Eating disorders can be a contentious issue to raise in conversation. As a doctoral researcher investigating new brain-targeted treatments in this field, I have learned that a broad spectrum exists pertaining to knowledge and attitudes towards this mental health disorder; ranging from an empathetic understanding of their devastating impact to an irked tone which dismissively questions their categorisation among ‘real health problems’.

However, one point of consensus among the general public is that the frail, near-skeletal frame of a teenage girl is the hallmark red flag for what constitutes the presence of an eating disorder. While anorexia nervosa (characterised by rigid and restrictive eating habits to bring about a low body weight) is a grave illness that merits widespread awareness, it is not the most prevalent eating disorder.

There is another diagnosis hiding in the shadows that continues to affect 3 times more lives than those impacted by anorexia. Binge eating disorder (BED) is recognised by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a psychiatric illness that afflicts millions of people worldwide.

It manifests as loss-of-control binge eating where an abnormally large amount of food is eaten within a short timeframe, with the absence of behaviours found in bulimia nervosa to compensate for the calories consumed during the binge episode (vomiting, excessive exercise, and laxative use constituting frequent methods). When binge eating occurs at least once a week, and additional features accompany it (distress, eating alone due to embarrassment, and feeling very guilty about this pattern of behaviour), diagnostic criteria for BED are met.

Estimations of population prevalence of BED range from 1-5% on different continents, averaging out with the global statistic conservatively placed at 2%. How can it be that there is such paucity of knowledge about an eating disorder affecting approximately 1 in 50 people worldwide?

I believe the answer lies in a confluence of factors. Firstly, BED didn’t exist in its own right in the clinical realm until 2013. Previously, it featured only in the DSM Appendix, under the Eating Disorders Not Otherwise Specified category. It now forms part of the triad of recognised eating disorders alongside anorexia nervosa and bulimia nervosa.

As a diagnosis in its relative infancy, it has yet to garner the attention of the media and popular culture, which, on balance, have been helpful in disseminating awareness of other eating disorders via character portrayals in movies and television series, prompting myriad opportunities to discuss and educate.

However, it is likely that another causal factor may play a greater role in hushing the voices of those struggling with symptoms of BED. A higher body mass index is correlated with this specific eating disorder, as binge eating episodes result in many people with BED gaining and maintaining a higher weight.

Weight stigma is recognition of the unpleasant social consequences of living in a larger body, where ridicule and discrimination in workplace and educational settings play the insidious role of ‘teaching’ people with BED symptoms to feel shame and suffer isolation for their unbalanced relationship with food.

In working with BED patients, I have heard many times a variation of the following refrain; ‘what’s the point in explaining – why would anyone believe I have an eating disorder, when all they see is fat?’

Further compounding the level of bias perpetuated, clinical care settings are not immune to this discriminatory behaviour. Research into the attitudes of health professionals has exposed an overweight bias held by some health care providers, particularly physicians, that obese individuals are lazy, and lacking will-power, and deemed undisciplined and non-compliant with treatment.

Combined with the aforementioned blind spot in public consciousness, the knock-on effects of pervasive weight stigma shape an environment where those with symptoms of BED either don’t know they may meet criteria for an eating disorder that is causing them marked psychological distress, or they are reluctant to express their concerns to their doctor and take the first step towards treatment.

The World Health Organization’s (WHO) survey data spanning 14 countries indicates that almost 80% of those who experience BED at some point in their lives have suffered from another mood, anxiety or substance use disorder. Daily stigmatising experiences and a lack of understanding from family, friends and doctors exacerbate the emotional distress felt, leading to more frequent binge eating episodes and co-morbid illnesses.

To conclude, binge eating disorder is not being talked about, in part because our public sphere is implicitly and explicitly communicating that we aren’t ready and willing to listen. Widespread derision is anathema to the cultivation of compassion, and as a society, we have much terrain to cover to collectively achieve a place of empathy and understanding. Only then, can we facilitate a space for those with BED to begin sharing their stories in greater numbers.