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Open Access Full Text Article
http://dx.doi.org/10.2147/AHMT.S148050
A narrative review of binge eating disorder in adolescence: prevalence, impact, and psychological treatment strategies
Eleonora Marzilli1
Luca Cerniglia2
Silvia Cimino1
1Department of Dynamic and Clinical Psychology, Psychology and Medicine Faculty, Sapienza – University of Rome, 2Department of Psychology, Psychology Faculty, International Telematic University Uninettuno, Rome, Italy
Abstract: Binge eating disorder (BED) represents one of the most problematic clinical condi- tions among youths. Research has shown that the developmental stage of adolescence is a critical
stage for the onset of eating disorders (EDs), with a peak prevalence of BED at the age of 16–17
years. Several studies among adults with BED have underlined that it is associated with a broad
spectrum of negative consequences, including higher concern about shape and weight, difficulties
in social functioning, and emotional-behavioral problems. This review aimed to examine studies
focused on the prevalence of BED in the adolescent population, its impact in terms of physical,
social, and psychological outcomes, and possible strategies of psychological intervention. The
review of international literature was made on paper material and electronic databases ProQuest,
PsycArticles, and PsycInfo, and the Scopus index were used to verify the scientific relevance of
the papers. Epidemiological research that examined the prevalence of BED in adolescent samples
in accordance with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition showed
a prevalence ranging from 1% to 4%. More recently, only a few studies have investigated the
prevalence of BED, in accordance with the Diagnostic and Statistical Manual of Disorders, Fifth
Edition criteria, reporting a prevalence of ~1%–5%. Studies that focused on the possible impact that BED may have on physical, psychological, and social functioning showed that adolescents
with BED have an increased risk of developing various adverse consequences, including obesity,
social problems, substance use, suicidality, and other psychological difficulties, especially in the
internalizing area. Despite the evidence, to date, reviews on possible and effective psychological
treatment for BED among young population are rare and focused primarily on adolescent females.
Keywords: binge eating, adolescence, prevalence, impact, treatment
Introduction Binge eating disorder (BED) is an empirically validated eating disorder (ED),1–3 intro-
duced in May 2013 in the Diagnostic and Statistical Manual of Disorders, Fifth Edi-
tion (DSM-5).4 BED is characterized by recurrent episodes of unusually large amount
of food intake without compensatory behaviors, and it is associated with subjective
experience of feeling of loss of control (LOC) and marked distress.5–8 Originally, BED
was introduced in the appendix of the Diagnostic and Statistical Manual of Disorders,
4th Edition, Text Revision (DSM-IV-TR),9 as a subcategory of Eating Disorders Not
Otherwise Specified (EDNOS). Criteria required binge eating episodes at least twice
per week for 6 months, but the new DSM-5 changed this threshold to at least once a
week for 3 months.10 Generally, binge eating episodes are preceded by intense feeling
of craving,11 and several researchers have suggested that binge eating may serve as a
maladaptive strategy for coping with negative mood states.12–16
Correspondence: Luca Cerniglia Department of Psychology, Psychology Faculty, International Telematic University Uninettuno, Corso Vittorio Emanuele II, 39 – 00100, Rome, Italy Tel +39 06 69201 Email [email protected]
Journal name: Adolescent Health, Medicine and Therapeutics Article Designation: REVIEW Year: 2018 Volume: 9 Running head verso: Marzilli et al Running head recto: Binge eating disorder in adolescence DOI: http://dx.doi.org/10.2147/AHMT.S148050
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Marzilli et al
BED is the most prevalent form of ED and one of the
primary chronic illnesses among adolescents.17 Adolescence
is a transitional developmental stage characterized by rapid
and deep physical, psychological, and neural development
changes, and it represents a critical period for the onset of
EDs, including BED.18–21 During this period, youths experi-
ence fast neurobiological and body modifications, which
may be accompanied by increased concern and attention
for body size and shape,22–24 as the awareness of societal
pressures for thinness and relationships with peers becomes
increasingly important, leading to a higher concern about peer
acceptance.25–27 For these reasons, although EDs can affect
individuals of all ages, adolescence represents a peak lifetime
period of increased vulnerability for the onset of EDs.28,29 In
particular, an increased prevalence of ED symptoms among
youths aged 14–16 years has been evidenced,30 with two
peaks of onset of BED, the first immediately after puberty, at
a mean age of 14 years,31 and the second in late adolescence
(19–24 years), between 18 and 20 years.32
In the general population, international research has
reported that 26% of female and 13% of male adolescents
have experienced an episode of binge eating at least once in
the last 12 months33 and that subclinical symptoms of BED
can be associated with a higher risk of developing BED34
and/or other adverse outcomes, including lower self-esteem
and higher body dissatisfaction.35
It is noteworthy that binge eating episodes in adolescence
could be difficult to differentiate from nonclinical behaviors,
as youths could indulge in large food consumption due the
developmentally specific growth spurts.36 Consequently, it has
been suggested that the criterion of LOC eating is the most
salient marker of BED in this developmental phase, especially
for early adolescents.37 Furthermore, adolescents may also
show less frequent episodes of binge eating than it is neces-
sary to pose a diagnosis of BED according to the Diagnostic
and Statistical Manual of Mental Disorders.18,38,39 For these
reasons, it is important for clinicians to consider subthreshold
binge eating disorder (SBED) in adolescents.32,34,37,40
It has also been evidenced that female adolescents fre-
quently report less overeating than male adolescents,41 but
more severe indicators of loss of control,10,42 and distress
during binge eating episodes.10,41 Moreover, several studies
among adults with BED have shown that this ED is associated
with various adverse consequences, including higher distress
and concern about shape and weight,43 social impairment,8,44
and both clinical and subclinical forms of psychological
difficulties, especially anxiety and depressive symptoms.7
Based on these theoretical and empirical premises, the
aim of this narrative review was to examine the current
knowledge45 of the prevalence of BED in adolescent popula-
tion, outcomes associated in terms of physical, social, and
psychological consequences, and possible psychological
strategies of intervention.
Research methods The methodological approach adopted in this paper consists
of a narrative review,45,46 an interpretive-qualitative form of
research that, when include some features of a systemic meth-
odology,47 can allow synthesizing the findings of literature
about a specific theme and improve our knowledge on the
topic.48 Specifically, our methodological research (Table 1)
was inspired by the four steps provided by Egger et al49 as
follows: 1) formation of a working group, composed of three
operators expert in BEDs; one of them has acted as a meth-
odological operator and the other two as clinical operators;
2) formulation of the review questions on the basis of the
state of the art of BED in adolescent population (in terms
of its prevalence, impact, and possible psychological treat-
ment strategies), as made in the abstract; 3) identification
of relevant studies: the review of international literature was
performed through an extensive search on paper materials in
university libraries and through electronic databases such as
ProQuest, PsycArticles, and PsycInfo and indexing papers
published from January 2007 to June 2017, together with
the use of Scopus index to verify the scientific relevance
of papers. First, in order to examine the prevalence rates of
binge eating in adolescent population, we were specifically
interested in articles that reported the prevalence of both BED
and SBED, in accordance with DSM-IV and DSM-5 criteria,
and assessed diagnoses with self-report questionnaires and/
or interview instruments. Despite self-report measurements
have methodological limitations compared with interview-
based assessments, we also included studies using report
data to classify diagnoses, because epidemiological research
of BED in adolescence is still scarce, and these studies may
provide important preliminary data for future studies. This
research was performed by using relevant combined keywords
such as “binge eating disorder,” “BED,” “subthreshold BED,”
“adolescent,” “youth,” “prevalence,” and “epidemiology.”
Second, to explore the possible impact of BED on ado-
lescents’ health and mental health, we searched for studies
presenting physical, social, and psychological outcomes in
female and male adolescents with BED and SBED, using the
following combined search terms: “adolescence,” “binge eat-
ing,” “subthreshold BED,” “outcomes,” “long-term effects,”
“impact,” “correlates,” and “consequences.”
Finally, to examine the research focused on possible
psychological treatment strategies, we used the keyword
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Binge eating disorder in adolescence
search function by entering the following terms: “binge eating
disorder,” “adolescence,” “youth,” “psychological treatment,”
“psychotherapy,” and “intervention.”
Given that the criterion of LOC eating has been sug-
gested to be a more appropriate indicator of binge eating in
adolescence with respect to amount of food consumed,37 we
also included treatment studies specifically focused on the
reduction of LOC.
We examined the title and screened abstracts of each
identified article using these initial search strategies. Then,
we also conducted a hand-search of the reference lists of
published articles, and papers were inspected for their rel-
evance in the review. On the basis of the evidence of two
peaks of onset for BED31,32 (the first in early adolescence
and the second in late adolescence),50 we included in this
review only articles in which sample of adolescents was
aged between 10 and 24 years. Furthermore, we selected
only papers in which sample or subsample of adolescents
was diagnosed with BED or SBED, in accordance with
either DSM-IV or DSM-5 criteria, or studies that examined
binge eating symptoms and/or episodes without compensa-
tory behaviors. Other inclusion criteria were that articles in
English language and published in peer-reviewed journals.
Thesis dissertations were excluded.
The final step is 4) the analysis and presentation of the
outcomes; we identified a total of 25 articles, 00 for preva-
lence,10,18,39,40,51–53,59–62 11 for outcomes,18,39,40,59–61,64–68 and 6 for
psychological treatment.79–84 The data extrapolated from these
revised studies were collocated in tables and carried out in
the form of a narrative review. Table 1 shows the summary
of the methodology used in the review. The flow diagram of
the narrative review is shown in Figure 1.
Results Prevalence of BED in adolescence Given that BED has only recently been introduced into the
psychiatric nomenclature, epidemiological research is very
limited, especially for adolescent populations. We found 13
prevalence studies specifically focused on youths, which have
used different types of measurements to assess diagnoses
(Table 2). Five studies18,40,51–53 have examined the prevalence
of BED in accordance with Diagnostic and Statistical Manual
of Mental Disorders, 4th Edition (DSM-IV) and overall
reported a rate of prevalence from 1% to 4%. For example, a
study by Decaluwé and Braet51 in a population of obese ado-
lescents, using interview measurements, has reported a rate of
~2%. Two other studies52,53 have examined the rate of BED in general adolescent population, but using self-report question-
naires, reporting a slightly lower prevalence of 1.2%, with
a higher rate among female adolescents. These studies51,52
have also underlined the presence of high percentage of
youth who did not meet full-threshold criterion for an ED
diagnoses, suggesting limitations of classification systems
for epidemiological research among adolescent populations.
Finally, we considered two studies18,40 that, using interview-
based assessments, have provided the prevalence rates also for
SBED, evidencing a higher prevalence of this form in this phase
of development. One study40 was focused only on adolescent
girls, finding a rate of 1% for BED and 4.6% for SBED. The
second study18 had considered both sexes of adolescent popu-
lation, reporting a prevalence of 1.6% for BED and 2.5% for
SBED and evidencing higher rates among girls for SBED also.
Changes to diagnostic criteria from DSM-IV-TR to
DSM-5 have allowed reducing the prevalence of EDNOS,54
which were ~50% in clinical samples55,56 and 70% in commu-
Table 1 Summary of methodology
Step General activities Specific activities
1 Formation of a working group Three psychologist experts in binge eating disorder: 1. One as a methodological operator 2. Two as clinical operators
2 Formulation of the review questions
Evaluation of the state of the art on the prevalence of BED in adolescence, its impact, and its possible psychological treatment strategies
3 Identification of relevant studies on ProQuest, PsycArticles, and PsycInfo
1. Identification of the keywords on the basis of the field of interest of the papers to be searched, grouped in inverted commas (“…”) and used separately or combined
2. Use of the Boolean AND operator, in order to establish a logical relationship among concepts 3. Research modalities: advanced search 4. Limits: papers published in the last 10 years; languages: English; type of paper: peer-review 5. Manual search through the reference lists of articles, using the Scopus index to verify the
scientific relevance of papers 4 Analysis and presentation of the
outcomes The data extrapolated from revised studies were collocated in tables and presented in the form of a narrative review
Note: Our methodological strategy was inspired by four steps proposed by Egger et al.49
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Marzilli et al
nity samples.57,58 To date, the few studies that have examined
the prevalence of BED in adolescent samples, in accordance
with the recently proposed DSM-5 criteria, found the preva-
lence of approximately between 1% and 5%.10,31,32,39,59–62
In particular, we found three studies39,59,61 that have lon-
gitudinally examined the prevalence of BED in adolescent
community samples and that suggested an increase of rate
over time. For example, Field et al61 found a BED prevalence
of 2.5%, which tended to increase during the development,
with a peak at 19–22 years of age.
Two other studies39,59 have confirmed these findings also
among male adolescent samples. Interesting, a study by Allen
et al59 has reported that BED prevalence increased over time
among female adolescents, starting from 0.7% in 14-year-
old subjects, reaching 1.4% when they were 17 years, and
finally growing up to 4.1% when they were 20 years old.
In male adolescents, BED prevalence was estimated to be
absent (0%) at 14 years of age and 1.2% at 17 years and was
decreased to 0.7% at 20 years, suggesting that adolescent
girls have a higher risk of maintaining BED over the course
of life. However, another study37 found that prevalence of
BED generally increased over time among both female and
male adolescents, peaked at ~3.3% at an age of 22 years for girls and 1.2% at 24 years for boys.
More recently, two cross-sectional studies31,62 have
reported lower rates of prevalence (~1.5%), but among samples of younger adolescents with respects to previous
studies in which an increase of prevalence has been evidenced
over time.
Finally, we considered three studies10,32,60 focused also
on the prevalence of SBED. Interestingly, the study by Stice
et al32 has examined the prevalence of EDs in the same female
Figure 1 Flowchart of narrative review. Note: *Some studies were pertinent to more than one section.
Articles identified through databases (ProQuest, PsycArticles, PsycInfo)
(n=5,006)
Records screened (n=28)
Records excluded (n=4,978)
Reasons: - Not pertinent, n=4,642 - Duplicated, n=298 - Other manuscript type, n=29 - Non-English, n=9
Full-text articles reviewed for potential inclusion
(n=32)* - Prevalence, n=19 - Impact, n=19 - Treatment, n=14
Studies included in narrative review (n=25)*
- Prevalence, n=13 - Impact, n=12 - Treatment, n=6
Articles included from reference lists and citation tracking
(n=4)
Articles excluded (n=7)
Reason: - Wrong study design or
subjects, n=7
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Binge eating disorder in adolescence
adolescent samples of their previous study,40 but considering
the new DSM-5 criteria, finding an increased prevalence of
BED of ~2%. Two other studies10,60 have replicated similar results but considering also male adolescents. One study60
was consistent with the previous findings, underlining that
female adolescents had a higher prevalence of BED and
SBED with respect to their peer male adolescents. In contrast,
another study10 has evidenced a higher rate of BED among
female adolescents, but male adolescents reported higher
rate of SBED.
Impact of BED on physical, psychological, and social functioning As seen in the above paragraph, epidemiological research
has underlined that BED is common in adolescent popula-
tion. Research that has focused on the possible consequences
of BED on physical, psychological, and social functioning
has evidenced that adolescents suffering from BED have an
increased risk of developing a variety of adverse outcomes,
which may persist into young adulthood.63
Specifically, we reported data from 12 studies showing
that BED in adolescence was predictive of a broad spec-
trum of negative outcomes, including obesity,39,60,61,64 social
impairment,18,64,65 other psychological difficulties, especially
depressive symptoms,39,59–61,64,67,68 anxiety,60,68 and emotional
distress,32,40,68 substance use,39,60,61 and propensity to suicide
and deliberate self-harm18,32,60,66 (Table 3).
Regarding the impact of BED on physical health, four
prospective cohort studies39,60,61,64 have underlined that BED
was predictive of overweight and obesity, both in girls and
boys.39,60,64 In particular, in early adolescents with BED, it has
been reported a body mass index (BMI) of ~23 kg/m2,59 is indicative of a healthy weight. However, among this popula-
tion, BMI tended to increase during later adolescence, with a
mean score of 27 kg/m2 among youths with BED59 and of 26
kg/m2 for SBED,32 representative of a overweight condition
(25 < BMI < 29.9 kg/m2), up to a rate of 60% of obese (BMI >30 kg/m2),31 suggesting that binge eating might represent a crucial risk factor for obesity. A study by Field et al61 has
shown that 35.1% of female adolescents became overweight
Table 2 Prevalence of binge eating disorder in adolescent samples
Reference Age (years) Sample (N) Methods Prevalence (%)
Total Female Male Screening Criteria Total Female Male
Decaluwé and Braet51 10–16 196 111 78 ChEDE DSM-IV 1 1 0 Kjelsås et al52 14–15 1,960 1,026 934 SEDs DSM-IV 1.2 1.5 0.9 Ackard et al53 13–18 4,746 2,373 2,273 EAT DSM-IV 1.1 1.9 0.3 Stice et al40 12–15
20 496 496 – EDDI DSM-IV 1a
4.6b 1a
4.6b –
Swanson et al18 13–18 10,123 – – CIDI DSM-IV 1.6a
2.5b 2.3a
2.6b 0.8a
2.3b
Field et al61 16–24 8,594 8,594 – 2-part questions
DSM-5 2-2.5 – –
Allen et al59 14–17–20 1,383 715 668 ChEDE EDE-Q
DSM-5 0.9 1.3 2.4
1.8 1.4 4.1
0 1.2 0.7
Sonneville et al39 16–24 16,882 9,039 7,843 2-part question
DSM-5 2–3 2.3–3.1 0.3–1
Crow et al62 13–18 10,123 – – 2-part question
DSM-5 1.6 – –
Smink et al31 19 1,597 861 739 CIDI EDE
DSM-5 1.5 2.3 0.7
Stice et al32 12–15 20
496 496 – EDDI DSM-5 3a
3.6b 3a
3.6b –
Micali et al60 14–16 6,140 5,069
3,416 3,059
2,742 2,154
2-part question
DSM-5 0.5a 0.03b
1.15a 0.42b
0.61a
0.03b
1.15a 0.72b
0.33a
0.04b
0.6a 0b
Lee-Winn et al10 13–18 9,336 4,738 4,598 EDDI DSM-5 0.78a
1.33b 1.1a
1.2b 0.46b
1.47b
Note: aThreshold-BED; bsubthreshold BED. Abbreviations: BED, binge eating disorder; ChEDE, Child Eating Disorders Examination; CIDI, Composite International Diagnostic Interview; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; EAT, Eating Attitudes; EDDI, Eating Disorder Diagnostic Interview; EDE-Q, Eating Disorder Examination-Questionnaire; SEDs, Survey for Eating Disorders.
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Table 3 Binge eating and physical, social, and psychological outcomes
Reference Age (years)
Sample (N)
Outcome Results (OR; 95% CI) or (p-value) or (Cohen’s d) or (%)
Field et al61 16–24 859 Overweight/obesity Use drugs Binge drink Depressive symptoms
BED was predictive of overweight/obesity (OR: 1.9; CI: 1.0–3.5) and depressive symptoms (OR: 2.3; CI: 1.0–5.0) in female adolescents. No association was found with binge drinking
Sonneville et al39
12–24 14,166 Overweight/obesity Use drugs Binge drink Depressive symptoms
Binge eating was significantly associated with incident overweight/obesity (OR: 1.73; CI: 1.11–2.69), starting to use marijuana (OR: 1.85; CI: 1.27– 2.67) and other drugs (OR: 1.59; CI: 1.08-2.33), and with the onset of high depressive symptoms among both female adolescents (OR: 2.12; CI: 1.32–3.40) and male adolescents (OR: 3.21; CI: 0.68–15.27)
Micali et al64 13–15 7,082 Overweight/obesity Social impairment Family burden Emotional-behavioral disorders
Bingeing/overeating was predictive of higher BMI z scores at 15 years of age (p<0.0001), both in adolescent girls and boys. Bingeing/overeating in girls was associated with social impairment (p<0.0001), burden to parents (p<0.0001), and both emotional (p<0.01) and behavioral (p<0.01) disorder In male adolescents, bingeing/overeating was associated with social impairment (p<0.0001), family burden (p<0.0001), and both emotional (p<0.0001) and behavioral (p<0.0001) disorder
Micali et al60 14–16 6,140 Overweight/obesity Depression Anxiety Alcohol use Substance use Self-harm
BED was prospectively associated with obesity (OR: 3.58; CI: 1.06–12.14), depression (OR: 2.00; CI: 1.06–3.75), anxiety (OR: 3.53; CI: 1.58–7.86), and drug use (OR: 3.39; CI: 1.35–8.48). SBED had prospective associations with depression (OR: 2.11; CI: 1.44–3.10), anxiety (OR: 7.90; CI: 2.53–24.67), drug use (OR: 2.15; CI: 1.14–4.04), and deliberate self-harm (OR: 2.32; CI: 1.43–3.75)
Ranzenhofer et al65
12–17 158 Depressive symptoms Health Social/interpersonal functioning Work/school Mobility Self-esteem Activities of daily living
BED was associated with depressive symptoms (p<0.05), health (p<0.05), mobility (p<0.05), and self-esteem (p<0.01). Adolescent girls, compared to boys, reported lower levels of activities of daily living, mobility, self-esteem, and social/interpersonal functioning (p<0.05), but not health or work/school
Swanson et al18
13–18 10,123 Mental health Social impairment Suicidality
BED and SBED were associated, respectively, to mood disorder (OR: 4.6; CI: 2.7–7.7),a (OR: 2.0; CI: 2.2–3.4);b anxiety (OR: 5.0; CI: 3.0–8.1),a (OR: 1.7; CI: 1.1–2.6);b substance abuse (OR: 3.1; CI: 1.3–7.2),a (OR: 2.7; CI: 1.6–4.6);b and behavioral disorder (OR: 3.1; CI: 1.0–9.4),a (OR: 2.5; CI: 1.4–4.2)b
62.6% of adolescents with BED and 34.6% with SBED reported impairment in the last year, specifically in household chore (45%,a 23.5%b), school or work (46.2%,a 20.6%b), family life (45.7%,a 21.3%b), and social life (51.6%,a 20.9%b). 8.7% of BED and 2.8% of SBED reported several impairment in the domain of household chore (4.8%,a 2.2%b), school or work (1.9%,a 2.6%b), family life (3.7%,a 2.1%b), and social life (5.7%,a 2.1%b). 34.4% of BED and 18% of SBED reported suicidal ideation, 5.1% of BED and 5.1% of SBED declared suicidal plan, and 15.1% of BED and 5.3% of SBED showed suicidal attempt. Finally, they reported significant higher suicidal ideation (p<0.5)a,b and attempt (p<0.05)b than control did
Skinner et al67
12–23 4,798 Depressive symptoms Female adolescents with binge eating or overeating had a higher risk to develop depressive symptoms after 2 years (OR: 1.9; CI: 1.2–2.9 and OR: 1.9; CI: 1.1–3.4, respectively). Female adolescents with depressive symptoms at baseline had a higher risk to start binge eating (OR: 2.3; CI: 1.7–3.0) or overeating (OR: 1.9; CI: 1.4–2.5) at follow-up
Allen et al59 14–20 1,383 Depressive symptoms Physical quality of life Mental quality of life
BED was longitudinally associated with depressive symptoms (p<0.05) and poor mental health quality of life (p<0.05), in both male and female adolescents
Allen et al68 14–20 1,383 Depression Anxiety Psychological functioning
BED was significantly and longitudinally associated with depressive (p<0.01; d=0.73), anxiety (p<0.01; d=1.25), and stress (p<0.01; d=1.31) symptoms and poor mental quality of life (p<0.01; d=0.83) in adolescents with BED
Stice et al40 12–20 496 Mental health service use Functional impairment Emotional distress
Adolescents with BED and SBED reported more mental health treatment (p<0.01), functional impairment (p<0.05), and emotional distress (p<0.01) than the control group
(Continued)
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Binge eating disorder in adolescence
and/or obese over the following years, with a significant
higher incidence compared with their peers with other EDs.
Three other longitudinal studies39,60,64 have reported similar
findings for both female and male adolescents, evidencing
that binge eating symptoms are predictive of negative physi-
cal consequences (such as obesity) among both sexes.
Furthermore, research has underlined that the impact of
BED in adolescence reaches beyond physical adverse out-
comes. In particular, we considered three studies18,64,65 that
have suggested that the presence of BED was predictive of
a broad spectrum of negative social/interpersonal and out-
comes and lower quality of life, in both obese and general
adolescent population. A study by Ranzenhofer et al65 focused
on an obese adolescent population has shown that binge eat-
ing youths reported severe impairments in the domains of
health, mobility, and self-esteem compared with their peers
without binge eating, even after controlling for body com-
position. At the same time, two studies18,64 have replicated
similar results also in population-based samples, evidenc-
ing that bingeing/overeating symptoms were significantly
associated with both social impairment and family burden, in
girls and boys. As regards possible different impact of BED
and SBED on adolescents’ quality of life, one study64 has
evidenced that 62.6% of adolescents with BED and 34.6%
of adolescents with SBED reported impairment in the past
year, especially in the domains of social life and household
chore, respectively. About 9% of adolescents with BED had
severe impairments, particularly in social life, while 2.8% of
those with SBED reported severe school or work impairment.
Although the research design did not allow causal links, it
represented the first population-based study focused on the
impact of both threshold and subthreshold of BED in a large
population-based samples of female and male adolescents.
With specific regards to the effects on psychological
health, we have identified eight studies18,39,40,59–61,67,68 that
have underlined that BED in adolescence is associated with
various adverse mental health outcomes, especially anxiety
and depressive symptoms. Two studies61,67 have focused on
community sample groups of female adolescents, evidencing
a strong association between BED and depressive symptoms.
Moreover, in comparison with the other subtype of EDs, BED
was the only one illness predictive of depressive symptoms.61
A study by Skinner et al67 has shown that prospective asso-
ciations between binge eating and depressive symptomatol-
ogy had similar strength in both directions, suggesting the
presence of a bidirectional relationship between these two
psychopathological difficulties.
More recently, three studies39,59,68 have confirmed these
associations also for adolescent boys. One of them39 has
reported a higher power of prospective associations between
BED and depressive symptoms among boys. Moreover, these
studies have also evidenced an expanded range of adverse
psychological health outcomes predicted by BED, including
anxiety and stress symptoms, substance use, and a general
low quality of life. However, associations with stress and
anxiety symptoms had large effect size.68
Given that prevalence studies have underlined that SBED
is very frequent in adolescent population, we considered four
studies18,32,40,60 that have examined the impact of both BED
and SBED on psychological well-being. Two longitudinal
studies32,40 on female adolescent community sample have
reported that youths with both BED and SBED showed
higher mental health difficulties, functional impairment, and
emotional distress, than controls did, with no significant dif-
ferences between the two forms of disease respect to these
variables. Consistent with previous studies, a cross-sectional
study by Swanson et al18 on a community sample of adoles-
cent girls and boys found significant associations between
both BED and SBED with mood disorder, anxiety, alcohol,
and drug use, in female and male adolescents (aged 13–18
years). In this study, adolescents with BED showed more
difficulties in the area of anxiety, while those with SBED
Reference Age (years)
Sample (N)
Outcome Results (OR; 95% CI) or (p-value) or (Cohen’s d) or (%)
Stice et al32 15–23 496 Functional impairment Emotional distress Suicidality Mental health service utilization
BED was significantly associated with functional impairment (p<0.01; d=1.06), emotional distress (p<0.01; d=1.22), suicidality (p<0.01; d=1.14), and mental health treatment (p<0.01; d=1.10). SBED was associated only with emotional distress (p<0.01; d=0.94) and suicidality (p<0.01; d=0.51)
Forrest et al66
13–18 10,123 Suicidality BED was associated with elevated odds of suicidal ideation (OR: 3.81; CI: 2.14–6.77; p<0.001) and attempting (OR: 5.01; CI: 1.62–15.48; p<0.01)
Notes: aThreshold BED; bsubthreshold BED. Cohen’s d effect size: 0.20 = small, 0.50 = medium, and 0.80 = large. Abbreviations: BED, binge eating disorder; BMI, body mass index; CI, confidence interval; OR, odds ratio; SBED, subthreshold binge eating disorder.
Table 3 (Continued)
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Marzilli et al
were associated with a higher risk for alcohol and drug use.
Another study60 confirmed similar results even longitudinally,
reporting that the main significant associations were between
SBED and both anxiety and depressive symptoms.
Finally, given that research has underlined clinically
significant impairment of BED in adolescence, in terms of
physical and mental health difficulties, we considered four
studies18,32,60,66 that have also examined its possible impact on
suicidality (in terms of suicidal ideation, suicidal thoughts,
and suicidal attempts) or self-injury. Two studies18,32 found
significant associations between BED and SBED and suicid-
ality in female and male adolescents, with a higher effect size
for BED. Another study60 has evidenced that SBED, but not
BED, was prospectively significantly associated with delib-
erate self-harm. Finally, a recent study by Forrest et al66 has
reported that the majority of adolescents with BED reported
that suicidal ideation followed BED onset, suggesting that
binge eating might represent an important risk factor for
suicidality in adolescent population.
Psychological treatment strategies Despite the high prevalence of BED in adolescent populations
and the severe physical, social, and psychological associ-
ated outcomes, systematic studies on possible and effective
psychological treatment for BED among young population
are scarce.
Several psychological intervention options have been
studied for the treatment of BED in adulthood,69 such as 1)
cognitive behavioral therapy (CBT),70–72 which concentrates
on changing dysfunctional patterns of eating-related thinking
and behaviors; 2) behavioral weight loss treatment,73 which
are specifically focused on physical activity and modifying
diet to reduce overweight and obesity; 3) interpersonal psy-
chotherapy (IPT),69,75 a short-term psychotherapy focused on
reducing interpersonal difficulties associated with the onset
and/or maintenance of BED; and 4) dialectical behavior
therapy (DBT),76,77 which is directly focused on emotional
dysregulation and difficulties in coping with one’s own
emotions, by promoting the capacity to recognizing, tol-
erating, and regulating their emotions and mood states.78
Notwithstanding research has demonstrated their efficacy
in reducing binge eating in the short and long term, to date,
very few studies have examined the possible effectiveness
of these psychological interventions also in adolescents with
BED. In particular, we found only six studies79–84 that have
developmentally adapted these treatments to adolescent girls
and in small samples. Two of them79,80 have examined the
effectiveness of CBT, two81,82 are focused on IPT and the other
two83,84 have used DBT (Table 4). We found that no study has
focused on psychological intervention on male adolescents.
With regard to CBT studies, DeBar et al79 have used an
adolescent adaptation of CBT in a sample of female ado-
lescents with BED (52%), recurrent binge eating episodes
(32%), or bulimia spectrum disorders (16%). Subjects in
CBT group were compared with a usual-delayed treatment
(TAU-DT) control group (N=13), in which adolescents received CBT 6 months later. All participants were assessed
at baseline and at 3- and 6-month follow-up sessions. Female
adolescents in CBT group showed significantly higher absti-
nence of binge eating episodes at 3- and 6-month follow-up
than their peers of TAU-DT group, with a robust effect size.
At follow-up, totality of participants of CBT was abstinent.
Moreover, the intervention also produced significant improve-
ments in other shape-, weight-, and eating-related concerns,
although with a smaller effect size. Finally, girls in the CBT
group showed a significant lower depressive symptoms at
both the follow-up sessions. However, subjects of TAU-DT
group, who were additionally followed up at 9 and 13 months,
reported similar outcomes. Although this study provided
a preliminary evidence of the efficacy of CBT in reduc-
ing binge eating symptoms and their secondary outcomes
among adolescent population, homogeneity and small size
of sample did not permit generalizability of these findings.
Another study by Jones et al80 has investigated the use of
an Internet-facilitated CBT-self-help intervention along
16 weeks, compared to a 9-month-wait-list control (WLC)
group, for weight maintenance and the reduction of binge
eating episodes. In particular, the treatment program was
composed by an integrated intervention in which behavioral
weight loss (BWL) was combined with CBT. This choice was
due to the evidence that in adolescence the specific increased
focus on body weight, control of eating behaviors, and
dietary that characterizes traditional weight loss programs73
could produce the paradoxical effect of increasing the risk
and/or severity of ED symptomatology.85 Moreover, despite
traditional BWL programs being found to be effective in the
treatment of BED in adults,74 they are specifically focused
on the objective overeating episodes, neglecting the aspects
of loss of control which are particularly central in BED in
adolescence.37 Subjects in CBT group showed significantly
lower BMI and BMI z scores at follow-up assessment, a
greater decrease in both objective and subjective binge epi-
sodes at both posttreatment and follow-up assessments, and
a significant reduction of weight- and shape-related concerns
than control did, supporting the effectiveness of this interven-
tion also in female adolescents with BED.
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Binge eating disorder in adolescence
Regarding IPT that has been suggested to be an important
strategy to reduce binge eating and associated interpersonal
problems,69 we found only two studies81,82 that evaluated
its effectiveness in adolescents with BED. A pilot study by
Tanofsky-Kraff et al81 focused on IPT in a sample of female
adolescents who were at-risk for excessive weight gain, with
and without LOC eating, and reported a significant reduction
in LOC episodes at 6-month follow-up and in BMI over 1
year, compared with girls randomly assigned to a standard-
of-care health education (HE) program group. However, as
in most pilot studies, the absence of statistical power did not
allow generalizable conclusions on the reported effectiveness.
Consequently, more recently, the same authors82 conducted an
adequately powered clinical trial to verify the effectiveness
of an adapted IPT group of girls compared to an HE control
group. Adolescents of both the groups reported significant
reduction of dimensions of BMI (expected BMI gain, BMI
z score, and BMI percentile), anxiety and depressive symp-
tomatology, and LOC episodes over 1-year follow-up, with
no differences between groups. However, girls in IPT group
have shown a significant decrease of binge eating episodes
at 12-month follow-up.
Finally, we reported two studies83,84 specifically interested
in examining the effectiveness of DBT in reducing binge
eating symptoms. One of them, Safer et al’s study,83 was
a case report of a 16-year-old girl, who has shown a sig-
nificant reduction of binge eating episodes after treatment,
and abstinence from binging at 3-month follow-up. Despite
potential limitations of case–control studies, we considered
this study because it provided a preliminary support for the
utility of the adolescent modified version of DBT in reducing
binge eating episodes. Finally, Mazzeo et al84 examined the
effectiveness of DBT in adolescent girls, compared to a BWL
treatment control group, reporting a significant reduction
Table 4 Psychological treatment studies for adolescents with BED
Reference Age (years)
Psychological treatment
Control group Sample (N) Results (OR: 95% CI) or (p-value) or (Cohen’s d) or (%)
EG CG
DeBar et al79 12–18 CBT (8 sessions over 6 months)
TAU-DT 13 12 CBT participants had a significant higher rate of abstinence from recurrent binge eating at 3 months (p<0.01) and at 6 months (p<0.01; d=1.467), a significant greater improvement in eating-related concerns (p<0.05; d=0.80), shape-related concerns (p<0.01; d=1.04), and weight-related concerns (p<0.01; d=0.64) and significant higher reduction in depressive symptoms (p=0.051; d=0.57) at both 3 and 6 months
Jones et al80 15 Internet-facilitated CBT-self-help intervention (16 session over 16 weeks)
WLC 52 53 Internet-facilitated CBT-self-help intervention was associated with a significant reduction of BMI z scores (p<0.01; d=0.80) and BMI (p<0.01; d=0.60) at 9-month follow-up assessment, a significant decrease of objective and subjective binge episodes at both posttreatment assessment (p<0.01) and follow-up assessment (p<0.05) and a significant lower weight- and shape- related concerns (p<0.05)
Tanofsky- Kraff et al81
12–17 IPT (12 sessions over 12 weeks)
HE 19 19 IPT was associated with significant reduction in LOC episodes at 6-month follow-up (p<0.05) and in BMI (p<0.05) over 1 year
Tanofsky- Kraff et al82
12–17 IPT (12 sessions over 12 weeks)
HE 56 60 Both IPT and HE were associated with a significant decrease in expected BMI gain (p<0.001), BMI z score (p=0.003), BMI percentile (p<0.001), anxiety and depressive symptoms (p<0.001), and the frequency of LOC episodes (p<0.001) over 12-month follow-up. IPT was associated with a significant higher reduction of objective binge eating (p<0.05) at the 12-month follow-up
Safer et al83 16 DBT (30 sessions over 6 months)
None 1 0 DBT was associated with decreased binge eating episodes by the end of treatment and abstinence at 3-month follow-up
Mazzeo et al84 13–17 DBT (12 sessions over 12 weeks)
BWT 28 17 DBT and BWT were associated with significant reductions in eating-related concern (p<0.05), shape-related concern (p<0.05), restraint (p<0.05), global disordered eating attitudes (p<0.05), and negative (p<0.05) effect
Notes: Cohen’s d effect size: 0.20 = small, 0.50 = medium, and 0.80 = large. Abbreviations: BET, binge eating disorder; BMI, body mass index; BWT, behavioral weight loss treatment; CBT, cognitive behavioral therapy; CG, control group; CI, confidence interval; DBT, dialectical behavior therapy; EG, experimental group; HE, health education; IPT, interpersonal psychotherapy; LOC, loss of control; OR, odds ratio; TAU-DT, treatment as usual-delayed treatment; WLC, wait-list control.
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Marzilli et al
in eating-related concern, shape-related concern, restraint,
global disordered eating attitudes, and negative effect in
both the groups.
Summary What is the prevalence of BED in adolescence? BED has only recently been introduced into the psychiatric
nomenclature, and consequently, epidemiological research
of this ED in adolescence is in the early stages. Prevalence
rate for BED was reported in 13 studies, five of them18,40,51–53
using DSM-IV criteria and eight of them10,31,32,39,59–62 using the
DSM-5 criteria. Altogether, our review of the literature on the
prevalence of BED has shown that this disorder is very com-
mon in adolescence phase, with a rate approximately ranging
from 1% to 5%. Moreover, one study18 has also examined the
incidence of BED in female adolescent populations, reporting
a rate of 343 per 100,000 persons.
Although most studies have been conducted with the
samples of teenage girls, nine studies10,18,31,39,51–53,59,60 have
focused on both the sexes, reporting significant sex-related
differences. In particular, girls showed a higher risk for BED
than boys (1%–4%; 0%–1.2%, respectively).31,39,52,53,57 How-
ever, this sex-related difference was less pronounced in other
EDs.86 For this reason, BED represents the most common ED
among male adolescent population.87 Moreover, longitudinal
studies that we reviewed have evidenced that the prevalence
of BED tended to increase over time, with a peak at 19–22
years of age for female adolescents39,61 and at 24 years for
male adolescents.39
Interestingly, it has been evidenced that in adoles-
cents, BED frequently manifests in attenuated, sub-
clinical forms.18,38,39 Indeed, studies with subthreshold
adolescents10,18,32,40,60 found a twofold BED prevalence. More-
over, the prevalence in male adolescents was lower than that
in female adolescents also with respect to SBED diagnoses,
with 0.3%–4.6% in girls and 0%–2.3% in boys.10,18,60
However, the validity of some of the reviewed studies can
be questioned, because the prevalence rate and the definition
itself of binge eating may differ depending on the assessment
measurements used by researchers. In particular, studies that
have used self-report assessments52,53,59,61 tended to report
higher prevalence than interview-based studies.10,18,31,32,39,40,62
This may depend on the fact that interviews may allow
clarifying the subjective experience of “lack of control
overeating” and objectively measure the “large food con-
sumption,” which represent two key criteria for the clinical
diagnosis of BED. Other specific problems are the general
tendency of individuals suffering from BED to hide their ill-
ness, the limited awareness of the clinical relevance of their
disordered eating, and, consequently, the difficulty to seek
for professional help.18,88 For these reasons, future studies
on large sample of adolescents from the general population
are needed.
What are the physical, social, and psychological outcomes of BED in adolescence? Research in the last decade has documented the clinical
significance of BED in terms of adverse physical, social,
and psychological health problems commonly associated
with this condition. In particular, with regard to physical
outcomes, several studies have reported that BED and SBED,
in both female and male adolescents, were predictive of high
rates of overweight and obesity.39,60,61,64 This finding supports
the view of clinical significance of binge eating, given the
important consequences on health associated with obesity
in adolescent and adult populations. Indeed, international
research has evidenced that obesity is associated with an
increased risk to develop severe medical conditions, such as
type II diabetes mellitus (DM), hypertension, cardiovascular
disease, fatty liver disease, and a higher risk for morbidity
and mortality.89
However, many studies have underlined that the impact
of BED leads to an increased risk of developing a variety
of adverse social and emotional-behavioral outcomes, in
both obese and population-based adolescent samples.18,65 In
particular, the cross-sectional and prospective studies that we
considered here have evidenced that both BED and SBED
significantly affect health-related quality of life, with marked
impairment especially in social and family relationships,
and are also associated with negative self-esteem.64,65 More
specifically, adolescents with BED tended to show more
difficulties in social/interpersonal functioning and work/
school achievements, while SBED was strongly associated
especially with lower quality of general daily living and
family burden.18,39,40,59–61,67,68 Although these consequences
of binge eating may be similar for both female and male
adolescents, female adolescents reported the highest levels
of impairment.18,64,65
Moreover, the studies we reviewed have also evidenced
a growing interest in examining possible associations of
BED with psychiatric comorbidities. These studies have
evidenced that BED in adolescence is a strong predictor of
a large spectrum of mental health difficulties. Most of them
showed prospective associations with internalizing problems,
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Binge eating disorder in adolescence
especially depressive (reported by ~45% of subjects with BED), anxiety, and distress symptoms (as displayed by about
one third of adolescents with BED),18,59–61,64,65,67 and suggest-
ing a higher impact on male adolescents.39 Substance use
also seems to affect one fourth of subjects with BED.18,39,60
Finally, a few studies have also examined the possible
impact of BED on suicidality.18,32,60,66 To date, research in this
field is scarce, but some studies suggested that adolescents
with either BED or SBED, as well as other EDs,90 had a
higher risk of suicidal ideation and attempts than non-eating-
disordered youths. In particular, suicidal ideation is found in
~30% adolescents with BED and 20% with SBED, and the frequency of suicidal attempts was 15.1% and 5.3%, respec-
tively.18,32,66 The presence of several self-harm behaviors
among BED adolescents has also been evidenced.60 More-
over, although BED is found to co-occur with several mental
disorders that are known to increase mortality risks,91,92 to our
knowledge no study has so far been published to systemati-
cally examine the effects of BED on mortality.
What is the effectiveness of existing psychological interventions for BED in the adolescent population? To date, evidence for effective treatments for adolescents with
BED is growing but yet scarce and inconsistent. This may be
due to the fact that BED has only recently been included as a
diagnostic category in DSM-5, and, consequently, attention of
clinicians on specific intervention in this area is at its dawn.
However, as our review has shown, in the last decade,
researchers and clinicians have developmentally adapted
some of the intervention approaches that proved effective
for the treatment of BED in adult samples.67–73 In particular,
we have identified some small trials of CBT,79,80 IPT,81,82 and
DBT83,84 involving adolescents and young adults with BED.
In accordance with the NICE guidelines,93 CBT is recom-
mended to be the standard treatment for adult subjects suffer-
ing from BED, and our review has confirmed its effectiveness
in reducing binge eating symptoms and the severity of risk
factors also among adolescent population.79 Moreover, it has
also been evidenced that Internet-based CBT interventions80
can provide a valid support, especially in the early phase of
the syndrome. Furthermore, online interventions have been
shown to have many advantages for their accessibility, due
to the reduced cost and time required, and they may also
facilitate adolescent help-seeking. Also the few studies that
have used adolescent-adapted IPT81,82 and DBT83,84 have
reported findings that seem promising in reducing both binge
eating problems and co-occurring mental health symptoms.
Interestingly, some interventions have also favored weight
loss or a weight maintenance. Given that adult population
with BED has been evidenced that overweight typically fol-
lowed the onset of binge BED,94 previous findings underlined
that an early identification and intervention on binge eating
in adolescence may reduce the risk of excessive weight gain
and, thus, help to prevent adult obesity.
Notwithstanding the studies we reviewed have evidenced
some positive preliminary results in reducing binge eating
episodes and associated psychopathological symptoms, all
of them had small sample size and relatively short follow-up
intervals, precluding definitive conclusions about their effec-
tiveness and appropriateness, and suggesting the necessity
of implementing long-term longitudinal studies to verify
the persistence of clinical benefits over time. Furthermore,
additional research comparing these different methodological
interventions is needed.
Moreover, to the best of our knowledge, no study has yet
been conducted to confirm the effectiveness of psychological
treatment in male adolescents with BED.
Finally, it is important to emphasize that epidemiologi-
cal studies have suggested that only a small percentage of
adolescents with BED (specifically, 11.9%) tended to seek
clinical help.18 Moreover, the high rate of adolescents who
do not meet full-threshold criteria, although they are affected
by various severe physical and psychological negative conse-
quences, makes it even harder to identify them, suggesting the
importance of implementing primary prevention programs
aimed at increasing awareness, reducing stigma, and promot-
ing acceptance of intervention.
Conclusion International research has underlined that adolescence is
characterized by a high risk for the onset of BED, which
represents the most common ED subtype among youths,
posing severe risks to their physical and mental health. Sev-
eral studies have evidenced the complex etiopathogenesis
of BED, which seems to result from dynamic and reciprocal
relationships between different type of variables, including
biological (in particular, familial genetic predisposition and
epigenetic processes),95,96 psychological (such as personal-
ity traits of perfectionism and impulsivity, negative effect
or depressive symptoms, weight and eating concerns, and
body dissatisfaction),98–100 and environmental risk factors, in
terms of parental influences on childhood eating behavior,95
parental psychopathology and psychopathological risk,101
early adverse experiences, and the presence of traumatic
experiences in the parents.102 Among individual risk factor,
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Marzilli et al
it has also been reported that dietary restraint, a general rigid
eating habits and maladaptive weight control behaviors repre-
sent significant risk factor for the onset of BED.103 Moreover,
many studies have reported the predictive role played by peer
influences and perception of a lack of peer support,104,105 as
well as by cultural influences (especially social pressure for
thinness and the resulting body dissatisfaction)97,106 on the
onset of BED. Overall, these findings suggest the impor-
tance of implementing longitudinal studies and randomized
controlled trials to increase our knowledge of long-term
outcomes of BED and support the planning of evidence-based
prevention programs and treatment strategies targeted on the
risk factors for the onset and maintenance of BED. Given
the high prevalence of adolescents who reported SBED,
early detection is needed in order to prevent the evolution
and worsening of eating symptoms. Moreover, although it
has been underlined that a high prevalence of BED may also
be found in male adolescent population, there is a dearth of
studies that have specifically focused on the possible effec-
tiveness of intervention programs in boys with BED. Thus,
future studies including both female and male adolescents
with BED are needed.
Disclosure The authors report no conflicts of interest in this work.
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