistance in the form of proofreading, copy editing, and fact checking was also provided by CHC.</p>
  <p class="end-matter"><span class="bold-italic">Role o</span><span class="bold-italic">f t</span><span class="bold-italic">he sponsor:</span> The study sponsor, Shire Development LLC, was involved in the design and conduct of the study and in the collection, analysis, and interpretation of the data. The final content of this manuscript, the ultimate data interpretation, and the decision to submit the manuscript for publication in <span class="italic">The Primary Care Companion for CNS Disorders</span> were made by the authors independently.</p>
  <p class="end-matter"><span class="bold-italic">Previous presentation:</span> These data were presented at the 168th Annual Meeting of the American Psychiatric Association; May 16–20, 2015; Toronto, Ontario, Canada.</p>
  <p class="end-matter"><span class="bold-italic">Acknowledgments:</span> The authors would like to acknowledge Edward A. Witt, PhD (Kantar Health, Horsham, Pennsylvania) for his contribution to the design, analysis, and data collection of the VALIDATE study and Carlos Grilo, PhD (Program for Obesity, Weight and Eating Research, Yale School of Medicine, New Haven, Connecticut) for his insightful comments on the initial draft of this manuscript. </p>
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