International Journal of Obesity (2009) 33, 342–353
& 2009 Macmillan Publishers Limited All rights reserved 0307-0565/09 $32.00
www.nature.com/ijo
ORIGINAL ARTICLE
Associations among binge eating behavior patterns
and gastrointestinal symptoms: a population-based
study
F Cremonini1, M Camilleri1, MM Clark2, TJ Beebe3, GR Locke1, AR Zinsmeister3, LM Herrick1,4
and NJ Talley1,5
1
Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, MN, USA;
Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA; 3Division of Biostatistics, Mayo Clinic,
Rochester, MN, USA; 4School of Nursing, University of Minnesota, Rochester, MN, USA and 5Department of Internal
Medicine, Mayo Clinic, Jacksonville, FL, USA
2
Background: The psychological symptoms associated with binge eating disorder (BED) have been well documented. However,
the physical symptoms associated with BED have not been explored. Gastrointestinal (GI) symptoms such as heartburn and
diarrhea are more prevalent in obese adults, but the associations remain unexplained. Patients with bulimia have increased
gastric capacity. The objective of the study was to examine if the severity of binge eating episodes would be associated with
upper and lower GI symptoms.
Methods: Population-based survey of community residents through a mailed questionnaire measuring GI symptoms, frequency
of binge eating episodes and physical activity level. The association of GI symptoms with frequency of binge eating episodes was
assessed using logistic regression models adjusting for age, gender, body mass index (BMI) and physical activity level.
Results: In 4096 subjects, BED was present in 6.1%. After adjusting for BMI, age, gender, race, diabetes mellitus, socioeconomic
status and physical activity level, BED was independently associated with the following upper GI symptoms: acid regurgitation
(Po0.001), heartburn (Po0.001), dysphagia (Po0.001), bloating (Po0.001) and upper abdominal pain (Po0.001). BED was
also associated with the following lower GI symptoms: diarrhea (Po0.001), urgency (Po0.001), constipation (Po0.01) and
feeling of anal blockage (P ¼ 0.001).
Conclusion: BED appears to be associated with the experience of both upper and lower GI symptoms in the general population,
independent of the level of obesity. The relationship between increased GI symptoms and physiological responses to increased
volume and calorie loads, nutritional selections and rapidity of food ingestion in individuals with BED deserves further study.
International Journal of Obesity (2009) 33, 342–353; doi:10.1038/ijo.2008.272; published online 13 January 2009
Keywords: binge eating; exercise; GI symptoms
Introduction
Gastrointestinal (GI) disorders, especially functional GI
disorders, have been shown to induce high health-care
utilization and negative impact on quality of life.1 Chronic
GI symptoms such as heartburn and diarrhea are more
prevalent in obese adults, but the associations remain
unexplained.2 Binge eating disorder (BED) occurs in a subset
Correspondence: Dr NJ Talley, Department of Internal Medicine, Mayo Clinic,
4500 San Pablo Road, Davis Building, 6th Floor E/B, Jacksonville, FL 32224,
USA.
E-mail: [email protected]
Received 18 March 2008; revised 4 November 2008; accepted 18 November
2008; published online 13 January 2009
with obesity; rapid food ingestion might lead to GI
symptoms but this has been little explored.3 The objective
of this study was to examine if binge eating is associated with
upper and lower GI symptoms, and to explore the relationships between BED, obesity and GI symptoms.
Obesity has become a major epidemic worldwide. According to the National Center for Health Statistics, more than
half of the US population aged 20 or older is overweight
(body mass index, BMI): 25.0–29.9 kg/m2), and a quarter are
obese (BMI X30 kg/m2).4 Researchers in Europe have found
an association between a higher BMI and the presence of
symptoms compatible with gastroesophageal reflux disease.5
A population-based case–control study in Norway observed
that obesity was associated with a higher prevalence of
endoscopic esophagitis.6 In a survey of residents of Olmsted
Binge eating, exercise and GI symptoms
F Cremonini et al
343
County, MN, USA, Delgado-Aros et al.2 found that individuals with a higher BMI were more likely to report symptoms
attributable to the upper and lower GI tract, including
vomiting, upper abdominal pain, bloating and diarrhea. In
addition, increases in body weight of over 4.5 kg over a
10-year period are associated with the onset of new GI
symptoms.7 However, an explanation for this link between
obesity and GI symptoms remains to be provided.
Obese individuals with BED may help account for this
association. Features of BED include eating a large amount of
food in a short period of time, eating rapidly and experiencing a perceived loss of control over eating.8,9 From a
physiological perspective, excessive intake of food over
a relatively short time could potentially overcome the
functional accommodation and emptying reserve of the
stomach, and contribute to the genesis of GI symptoms in
obese individuals. BED has been reported to be relatively
frequent in obese adults although the exact prevalence is
unclear.10–12 A survey of 1632 overweight individuals in the
Midwest of the United States found that approximately 9%
of men and 13% of women were likely to be binge eaters.13
The psychological factors associated with BED are well
documented. Obese binge eaters report higher levels of
depression, more negative body image, lower quality of life14
and lower self-confidence compared to obese non-binge
eaters.15,16 In contrast, the physiological characteristics
associated with BED are not well understood.
The effect of specific patterns of eating behavior such as
binge eating on the development of both upper and lower GI
symptoms in obesity is incompletely defined. Crowell et al.3
found associations between binge eating, obesity and
symptoms of irritable bowel syndrome in a small, tertiary
referral patient study, but no population-based data are
currently available. In addition to perhaps helping design
more efficacious interventions for BED, if patterns of food
ingestion contribute to the development of unexplained GI
symptoms, then attention to eating patterns may provide for
a simple, safe and potentially effective nonpharmacological
or behavioral method to treat symptoms suggestive of
functional GI disorders. It is also conceivable that some
individuals presenting for medical treatment for GI symptoms could be better managed by identification and receiving
treatment for concurrent BED. This is an important issue
given the recent attribution of cardiovascular events, and
ischemic colitis to serotonergic agents that were used for the
treatment of such GI symptoms.17 Such vascular risks may be
even more pertinent in obese individuals, who often have
vascular comorbidity.
In searching for physiological differences in BED, Geliebter
and colleagues have demonstrated that the stomach capacity
of patients with BED is greater than that of controls. The
stomach capacity of non-BED obese individuals,18,19 measured either with intubated20 or noninvasive imaging, was
not significantly different from that of controls.21,22 We have
also observed that increased gastric capacity is associated
with lower postprandial symptoms and satiation.23 Thus, it
is thought that due to increased gastric accommodation in
BED, there may be less of an upper GI symptom burden, but
the increased intake may precipitate colonic discomfort
because of an increased osmotic load downstream.
Given the increased gastric capacity of patients with BED,
the hypothesis of this study was that BED would be
associated with reduced upper abdominal symptoms, but
greater lower GI symptoms. The aim of this study was to
assess the association between binge eating episodes and
upper and lower GI symptoms in a cross-sectional population study. We also assessed the impact of physical activity
levels, and other demographic and lifestyle covariables (age,
race, educational level, presence of diabetes mellitus,
cigarette smoking and alcohol consumption) on the association of binge eating episodes with GI symptoms. The effects
of physical activity level on GI symptoms were explored
because epidemiological and clinical studies have reported
contrasting results on the effects of physical activity level on
GI morbidity and function,24 and because it is unknown
whether physical activity level moderates any effect of BED
on induction of GI symptoms.
Methods
Sampling frame
The responses utilized in this study were obtained from two
distinct sampling frames. The first was based on an
enumeration of the local community through the medical
records linkage system (the Rochester Epidemiology Project,
REP) and the second was a purchased list-based sample of
noninstitutionalized residents of Olmsted County, MN, who
were 18 years and older. This study was approved by Mayo
Clinic’s Institutional Research Review Board, and
participants were informed regarding the research purpose
of the survey. Because Mayo Clinic is considered a covered
entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations, the Mayo IRB
typically requires a signed HIPAA Authorization Form
(HAF) for all studies that involve receipt of personal health
information, including survey-based investigations. Consistent with the HIPAA guidelines (http://www.hhs.gov/ocr/
hipaa), the HAF contained the following information: (1)
purpose (title of the study); (2) what patient information is
being used or disclosed; (3) who is authorized to receive and
use the patient information; (4) who is authorized to disclose
patient information; (5) right to refuse to sign and revoke
authorization at any time; (6) potential for re-disclosure of
patient information; (7) expiration date (for example, ‘end of
study’ vs ‘never’) and (8) signature. Information only from
those who completed and returned a signed HAF was used in
the present analyses.
First sampling frame. The initial sampling frame was
developed using the infrastructure of the REP, which
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F Cremonini et al
344
provides what is essentially an almost complete (495%)
enumeration of the population of Olmsted County, MN.25
This enumeration stems from the medical records linkage
system of the Mayo Clinic, which is the major health-care
provider in the county.25 The potential of this data system
for use in population-based studies has been described
previously.25,26 Using this enumeration of the county as
the sampling frame, a gender and age-stratified (10-year age
groups, age range 18–65 years) random sample of 4805
county residents was selected. The ethnic constitution of
southeastern Minnesota communities is approximately 90%
Caucasian, 5% Southeast Asian and 5% other minorities.25
Subjects were randomly selected using the enumeration of
the local community provided by the REP and mailed a
29-item survey containing questions about GI symptoms,
current height and weight, eating habits, physical activity,
education level, race, diabetes mellitus, alcohol and cigarette
use and family history of abdominal problems. Two separate
mailings were sent in November 2003 and January 2004.
Institutionalized subjects, or those who could not be located
by mail, subjects who had moved from the Olmsted County
from the last contact with the Mayo Clinic and subjects who
had denied authorization for research were considered
ineligible and excluded. The Mayo Clinic Survey Research
Center performed data retrieval and built the database.
Second sampling frame. The second sampling frame utilized
a list-appended random digit dial (RDD) sample whereby
postal addresses were appended to the RDD telephone
numbers if they were found in listed directories. This sample
was purchased from an outside survey sampling vendor and
included a total of 7000 noninstitutionalized adults aged 18
and older residing in Olmsted County. The questionnaire
sent in this mailing was a somewhat expanded version of the
initial survey. This second survey included items that
assessed mental health status. On this occasion, the data
collection protocol consisted of the following steps: an
initial mailed survey with a cover letter message explaining
the study; a second mailed survey 3 weeks after the initial
mailing, again with cover letter message, to nonrespondents
to the previous mailing; and nonrespondents to the previous
two mailings were sent to the telephone interviewing staff
approximately 5 weeks after the initial mailing.
The flow of the surveys is shown in Figure 1. A total of 943
subjects responded to the initial survey (response rate 26%)
and 3181 subjects (46% of the sample) responded to the
repeat survey. Responders and nonresponders were similar
sociodemographically (see results).
Questionnaire, binge eating patterns and exercise definitions
GI symptoms. All the items had been previously individually validated. The questions on GI symptoms were based on
the Bowel Disease Questionnaire but used a five-point Likert
scale.27 Constipation was defined as the report of less than
three bowel movements per week. Diarrhea was defined as
International Journal of Obesity
the report of more than three bowel movements per day. An
overall symptom score (mean over all 16 symptom items)
was also computed using the five-point Likert scale values for
each item.
Binge eating. Key questions on eating behavior were based
on the Questionnaire on Eating and Weight Patterns-Revised
and have been shown to reliably predict BED in previous
studies.13 The subjects were asked:
(1) In the last three months, did you often eat within any
two-hour period what most people would regard as an
unusually large amount of food? (choice Yes/No),
(2) If yes, during the times when you ate this way, did you
often feel you could not stop eating or control what or
how much you were eating? (choice Yes/No),
(3) If yes, over the past three months, how often did you feel
you could not stop eating or control what or how much
you were eating? (choices from 1 to 7 days per week).
Subjects were classified as ‘over-eaters’ if they provided a
positive response to question 1. Subjects responding positively to the first two questions and providing a frequency of
at most two episodes per week were characterized as ‘binge
eaters’ as many would not fully meet diagnostic criteria for
BED. We applied this more conservative approach due to use
of a mailed survey and the lack of clinical confirmation.
Those with three or more days per week of binge eating
episodes were classified as having BED, as they met
diagnostic criteria for this eating behavior pattern and
reported having a greater frequency of binge eating episodes
than the rest of the survey sample.13
Physical activity level.
follows:28
Physical activity was measured as
a. Aside from any work you do at home or at a job, do you do
anything regularly, that is, on a daily basis that helps you
keep physically fit? (choice Yes/No),
b. How often in your free time, do you take part in moderate
physical activity (such as bowling, golf, light sports or
physical exercise, gardening, taking long walks)? (choices
more than 4 times a week, 2–4 times a week, about once a
week, a few times a month, a few times a year, rarely or
never),
c. How often, in your free time, do you take part in vigorous
physical activity (such as jogging, racket sports, swimming, aerobics, strenuous sports)? (frequency choices as in
previous question).
The two questions eliciting self-report of exercise levels:28
‘moderate’(for example, walking, gardening) and ‘vigorous’
(for example, swimming, jogging, aerobics), both on sixpoint Likert frequency scales (rarely to daily) were used to
compute a quantitative physical activity level score. A
greater score was indicative of higher physical activity levels.
Binge eating, exercise and GI symptoms
F Cremonini et al
345
Survey 1
(2003-04)
4805 surveys sent
1038 ineligible
327 refused
943 respondents included (26% of eligible)
2497 no answer
Survey 2
7,000 surveys sent
(2005-06, includes
phone questioning)
3,292 survey forms returned/followed by phone
3,181 survey respondents included (46%)
111 returned surveys
excluded
• Incomplete data
• Incoherent demographic
information
• Denied authorization
Total of responders included with complete data
N=4124
Figure 1 Summary of survey recruitment.
For the purpose of summarizing symptom data, in
addition to the physical activity score, the responses to
these questions were also used to categorize the participants
into different levels of physical activity:
(1) High exercisers, reporting engaging in vigorous exercise at
least a few times a week.
(2) Moderate exercisers, reporting engaging in moderate
exercise at least two times a week and vigorous exercise
at most a few times per month.
(3) Light exercisers, reporting engaging in moderate exercise
at least a few times a month to once a week and vigorous
exercise at most a few times per month.
(4) Rare exercisers, reporting vigorous or moderate exercise at
most a few times a year.
Body mass index. The BMI was calculated from self-reported
height and weight. Data from the Third National Health and
Nutrition Examination Survey suggest that the misclassification of overweight and obese subjects obtained using selfreport BMI is minimal.29 BMI levels were based on the WHO
classification of obesity.30
Mental health status
Questions from the vitality and mental health scales were
used from the SF-12.31 The subjects were asked the following
questions with the stem of ‘How much of the time during
the past 4 weeks’:
(1) Did you have a lot of energy?
(2) Have you felt downhearted and blue?
The mean of these two responses (six-point Likert scale:
1 ¼ ‘all of the time’ to 6 ¼ ‘none of the time’), first reversing
the scale for the second question, was computed for each
subject. In addition, a question from the SF-12 on whether
physical health or emotional problems interfered with social
activities during the past 4 weeks was included as a covariate
along with the mean response of the two questions above to
adjust for mental health and physical/emotional status.
Demographic and other risk factors. Alcohol consumption
and smoking status were asked using single items covering
current use (past 30 days). Other questions also asked about
any history of abdominal pain in first-degree relatives, any
diagnosis of diabetes mellitus, education level attained and
ethnicity.
Statistical analysis
For the main analyses, respondents from both sampling
framesFthe enumeration of the local community through
the REP medical records linkage system and the purchased
list-based sample of Olmsted County residentsFwere
International Journal of Obesity
Binge eating, exercise and GI symptoms
F Cremonini et al
International Journal of Obesity
1.8 (1.0–3.9)
1.9 (0.0)
249
1.5 (1.0–3.2)
1.6 (0.0)
365
1.4 (1.0–4.1)
1.5 (0.0)
Abbreviation: BMI, body mass index. aMissing data on binge eating behavior.
3462
1.9 (1.1–3.4)
1.8 (0.1)
28
1.5 (0.0)
4104
1.4 (1.0–4.1)
45.0 (18.0–84.0)
30.5 (16.5–52.3)
8.0 (3.0–18.0)
45.1 (0.8)
31.1 (0.5)
9.5 (0.3)
250
250
250
44.0 (18.3–86.0)
28.3 (16.9–59.6)
10.0 (3.0–18.0)
44.4 (0.7)
29.2 (0.3)
10.5 (0.2)
365
365
365
52.0 (18.0–100.0)
26.1 (3.2–69.1)
9.0 (2.0–18.0)
52.1 (0.3)
26.9 (0.1)
9.9 (0.1)
3481
3481
3481
59.5 (19.1–89.0)
24.2 (19.5–33.1)
11.0 (4.0–18.0)
56.4 (3.7)
24.7 (0.7)
11.6 (0.8)
28
28
23
51.0 (18.0–100.0)
26.5 (3.2–69.1)
9.0 (2.0–18.0)
51.0 (0.2)
27.3 (0.1)
9.9 (0.1)
4124
4124
4119
Age
BMI
Exercise
score
Symptom
score
Median (range)
Mean (s.e.)
N
Median (range)
Mean (s.e.)
N
Mean (s.e.)
Median (range)
N
Mean (s.e.)
Median (range)
N
Mean (s.e.)
Median (range)
N
Binge eating
No binge eating
Missinga
Overall
Prevalence and predictors of binge eating
The characteristics of all responders are shown in Table 1 (by
binge eating) and Table 2 (by BMI category). Overall, 15% of
responders (615 of 4096 providing data on binge eating
episodes) reported experiencing some episodes of overeating
within the previous 3 months, whereas 250 (6.1%) reported
experiencing binge eating and 111 (2.7%) of these reported
having BED (Table 1).
The factors predicting binge eating are summarized in
Table 3. Increasing age reduced the odds for overeating and
binge eating (all categories), and whereas males had
increased odds for binge eating, they had decreased odds
Age, BMI, exercise score and GI symptom score by binge eating categories
Results
Table 1
combined. The associations between binge eating episodes,
physical activity levels and individual upper and lower GI
symptoms were assessed using multiple logistic regression, a
generalized logit link function. The estimated odds ratios
(OR) and 95% confidence intervals (CI) for categories of
symptom frequency were estimated from the coefficients
(and their standard errors) in the logistic regression models.
The OR for each GI symptom (separately) in binge eaters and
those with BED (both relative to no binge eating) were
estimated adjusting for age, gender, BMI, physical activity
level score and version of the survey in which the responses
were obtained. Additional models to assess the potential
‘interaction’ of binge eating episodes and BMI were also
examined by constructing dummy regression variables
corresponding to combinations of binge eating (none/any)
and BMI category (underweight, normal weight, overweight
and obese) with normal weight no binge eating as the
reference level. A test for interaction effects was based on the
difference in log likelihoods for the ‘no interaction’ and
‘interaction’ models. Furthermore, separate models in subjects with BMI less than 25 and in subjects with BMI equal to
or greater than 25 were also summarized.
Separate logistic models using just subjects responding to
the version of the survey containing the SF-12 were also
examined adjusting for ‘mental health status’ (two questions
characterizing mental health status and the question
regarding physical/emotional problems impact on social
activities). The univariate association of the three SF-12
measures with binge eating episodes was assessed using
contingency table analyses (w2-test) and their univariate
association with overall GI symptom score assessed using
Spearman’s correlations. A multiple linear regression model
using binge eating categories (binge eating, BED and no
binge eating as the reference level) to predict the overall GI
symptom score was also examined, including age, gender,
BMI, exercise score and the SF-12 measures as covariates.
An additional logistic model to predict binge eating (none,
binge eating and BED) was examined with age, gender, BMI
and physical activity score as the predictor variables.
Binge eating disorder
346
Binge eating, exercise and GI symptoms
F Cremonini et al
347
Table 2
Age, exercise and GI symptom scores by BMI categories
Underweight (o18.51)
N Mean (s.e.)
Normal (18.5–25)
Median (range)
N
Mean (s.e.)
Overweight (25–30)
Median (range)
N
Mean (s.e.)
Median (range)
Obese (X30)
N
Mean (s.e.)
Median (range)
Age
45 48.7 (3.2) 44.0 (18.2–96.0) 1488 48.4 (0.4) 48.0 (18.0–99.0) 1541 52.6 (0.4) 52.0 (18.0–94.0) 1050 52.4 (0.4) 52.2 (18.2–100.0)
Exercise score 45 9.8 (0.6) 10.0 (3.0–18.0) 1484 10.8 (0.1) 10.0 (2.0–18.0) 1540 10.0 (0.1) 9.0 (2.0–18.0) 1050 8.5 (0.1) 7.0 (3.0–18.0)
Symptom score 45 1.5 (0.1) 1.4 (1.0–3.4)
1478 1.5 (0.0) 1.4 (1.0–4.1)
1536 1.5 (0.0) 1.4 (1.0–3.8)
1045 1.6 (0.0) 1.5 (1.0–4.1)
Table 3
Features associated with binge eating (vs no binge eating)
Predictors
OR (95% CI) for overeaters
OR (95% CI) for binge eaters
OR (95% CI) for binge eating disorder
Age (per 10 years)
0.66 (0.61, 0.71)
0.69 (0.61, 0.79)
0.71 (0.62, 0.83)
Gender
Female
Male
BMI (per unit)
Exercise score (per unit)
1.0
2.2
1.09
1.03
1.0
0.9
1.12
1.03
1.0
0.5
1.13
0.98
(ref)
(1.7, 2.8)
(1.09, 1.11)
(1.00, 1.06)
(ref)
(0.6, 1.3)
(1.10, 1.15)
(0.99, 1.07)
(ref)
(0.3, 0.7)
(1.10, 1.16)
(0.93, 1.03)
Abbreviation: BMI, body mass index. Odds ratios (95% confidence intervals) indicated in bold type are significant at an a level of 0.05.
Table 4
Distribution of symptoms by binge eating category
Symptom
Abdominal pain
Fullness
Food staying in the
stomach
Bloating
Acid regurgitation
Heartburn
Nausea
Vomiting
Dysphagia
Stool blockage
Diarrhea
Constipation
Lumpy/hard stools
Loose/watery stools
Fecal urgency
Fecal incontinence
No binge eating
(N ¼ 3481)
N (%)
Binge eating
(N ¼ 365)
N (%)
Binge eating disorder
(N ¼ 250)
N (%)
239 (6.9)
87 (2.5)
128 (3.7)
27 (7.4)
5 (1.4)
17 (4.7)
34 (13.6)
6 (2.4)
14 (5.6)
247
193
211
48
63
58
100
188
98
181
197
178
131
25
21
21
7
7
6
14
31
12
19
28
22
13
41
36
35
6
10
11
14
41
14
20
33
40
23
(7.1)
(5.5)
(6.1)
(1.4)
(1.8)
(1.7)
(2.9)
(5.4)
(2.8)
(5.2)
(5.7)
(5.1)
(3.8)
(6.8)
(5.8)
(5.8)
(1.9)
(1.9)
(1.6)
(3.8)
(8.5)
(3.3)
(5.2)
(7.7)
(6.0)
(3.6)
(16.4)
(14.4)
(14.0)
(2.4)
(4.0)
(4.4)
(5.6)
(16.4)
(5.6)
(8.0)
(13.2)
(16.0)
(9.2)
(relative to females) for BED. Greater BMI values were
associated with increased odds for all categories of binge
eating, whereas physical activity level was only modestly
associated with binge eating.
Association between binge eating and GI symptoms
The symptom distribution (clinically important frequency
levels, for example, often or very often) by binge eating
categories is summarized in Table 4. The adjusted OR (95%
CI) for these clinically important frequency levels of
individual upper and lower GI symptoms in binge eaters
relative to non-binge eaters are shown in Figures 2 and 3.
BED was associated with the following upper GI symptoms: heartburn (OR 2.2, 95% CI 1.4–3.3, Po0.001), acid
regurgitation (OR 2.3, 95% CI 1.5–3.6, Po0.001), dysphagia
(OR 3.3, 95% CI 1.6–6.8, Po0.001), bloating (OR 3.6, 95% CI
2.3–5.5, Po0.001) and upper abdominal pain (OR 2.3, 95%
CI 1.4–3.6, Po0.001). BED was associated with the following
lower GI symptoms: diarrhea (OR 3.1, 95% CI 2.0–4.6,
Po0.001), urgency (OR 3.9, 95% CI 2.6–6.1, Po0.001),
constipation (OR 2.2, 95% CI 1.2–4.1, Po0.01) and a feeling
of anal blockage (OR 2.7, 95% CI 1.5–5.0, P ¼ 0.001). All
associations were adjusted for age, gender, BMI (as a
continuous covariate), physical activity level and version of
the survey.
Obesity and GI symptoms
The adjusted OR for the clinically important frequency levels
of symptoms in overweight and, separately, obese categories
(both relative to underweight/normal) are given in Table 5.
For example, obesity was associated with increased odds for
reporting of acid regurgitation (OR 3.39, 95% CI 2.36–4.87,
Po0.001), heartburn (OR 3.11, 95% CI 2.20–4.39, Po0.001),
diarrhea (OR 1.64, 95% CI 1.16–2.32, P ¼ 0.005), loose stools
(OR 1.63, 95% CI 1.11–2.29, P ¼ 0.005) and urgency (OR
1.46, 95% CI 1.03–2.09, P ¼ 0.036) after adjusting for age and
gender, binge eating, physical activity level and version of
the survey. Table 6 shows the OR estimated separately for
under/normal weight groups and overweight/obese groups.
The tests for interaction indicated significantly increased
odds for vomiting in binge eating (relative to no binge
eating) in normal weight, but not an increased odds in
International Journal of Obesity
Binge eating, exercise and GI symptoms
F Cremonini et al
348
8.0
8.0
O = Over eating
B = Binge eating
B = Binge eating
6.0
OR (95% CI)
OR (95% CI)
6.0
4.0
4.0
2.0
2.0
1.0
1.0
0.0
0.0
Pain
Nausea
Vomiting
Anal
blockage
Dysphagia
8.0
8.0
O = Over eating
B = Binge eating
Lumpy/
hard
O = Over eating
6.0
OR (95% CI)
OR (95% CI)
Constipation
B = Binge eating
6.0
4.0
2.0
4.0
2.0
1.0
0.0
O = Over eating
1.0
Fullness
Food
stays
Bloating
Acid reg Heartburn
Figure 2 (a, b) Odds ratios (95% confidence intervals) for clinically
important upper gastrointestinal symptom reporting in overeating (O), and
separately (B) binge eating, each relative to ‘no binge eating’ (adjusted for
age, gender, body mass index (BMI), physical activity score and version of the
survey in which the responses were obtained). Odds ratios with 95% CI that
do not contain the value 1.0 (horizontal reference line) are significant at an a
level of 0.05. Reg, regurgitation.
overweight or in obese subjects (P ¼ 0.005, difference in
model log likelihoods). A similar differential pattern was also
detected for lumpy/hard stools (P ¼ 0.025, difference in
model log likelihoods) with an increased odds for lumpy/
hard stools in normal weight subjects reporting binge eating,
but not in overweight subjects with and without binge
eating.
Mental health status and GI symptoms
Odds for symptom reporting in binge eaters and separately,
those with BED (each relative to no binge eating) were
estimated adjusting for mental health status and physical/
emotional impact on social activities. Table 7 shows the
results adjusting and not adjusting for these SF-12 questions.
It should be noted that the unadjusted OR were computed in
the subset of subjects that were mailed the second version of
the questionnaire because only the second survey contained
these items. Adjusting for these covariates typically
decreased the odds for reporting GI symptoms, suggesting
that mental and emotional health status may be a
International Journal of Obesity
0.0
Loose/
watery
Diarrhea
Urgency
Leakage
Figure 3 (a, b) Odds ratios (95% confidence intervals) for clinically
important lower gastrointestinal symptom reporting in overeating (O), and
separately (B) binge eating, each relative to ‘no binge eating’ (adjusted for
age, gender, body mass index (BMI), physical activity score and version of the
survey in which the responses were obtained). Odds ratios with 95% CI that
do not contain the value 1.0 (horizontal reference line) are significant at an a
level of 0.05.
confounder of binge eating effects. Indeed, significant
associations (Po0.001) between binge eating and the SF-12
questions used to define mental health status were observed,
and significant (Po0.001) univariate associations between
these measures and the overall GI symptom score. The
multiple linear regression model for the overall GI symptom
score did however indicate binge eating categories to be
significant (Po0.05) independent predictors of symptom
score.
Differences in populations and effect of individual surveys
Demographics (including age, gender and proportion in
single BMI classes) were not significantly associated with
whether respondents participated in the first or the second
survey. It is very unlikely that subjects participated in both
surveys. Whereas there is no real mechanism to confirm this
due to the de-identification process, it is unlikely that
respondents would complete two copies of the same survey
sent to them in a short period of time. The association
Binge eating, exercise and GI symptoms
F Cremonini et al
349
Table 5 Odds for symptom reporting in overweight and obese (relative to
normal/underweight)
Symptom
Body mass index category
Overweight
a
OR
Abdominal pain
Fullness
Food staying in the stomach
Bloating
Acid regurgitation
Heartburn
Nausea
Vomiting
Dysphagia
Anal blockage
Diarrhea
Constipation
Lumpy/hard stools
Loose/watery stools
Fecal urgency
Fecal incontinence
0.90
0.90
1.37
0.98
2.00
1.64
0.70
1.05
0.53
0.63
1.35
0.72
0.99
1.09
1.09
0.98
95% CI
(0.66,
(0.55,
(0.91,
(0.73,
(1.39,
(1.16,
(0.35,
(0.59,
(0.30,
(0.41,
(0.97,
(0.47,
(0.72,
(0.78,
(0.77,
(0.66,
1.23)
1.46)
2.07)
1.33)
2.86)
2.31)
1.40)
1.87)
0.95)
0.99)
1.88)
1.11)
1.37)
1.53)
1.54)
1.46)
Obese
OR
a
1.29
0.89
1.76
1.07
3.39
3.11
1.46
1.70
0.66
0.74
1.64
0.50
0.49
1.63
1.46
1.36
95% CI
(0.93,
(0.52,
(1.15,
(0.77,
(2.36,
(2.20,
(0.77,
(0.96,
(0.36,
(0.46,
(1.16,
(0.30,
(0.33,
(1.15,
(1.03,
(0.91,
1.78)
1.53)
2.70)
1.48)
4.87)
4.39)
2.75)
3.02)
1.18)
1.17)
2.32)
0.85)
0.75)
2.29)
2.09)
2.04)
Odds ratios (95% confidence intervals) indicated in bold type are significant at
an a level of 0.05. aOdds ratio (95% CI) from logistic regression model
adjusting for age, gender, binge eating category, physical activity score and
version of the survey.
between binge eating and GI symptoms was similar on both
surveys based on additional logistic regression models that
contained interaction terms for survey version by binge
eating categories. These terms were not significant and thus
dropped from the final models. The final models did retain a
term for survey version, which typically indicated smaller
odds for symptom reporting on the second version of the
survey (relative to the first survey). Finally, the overall
sample of responders was similar in terms of age and gender
distribution to the 2000 Olmsted County population demographic characteristics.
Discussion
This study reports, in a population-based sample, the
associations between frequency of binge eating episodes,
physical activity level and individual GI symptoms. In 4096
subjects from the Olmsted County population, BED was
associated with several upper and lower GI symptoms,
independent of BMI status or level of physical activity.
Previous population-based studies have suggested that
obesity is associated with increased prevalence of gastroesophageal reflux (both symptomatic and endoscopically
identified esophagitis).5,6 Obesity has also been linked to
other upper and lower GI symptoms, including bloating,
upper abdominal pain, diarrhea (but not constipation) and
vomiting.2 In this study, the prevalence of GI symptoms and
the associations of obesity with GI symptoms were very
consistent with previous population-based studies, further
supporting our view that the present population sample is
comparable with past random samples drawn from Olmsted
County where response rates were high.2
However, this study addresses the relative paucity of
information on the potential relationship between BED
and the pathogenesis of GI symptoms in people in the
community. Crowell et al.,3 in the only case–control study in
a tertiary referral sample of obese outpatients, reported
associations between specific GI symptoms and binge eating,
although only 119 obese patients and 19 controls were
evaluated. These authors found significantly more frequent
reports of nausea, vomiting, bloating, abdominal pain and
dyschezia (sense of anal blockage or difficulty with evacuation) in obese binge eaters compared to controls.3 We could
not confirm an association of binge eating with nausea and
vomiting; however, in addition to the expected gastroesophageal reflux symptoms, we found associations of BED
with bloating, abdominal pain, constipation, a sense of anal
blockage and diarrhea in this general population sample.
The pathophysiological bases underlying the higher prevalence of upper GI symptoms in binge eaters are unclear.
This higher prevalence was also contrary to the study
expectations. Previous research has demonstrated that BMI
and stomach volume are independent factors in determining
postprandial satiation.32 BED is also associated with increased gastric volume/capacity,18,20 which should be protective against increased upper GI symptoms in response to
food ingestion. Conceivably, the delivery of unusually large
amounts of food to the stomach may exceed the large gastric
capacity in binge eaters, and it may be inadequately
counteracted by gastric reflex adaptive relaxation,33 causing
higher wall tension34 and resulting in the perception of
abdominal pain and bloating. Studies using single-photon
emission computed tomography imaging show fasting
gastric volumes predict food intake in overweight and obese
individuals,32 as well as the postprandial symptoms of
fullness and bloating in response to a challenge meal.23
However, Geliebter and colleagues18,20 have shown that
gastric capacity in obese subjects with bulimia is significantly
greater than non-bulimic control individuals, irrespective of
body weight. The increased gastric capacity may represent an
adaptive mechanism to excessive food intake.19 Conversely,
lower fasting volumes are associated with the presence of
post-meal symptoms in functional dyspepsia.35 The rapid
pattern of ingestion of large amounts of food appears to be
important given the normal stomach capacity of obese
people with BMIs of up to 45.21 In binge eaters, the large
amounts of food eaten appear to counteract the mechanisms
of lower esophageal sphincter competence,36 possibly resulting in larger quantities of gastric refluxate reaching the distal
esophagus and contributing to acid regurgitation and heartburn. In turn, acid reflux could be the underlying abnormality in subjects complaining of dysphagia.37
The potential mechanisms for generation of lower GI
symptoms in binge eaters also need exploration. One
potential hypothesis is that larger and more rapidly delivered
food boluses to the small intestine represent larger osmotic
International Journal of Obesity
Binge eating, exercise and GI symptoms
F Cremonini et al
350
Table 6
Odds for symptom reporting in eating pattern (overeating vs none, and binge eating vs none) separately by BMI category
Symptom
Eating pattern
Body mass index categories
Underweight/normal
a
OR
Abdominal pain
Fullness
Food staying in the stomach
Bloating
Acid regurgitation
Heartburn
Nausea
Vomiting
Dysphagia
Stool blockage
Diarrhea
Constipation
Lumpy/hard stools
Loose/watery stools
Fecal urgency
Fecal incontinence
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
1.43
2.98
1.16
2.97
2.48
2.85
1.56
6.54
0.80
3.86
0.55
4.83
2.88
4.92
2.44
6.86
0.56
12.68
2.74
3.60
1.50
8.29
1.67
2.69
1.89
3.27
2.20
5.93
1.14
4.33
0.52
5.13
Overweight/obese
95% CI
(0.62,
(1.20,
(0.33,
(0.84,
(0.90,
(0.93,
(0.65,
(2.62,
(0.23,
(1.39,
(0.16,
(1.94,
(0.90,
(1.35,
(0.67,
(2.37,
(0.07,
(4.47,
(1.09,
(1.30,
(0.56,
(3.67,
(0.62,
(0.99,
(0.80,
(1.41,
(0.91,
(2.51,
(0.38,
(1.73,
(0.07,
(1.99,
3.29)
7.44)
4.05)
10.48)
6.88)
8.76)
3.72)
16.32)
2.74)
10.73)
1.87)
12.01)
9.27)
17.96)
8.93)
19.87)
4.34)
35.92)
6.92)
9.95)
4.01)
18.71)
4.50)
7.34)
4.49)
7.57)
5.31)
13.97)
3.37)
10.82)
3.94)
13.25)
a
OR
1.33
2.26
0.33
0.51
1.24
1.42
1.38
3.07
1.33
2.48
1.09
2.22
0.76
0.66
0.65
0.86
1.30
1.53
1.87
2.63
1.73
2.56
1.33
1.92
1.42
1.48
1.75
1.97
1.94
4.21
1.65
2.69
95% CI
(0.78,
(1.35,
(0.08,
(0.15,
(0.65,
(0.70,
(0.80,
(1.88,
(0.77,
(1.55,
(0.63,
(1.37,
(0.22,
(0.19,
(0.23,
(0.33,
(0.49,
(0.57,
(0.86,
(1.23,
(1.08,
(1.62,
(0.58,
(0.90,
(0.75,
(0.75,
(1.04,
(1.18,
(1.11,
(2.59,
(0.87,
(1.51,
2.28)
3.76)
1.36)
1.69)
2.35)
2.86)
2.39)
4.99)
2.29)
3.96)
1.86)
3.61)
2.58)
2.26)
1.85)
2.25)
3.42)
4.09)
4.10)
5.64)
2.76)
4.03)
3.04)
4.08)
2.70)
2.92)
2.96)
3.30)
3.39)
6.83)
3.13)
4.79)
Odds rations (95% confidence intervals) indicated in bold type are significant at an a level of 0.05. aOdds ratios for the designated category of the symptom in
overeating vs no binge eating; and separately, binge eating vs no binge eating, from logistic regression models adjusting for age, gender, physical activity score and
version of the survey.
loads, resulting in intestinal secretion, and a prominent
colonic motor response resulting in increased delivery of
stool to the distal colon, increasing stool volumes, reduction
in stool consistency, leading to diarrhea and urgency.
Whereas this study did not inquire about eating more
rapidly than usual, one of the important clinical features of
BED is eating more rapidly than usual. It is also possible that
abnormally high postprandial secretion of gut peptides or
neurotransmitters (such as cholecystokinin or serotonin)
occurs in the presence of meals that are much larger than
usual, contributing to alterations in bowel sensorimotor
function.38,39 These data suggest that detailed GI and colonic
transit, hormonal responses to meal ingestion and colonic
motor function should be investigated further in patients
with bulimia, and particularly in those with BED. Irrespective of the pathophysiology and mechanisms involved, it is
intriguing that the association of higher BMI alone with
symptoms was relatively modest after adjusting for demographic factors and for binge eating behavior, suggesting
International Journal of Obesity
eating patterns are more closely linked, than bodily habitus,
to symptom generation in the GI tract.
Whereas many of the GI symptoms in patients with eating
disorders may be attributable to the eating pattern and the
volume or calorie content of food ingested, our hypothesis is
that the associations with constipation and sense of anal
blockage are independent of feeding issues, and are more
likely to result from associated pelvic floor or anal sphincter
dyssynergia. We have previously noted the association of
another eating disorder, rumination syndrome, in tertiary
referral patients attending a program for spastic rectal
evacuation disorders.40 A retrospective review suggested that
increased BMI is not associated with delayed colonic transit;
however, it is associated with reduced colonic compliance
and pain sensation during distension of an intracolonic
balloon.41 Prospective studies are, therefore, required to
assess rectal evacuation function, and colonic sensory and
motor physiology in the colon of obese individuals and
people with binge eating who may have normal weight.
Binge eating, exercise and GI symptoms
F Cremonini et al
351
Table 7 Odds for symptom reporting for eating pattern (overeating vs none, and binge eating vs none) unadjusted, and adjusted for mental health status (using
questions from SF-12)
Symptom
Unadjusted a
Eating pattern
Adjusted
For mental health status
OR
Abdominal pain
Fullness
Food staying in the stomach
Bloating
Acid regurgitation
Heartburn
Nausea
Vomiting
Dysphagia
Stool blockage
Diarrhea
Constipation
Lumpy/hard stools
Loose/watery stools
Fecal urgency
Fecal incontinence
Overeaters
Binge eaters
Overeaters
Binge eaters
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
Overeating
Binge eating
a
1.20
2.22
0.33
0.95
1.14
1.10
1.82
2.87
1.12
2.21
1.07
1.89
0.70
1.58
0.52
2.13
1.42
2.71
1.49
2.05
1.67
3.36
1.14
2.56
1.30
2.03
2.22
2.79
1.63
4.07
1.17
3.57
95% CI
(0.69,
(1.29,
(0.06,
(0.36,
(0.57,
(0.48,
(1.07,
(1.66,
(0.62,
(1.32,
(0.61,
(1.11,
(0.21,
(0.62,
(0.16,
(1.01,
(0.58,
(1.15,
(0.69,
(0.93,
(1.02,
(2.11,
(0.51,
(1.30,
(0.69,
(1.07,
(1.32,
(1.68,
(0.89,
(2.43,
(0.55,
(1.98,
2.08)
3.81)
1.08)
2.51)
2.31)
2.53)
3.11)
4.96)
2.01)
3.73)
1.86)
3.21)
2.37)
4.02)
1.73)
4.52)
3.45)
6.39)
3.22)
4.53)
2.72)
5.36)
2.55)
5.01)
2.45)
3.87)
3.72)
4.71)
3.00)
6.83)
2.50)
6.45)
ORa
1.02
1.21
0.25
0.46
0.97
0.63
1.62
1.63
0.99
1.45
0.94
1.30
0.55
0.75
0.46
1.40
1.31
1.91
1.35
1.27
1.56
2.73
1.03
1.79
1.18
1.42
2.00
1.91
1.50
2.62
1.11
2.83
95% CI
(0.57,
(0.69,
(0.06,
(0.17,
(0.47,
(0.27,
(0.92,
(0.92,
(0.54,
(0.85,
(0.53,
(0.76,
(0.16,
(0.29,
(0.14,
(0.65,
(0.54,
(0.80,
(0.62,
(0.57,
(0.96,
(1.70,
(0.46,
(0.90,
(0.62,
(0.74,
(1.18,
(1.12,
(0.81,
(1.53,
(0.52,
(1.55,
1.80)
2.13)
1.08)
1.24)
2.02)
1.48)
2.83)
2.90)
1.80)
2.47)
1.66)
2.23)
1.91)
1.95)
1.54)
3.00)
3.22)
4.55)
2.96)
2.85)
2.56)
4.40)
2.34)
3.56)
2.24)
2.74)
3.38)
3.26)
2.78)
4.46)
2.38)
5.17)
Odds ratios (95% confidence intervals) indicated in bold type are significant at an a level of 0.05. aNote that the unadjusted values use only the subjects who
responded to the version of the survey containing the SF-12.
BED, on the other hand, may be associated with upper and
lower GI symptoms because it merely represents a marker of
underlying psychological distress rather than reflecting a
direct causal relationship. We did observe an association
between BED and the mental health score used, and
adjusting for this score attenuated all of the associations of
BED with GI symptoms except for diarrhea and fecal
urgency. Further work is needed using standardized psychiatric measures to determine if anxiety or depression, or
somatization, confounds any association of dyspepsia and
constipation with BED. It is also possible that the type of
foods eaten during a binge episode contributes to GI
symptoms because individuals with BED tend to select
higher fat foods during a binge episode42,43 compared to
their food selection on non-binge eating days. This potential
association between nutrient intake and GI symptoms
should be explored in future studies.
This study has other limitations. The low response rate to
the initial survey led us to conduct a repeat survey using
different methodology that did include direct telephone
contact with nonresponders. Although the response rate to
the repeat survey was still not ideal, we were able to accrue
data for a sample four times larger than the initial one.
Moreover, a comparison of our initial and final sample with a
recent survey on obesity and GI symptoms conducted in the
same population setting revealed very similar distributions
of age, gender and body weight categories between the two
samples, suggesting demographic homogeneity.2 We believe
that our sample is representative enough and is also large
enough to portray a reliable representation of the population
in question. We do not have the means to ascertain the
proportion of binge eaters in the individuals not responding
to our survey; there is the possibility that subjects affected by
BED or by GI symptoms may be somewhat more likely to
return our questionnaires, although the rate of binge eating
identified is comparable with previous estimates in this part
of the United States.13 There exists the possibility that in
combining the respondents from the two sampling frames
International Journal of Obesity
Binge eating, exercise and GI symptoms
F Cremonini et al
352
utilized in the current study, a certain amount of duplication
in response may have impacted the results. Whereas there is
no real mechanism to confirm or dispel this possibility due
to the de-identification process, we expect that respondents
would be unlikely to complete two copies of the same survey
sent to them in such a short time. Moreover, the likely
impact of a few redundant responses would be minimal.
Another limitation pertains to the screening tools used for
binge eating behavior. Our study was based on a short selfreport questionnaire that, although valid, included only
three screening questions for BED. Thus, there is the
possibility of having overestimated the prevalence of
BED,44,45 and in future studies a structured clinical interview
to assess BED may clarify this issue.46
The use of self-reported weight may also have been
problematic as studies have shown that adults will underreport their weight.47,48 A final limitation of this study is that
we did not specifically focus on postprandial occurrence of
symptoms, but one might expect an even closer relationship
of postprandial symptoms with eating behavior and therefore the significant associations likely represent conservative
estimates of the true associations between binge eating and
GI symptoms.
In conclusion, the impact of BED as a determinant of GI
morbidity at a population level is likely to have clinical
relevance. However, further insight into the potential
mechanisms need to be sought; these epidemiological data
provide the basis for planning the studies of GI physiology in
eating disorders such as measurements of GI and colonic
transit, gastric volume and rectal evacuation dynamics. This
study also highlights the potential importance to screen for
eating disorders such as BED among patients presenting with
GI symptoms because it is conceivable that behavioral
interventions (for example, on the rate and quantity of
ingested food) may resolve their symptoms without the need
to use pharmacological agents.
Acknowledgements
Dr Camilleri and Dr Talley received support by Grant
DK67071 from the National Institutes of Health for this
study.
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