Exploring the continuum of eating behaviour, from ‘normal’ to disordered eating

Jordan Beaumont Lecturer in food and nutrition, Sheffield Business School, Sheffield Hallam University, Sheffield, England

Why you should read this article:

• • To understand that there is a continuum in people’s eating behaviour from ‘normal’ to disordered eating

• • To familiarise yourself with the symptoms of binge eating behaviour

• • To learn about nursing interventions such as a screening tool for identifying binge eating behaviour

Eating is a distinct behaviour in humans, in that they must consume food to provide sufficient energy for the body to function and to ensure survival. Behaviours around food consumption can range from ‘normal’ to disordered, where some people may develop eating patterns that suggest a preoccupation with food or weight. This preoccupation can lead to inappropriate compensatory behaviours, such as purging or excessive exercise, or dysphoric mood following food consumption. This article discusses the continuum between ‘normal’ eating behaviours and eating disorders, with a focus on binge eating behaviour and binge eating disorder. The author also describes the use of a screening tool for identifying binge eating behaviour and suggests ways in which nurses might support patients in addressing disordered eating behaviours.

Nursing Standard. doi: 10.7748/ns.2024.e12354

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@JordanDBeaumont

Correspondence

J.Beaumont@shu.ac.uk

Conflict of interest

None declared

Beaumont J (2024) Exploring the continuum of eating behaviour, from ‘normal’ to disordered eating. Nursing Standard. doi: 10.7748/ns.2024.e12354

Published online: 22 August 2024

Keywords :

binge eating - body image - clinical - eating disorders - mental health - nutrition - nutritional intake - patients - professional

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Eating is a distinct behaviour in that humans must consume food to survive (Meule and Vögele 2013). Eating behaviour is defined by frequency (how often food is eaten) and size (how much is consumed) (Blundell and Gillett 2001). Individuals constantly make decisions about what, when and how much to eat, which are influenced by a complex interaction of physiological, psychological, genetic, social and environmental factors (Herman et al 2003, Blundell 2006, Abizaid and Horvath 2008, Grimm and Steinle 2011, Allom and Mullan 2014a).

The behavioural component of eating is essentially muscular movement under conscious control, where food is selected, placed in the mouth, chewed and the bolus is swallowed. However, as Muraven and Baumeister (2000) reflected, ‘most dieters can attest that refraining from such behaviours can seem more difficult and draining than performing them’. This difficulty in refraining from certain eating behaviours is likely due to the influence of internal control mechanisms and a wide range of internal and external factors.

In this article, the author provides an overview of the ‘continuum of eating behaviours’, with a focus on binge eating behaviour and binge eating disorder, and suggests some ways in which binge eating behaviour may be identified and managed.

Continuum of eating behaviour

While eating behaviour refers to all behavioural responses to food, it is often framed within the context of actual or perceived overconsumption of food and/or the control of dietary intake. Dakin et al (2023) conceptualised eating behaviours within four theoretical domains, which influence how people interact with food:

• • Homeostatic eating – responding to internal physiological cues linked to energy and nutrient availability, for example feelings of fullness arising from distention of the gastrointestinal tract.

• • Reflective eating – the conscious control of eating, for example self-regulation of eating or dietary restraint.

• • Reactive eating – eating in response to reward-based cues, emotions or life events.

• • Disordered eating – problematic eating linked with a preoccupation with food, weight and/or body image.

In the author’s view, eating behaviour can be considered a continuum between ‘normal’ eating and eating disorders. Figure 1 demonstrates how the continuum of eating behaviour is influenced by internal control mechanisms (homeostatic, reflective and reactive eating), individual factors, such as body image, and external factors, such as the cost of food. It also shows how disordered eating can result in a cycle of restraint and provides some examples of eating disorders. The information contained in the figure is based on a collation of the evidence cited in the article.

Figure 1.

Continuum of eating behaviour

‘Normal’ eating at one end of the continuum can be defined as the integration of the internal ‘top-down’ (reflective and reactive eating, driven by cognitive control) and ‘bottom-up’ (homeostatic eating, driven by body sensations) mechanisms to control food consumption by driving dietary intake when the person requires calories and resisting dietary intake when the person is satiated (Blundell et al 2015, Beaulieu and Blundell 2021). This type of eating behaviour may involve habits or rules, such as choosing low-calorie options to compensate for consumption of a high-calorie snack, but does not involve preoccupation with or restriction of food, negative feelings associated with consuming food, such as guilt, or compensatory behaviours such as purging or excessive exercise (Taylor et al 2005, Allom and Mullan 2014b).

At the other end of the continuum are eating disorders, defined in the International Classification of Diseases 11th Revision (ICD-11) (World Health Organization (WHO) 2024a) as involving ‘abnormal eating behaviour and preoccupation with food as well as prominent body weight and shape concerns’, which are ‘not explained by another health condition and are not developmentally appropriate or culturally sanctioned’.

Disordered eating lies between these two points of the continuum and may be expressed through, for example, binge eating behaviour, emotional eating or dietary restriction, resulting in a ‘cycle’ of restraint (the restriction of food), deprivation and disinhibition (a tendency to overconsume in response to cues, emotions or events) and negative emotions, such as feelings of guilt, poor body image and excessive focus on diet and weight.

Binge eating behaviour and binge eating disorder

Binge eating is characterised by a loss of control of eating behaviour, where the individual eats notably more or differently than their usual consumption over a short period of time, for example two hours (WHO 2024b). Individuals who present with binge eating behaviour may have an excessive focus on their dietary intake, weight and/or body image, which may induce negative feelings of anxiety, guilt and shame, as well as weight fluctuation (Wells et al 2020, WHO 2024b). These feelings and consequences can adversely affect an individual’s quality of life due, for example, to reduced social, emotional and psychological well-being (Hart et al 2020, van Hoeken and Hoek 2020) and can lead to a sense of loss of control around eating (Perelman et al 2023).

The ICD-11 states that binge eating disorder is ‘characterised by frequent, recurrent episodes of binge eating (e.g. once a week or more over a period of several months)’ (WHO 2024b). The ICD-11 diagnostic criteria for binge eating disorder (WHO 2024b) are shown in Box 1.

Box 1.

Diagnostic criteria for binge eating disorder

• • Frequent, recurrent episodes of binge eating (for example, once a week or more over a period of three months). Loss of control of eating may be described by the individual as feeling like they cannot stop or limit the amount or type of food eaten; having difficulty stopping eating once they have started; or giving up trying to control their eating because they know they will end up overeating

• • Binge eating episodes are not regularly accompanied by inappropriate compensatory behaviours aimed at preventing weight gain

• • Symptoms and behaviours are not better accounted for by another medical condition (for example, Prader-Willi Syndrome) or mental health condition and are not due to the effects of a substance or medicine on the central nervous system, including withdrawal effects

• • There is marked distress about the pattern of binge eating or significant impairment in personal, family, social, educational, occupational or other important areas of functioning

(Adapted from World Health Organization 2024b)

Prevalence

A systematic literature review reported that the prevalence of binge eating disorder is relatively low, at around 3% lifetime prevalence in women and around 1% in men (Galmiche et al 2019). However, a meta-analysis of global prevalence of eating disorders found that eating disorders in general are common in the general population and may be increasing, although the researchers cautioned that this may be due to changes in diagnostic criteria (Qian et al 2013).

Wilfley et al (2016) reported that binge eating disorder can affect 13-27% of individuals who are seeking weight loss treatment, while binge eating severity has been found to be positively correlated to body mass index (Finlayson et al 2011). While some evidence suggests that people with binge eating disorder are more likely to have obesity (Villarejo et al 2012), it is distinct from the condition (Davis 2009, Dalton et al 2013, Davis 2013) and is not a criterion for binge eating behaviour in the ICD-11 (WHO 2024b) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association 2013).

Key points

• • Binge eating is characterised by a loss of control of eating behaviour, where the individual eats notably more or differently than their usual consumption over a short period of time

• • A particular focus for people with binge eating behaviour is the effect on their weight status, therefore they may frequently measure their body weight or size

• • It is important to acknowledge that it may be difficult and/or distressing for the individual to discuss their eating behaviour and that they are vulnerable to experiencing stigma and shame

• • Management of binge eating behaviour should involve an evidence-based, person-centred and compassionate approach that addresses the specific needs of the individual

Symptoms

Binge eating episodes can be described as ‘objective’, where the person eats a larger amount of food than most people in similar circumstances, or ‘subjective’, where the person consumes an amount of food which might be objectively considered normal but which they experience as large (WHO 2024b). In both cases, the core feature of the binge eating episode is ‘the experience of loss of control over eating’ (WHO 2024b).

During a binge eating episode, food may be consumed more rapidly than usual, consumed in the absence of hunger or consumed alone, due to feelings of embarrassment, and the experience may be distressing and result in feelings of guilt or shame (Dingemans et al 2017). A particular focus for people with binge eating behaviour is the effect on their weight status, therefore they may frequently measure their body weight or size (Davis et al 2020).

No matter how hard a person may try, it is unlikely that the rewarding value of food will be diminished by the conscious decision to restrict consumption (dietary restriction); instead, the initiation of eating often occurs outside conscious awareness and is activated by the presence of food or related cues, such as the sight or smell of food or a response to life events (Higgs 2016, de Araujo et al 2020). Moreover, binge eating behaviour is not necessarily preceded by dietary restriction (Abbott et al 1998).

Individuals who display binge and emotional eating behaviour appear to have hyper-responsivity to the rewarding aspects of food, which is associated with reduced dietary self-regulation (Davis 2009, Dalton et al 2013, Davis 2013). This may lead to reactive or impulsive consumption of foods in response to internal or external cues and motivations, such as food craving, emotional eating and stress eating (French et al 2012, Dakin et al 2023). This can result in the consumption of perceived ‘forbidden’ foods – often those which are highly palatable and rewarding – which can negatively affect the person’s emotional state (Lowe and Butryn 2007, Johnson et al 2012, Seage and Lee 2017, Kelly et al 2022). Long-term control of binge eating behaviour and disordered eating more broadly requires a careful balancing of two conflicting goals – eating enjoyment and weight control (Stroebe et al 2013, Stroebe 2022).

Eating behaviour and nursing

Nurses’ work patterns and occupation-related stress can significantly influence eating behaviour and may contribute to binge or emotional eating. Evidence suggests that nurses working in hospitals experience unique influences on their eating behaviour, including long working hours, irregular working patterns and occupation-related stress (Horton Dias and Dawson 2020). A study by Gürkan et al (2022), involving 297 hospital nurses, reported that perceived stress was positively correlated with emotional eating, while a Korean study of 298 nurses in two hospitals reported that 8% of participants demonstrated ‘clinical-level abnormal eating behaviour’ and that sleep quality and passive coping were the main influencing factors regarding abnormal eating behaviours (Kim and Jung 2021). In addition, working shifts and experiencing depression had significant indirect effects on abnormal eating behaviours (Kim and Jung 2021). A Korean study reported that among 7,267 female nurses, 7% had symptoms of binge eating disorder, more than double the prevalence reported in other studies (Kim et al 2018).

Barriers to healthy eating among hospital nurses include workplace environmental factors, such as limited access to healthy foods, easy availability of snacks high in fat, salt and sugar and limited time to prepare meals (Marko et al 2023), which can result in binge-type eating, particularly in nurses who work long and erratic hours (Power et al 2017, Reis et al 2020).

Further resources

NHS England eating disorders training for health and care staff

Screening

Binge eating disorder is underdiagnosed and undertreated (Kornstein et al 2016), despite the availability of various resources that can be used to identify binge eating behaviour. One example is the Binge Eating Disorder Screener-7 (BEDS-7) (Table 1), which was developed to assist primary healthcare professionals to identify patients who may have binge eating disorder so that they can refer them for further assessment and diagnosis (Herman et al 2016). A ‘yes’ response to question two and marking at least one of the shaded boxes – that is, ‘sometimes’, ‘often’ or ‘always’ for questions three to six and/or ‘never or rarely’ or ‘sometimes’ for question seven – indicates the possibility of a binge eating disorder (Table 1). With regards to question seven, vomiting as a means of weight control is a symptom of bulimia nervosa and not binge eating disorder.

Table 1.

Binge Eating Disorder Screener-7 (BEDS-7)

The following questions ask about your eating pattern and behaviours within the past 3 months. For each question, choose the answer that best applies to you
During the past 3 months, did you have any episodes of excessive overeating (for example, eating significantly more than what most people would eat in a similar period of time)?			Yes	No
If you answered ‘No’ to question 1, you may stop here. The remaining questions do not apply to you
Do you feel distressed about your eating episodes or excessive overeating?			Yes	No
Within the past 3 months:	Never or rarely	Sometimes	Often	Always
During your episodes of excessive overeating, how often did you feel like you had no control over your eating (for example, not being able to stop eating, feeling compelled to eat, or finding yourself going back and forth for more food)?
During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?
During your episodes of excessive overeating, how often were you embarrassed by how much you ate?
During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterwards?
During the past three months, how often did you make yourself vomit as a means to control your weight or shape?

A ‘yes’ response in at least one of the shaded boxes indicates the possibility of a binge eating disorder (Adapted from Herman et al 2016)

Nurses could use the BEDS-7 with patients who self-report body shape or weight concerns linked with consumption of large amounts of food in a short timeframe. The tool can be completed by the patient alone or with assistance from the nurse.

Support

Following the use of a screening tool such as the BEDS-7, the nurse may try to engage the person in a discussion about their eating behaviour. There is no ‘correct’ way of eating and there are nuances in ‘normal’ and ‘healthy’ eating (Allom and Mullan 2014b, Verain et al 2022), therefore the nurse should consider individual heterogeneity when approaching discussions about management of binge eating behaviour (MacLean et al 2017). While it is important to explore the effects of disordered eating on the person’s physical and mental health, it is equally important to acknowledge the role of food in people’s lives. For example, food can be a source of pleasure and reward, used to build social connections and used as an expression of identity, culture or religion (Alonso-Alonso 2013, Neely et al 2014, Monterrosa et al 2020, Reddy and van Dam 2020). Nurses may also consider the individual and external factors shown in Figure 1 that influence eating behaviour.

There is no ‘one-size-fits-all’ strategy for addressing binge eating behaviour, since each individual presents with a different pattern of behaviour, caused by different factors to which they respond in individual ways. Similarly, each individual will have different support frameworks and care needs. Moreover, binge eating behaviour, and wider disordered eating, can affect people of any gender, age, ethnicity or culture (Pike et al 2013, Mitchison et al 2014), therefore nurses should be careful not to dismiss those who do not align with the ‘typical’ demographic profile described in research, which tends to be young Caucasian females (Qian 2013, Galmiche 2019). It is also important that the nurse is aware of the influence of family and/or peer groups in both the cause and management of disordered eating (National Institute for Health and Care Excellence (NICE) 2019).

The five-item toolkit proposed by Ogden (2018), originally developed to address weight loss through dieting, aligns well with supporting patients to address disordered eating (Box 2). It is important to acknowledge that it may be difficult and/or distressing for the individual to discuss their eating behaviour and that they are vulnerable to experiencing stigma and shame. Therefore, such conversations should be approached with sensitivity, empathy, compassion and respect (NICE 2019).

Box 2.

Supporting patients to address disordered eating

• • Nurses may support patients to manage disordered eating by discussing and/or supporting them to address the following areas:

• • Identifying opportunities for change – for example, by considering how certain life events that influence disordered eating might be better managed or avoided

• • Changing the way they think and feel about food, weight and body shape – for example, altering their perceptions of what constitutes ‘good’ and ‘bad’ foods, avoiding use of weight-centric measures such as body mass index. Nurses can provide patients with evidence-based guidance on healthy eating, such as the Eatwell Guide (https://www.nutrition.org.uk/media/ayth4ma4/eatwel-1.pdf)

• • Creating new behaviours – for example, meal planning and discussing different ways of managing negative emotions. Nurses can use information and resources from websites such as the British Nutrition Foundation (https://www.nutrition.org.uk/) and the British Dietetic Association (https://www.bda.uk.com/) to support behaviour change

• • Managing the environment – for example, understanding and avoiding triggers, such as avoiding supermarket aisles containing foods often chosen for binge eating or taking alternative routes to avoid passing certain food outlets

• • Moving forward and planning for the future – for example, practising mindfulness and self-compassion, reframing perceived failure as an opportunity to learn and adapt. Nurses can signpost patients to resources such as the American Heart Association guide to mindful eating (https://www.heart.org/en/healthy-living/healthy-lifestyle/mental-health-and-wellbeing/mindful-eating-infographic)

(Adapted from Ogden 2018)

Nurses can also signpost patients to organisations such as Beat Eating Disorders (www.beateatingdisorders.org.uk) or resources produced by YoungMinds (www.youngminds.org.uk/young-person/my-feelings/eating-problems). For patients who require specialist support, nurses can search REDCAN (www.redcan.org.uk/charities) for information on support services in specific geographical areas. Referral to an eating disorder service is usually made via the patient’s GP. Referral routes and service provisions will differ by locality.

Conclusion

Eating behaviours are influenced by internal control mechanisms and individual and external factors along a continuum from ‘normal’ to disordered eating. Individuals engaging in binge eating behaviour, characterised by a preoccupation with dietary intake, body image or weight status, can experience negative emotions in response to food consumption. Screening for binge eating behaviour and/or binge eating disorder can be achieved using a tool such as the BEDS-7. Management of binge eating behaviour should involve an evidence-based, person-centred and compassionate approach that addresses the specific needs of the individual.

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