Disordered Eating and Metabolic Health: Why Screening Matters

When we think of metabolic health, conversations often focus on blood sugar regulation, weight management, cholesterol levels, and blood pressure. But another critical factor is sometimes overlooked: disordered eating behaviors. These patterns of eating may not always fit neatly into the diagnostic criteria for eating disorders like anorexia nervosa or bulimia nervosa, yet they still significantly influence metabolic outcomes, cardiovascular risk, and long-term health.

For clinicians, understanding and screening for disordered eating is not only about addressing mental health—it is also about identifying a hidden driver of poor metabolic health. Left unrecognized, these behaviors can perpetuate insulin resistance, promote chronic inflammation, worsen weight cycling, and delay effective treatment for conditions like type 2 diabetes, metabolic dysfunction associated liver disease, and metabolic syndrome.

Defining Disordered Eating: What the Guidelines Say

The American Psychiatric Association (APA), through the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR), outlines specific eating disorder diagnoses such as anorexia nervosa, bulimia nervosa, binge eating disorder (BED), and avoidant/restrictive food intake disorder (ARFID). In addition, the DSM-5-TR recognizes Other Specified Feeding or Eating Disorder (OSFED), which includes clinically significant patterns that don’t meet full diagnostic criteria but still carry health risks.

The Academy for Eating Disorders (AED) emphasizes that subclinical or atypical disordered eating is highly prevalent, especially in people presenting for weight management or treatment of metabolic disease. Similarly, the American Diabetes Association (ADA) and Endocrine Society stress the importance of screening for disordered eating in individuals with obesity, prediabetes, or type 2 diabetes, given the higher prevalence of binge eating and restrictive patterns in these populations.

Guideline definitions highlight a crucial point: disordered eating exists on a spectrum, from subclinical behaviors like chronic dieting and compulsive exercise to full-threshold eating disorders with severe health implications. Regardless of where a person falls on this spectrum, the metabolic and psychological effects can be profound.

Common Types of Disordered Eating Behaviors

Chronic Dieting and Restrictive Eating – Repeated cycles of calorie restriction followed by overeating can lead to metabolic adaptations that slow resting energy expenditure, increase hunger hormones like ghrelin, and promote weight regain. Over time, this pattern may worsen insulin resistance and contribute to weight cycling, which is independently associated with cardiovascular risk.

Compulsive or Emotional Eating – Using food as a primary coping mechanism for stress, anxiety, or sadness can lead to frequent episodes of overeating high-calorie, nutrient-poor foods. This behavior often coexists with low physical activity and poor sleep quality, creating a cluster of risk factors for metabolic syndrome.

Binge Eating Disorder (BED) – Characterized by recurrent episodes of consuming unusually large amounts of food with a sense of loss of control, BED is now the most common eating disorder in the United States. It carries direct metabolic risks, including increased prevalence of obesity, type 2 diabetes, and dyslipidemia.

Night Eating Syndrome (NES) – Defined by delayed eating patterns, often with the majority of caloric intake occurring in the evening or nighttime, NES disrupts circadian rhythms and has been linked to obesity, impaired glucose tolerance, and depression.

Purging Behaviors – Self-induced vomiting, misuse of laxatives, or diuretics following food intake can cause electrolyte imbalances, cardiac arrhythmias, and gastrointestinal issues. While traditionally associated with bulimia nervosa, purging behaviors can also appear outside of full diagnostic categories.

Orthorexia Nervosa – Though not formally recognized in DSM-5-TR, orthorexia describes an unhealthy obsession with “clean” or “healthy” eating. This rigidity can impair social functioning, lead to nutritional deficiencies, and sometimes progress to other restrictive eating disorders.

I want to highlight two that as an Obesity Medicine Physician and Metabolic Health Expert, I encounter most frequently in my clinic.

Binge Eating Disorder: Recognition and Management

Binge Eating Disorder (BED) is defined as recurrent episodes of binge eating, occurring at least once a week for three months, without regular compensatory behaviors such as purging. These episodes are associated with eating more rapidly than normal, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, and feeling guilt or distress afterward.

Causes and Contributing Factors: While the exact cause of BED is not fully understood, it is considered to be multifactorial, with contributions from genetic predisposition, altered brain reward signaling (particularly involving dopamine), history of trauma or adverse childhood experiences, and chronic dieting behaviors. Emotional dysregulation and high stress levels are also common contributors.

Diagnosis: Clinicians typically use structured interviews or validated screening tools, such as the Binge Eating Disorder Screener-7 (BEDS-7), in addition to DSM-5-TR criteria.

Therapies: First-line treatments include cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), and dialectical behavior therapy (DBT), all of which help individuals regulate eating behaviors and manage triggers. Medical therapies include lisdexamfetamine (Vyvanse), the only FDA-approved medication for BED, and off-label use of SSRIs or topiramate in selected cases. Lifestyle interventions, including structured meal planning, mindfulness-based eating strategies, and regular physical activity, are also important components of care.

Night Eating Syndrome: Recognition and Management

Night Eating Syndrome (NES) is defined recurrent episodes of night eating, manifested by excessive food consumption after the evening meal or waking from sleep to eat, with awareness and recall of the episodes. To qualify for diagnosis, the behavior must cause significant distress or impairment and persist for at least three months.

Causes and Contributing Factors: NES is thought to involve dysregulation of circadian rhythms, alterations in melatonin and leptin secretion, and psychological stress. It is frequently associated with depression, insomnia, and metabolic disorders. Individuals with NES often have disrupted cortisol rhythms, which may exacerbate insulin resistance and weight gain.

Diagnosis: Tools such as the Night Eating Questionnaire (NEQ) are commonly used for screening. Polysomnography may be considered if there is concern about overlap with sleep-related eating disorder (SRED), which occurs without conscious awareness.

Therapies: Lifestyle interventions include maintaining a consistent sleep schedule, practicing stress management techniques, and limiting evening exposure to blue light to regulate circadian signals. Nutritional counseling can help distribute calorie intake more evenly throughout the day. Medical therapies that have shown benefit include sertraline (an SSRI), which may reduce nocturnal eating episodes, and in some cases, melatonin supplementation to restore circadian rhythm alignment.

Why Screening for Disordered Eating Matters in Metabolic Health

For clinicians managing metabolic health, unrecognized disordered eating can complicate care plans. For example, recommending strict dietary restriction to a patient with undiagnosed binge eating disorder may worsen binge episodes and lead to further weight cycling. Likewise, ignoring night eating syndrome in a patient with poorly controlled diabetes can undermine glycemic management despite medication adjustments.

Routine screening allows medical teams to provide tailored, compassionate care that addresses both metabolic and psychological needs. Early recognition reduces stigma, prevents progression to more severe illness, and supports long-term cardiometabolic health.

A Message to Patients: You Are Not Alone

If you recognize aspects of your own eating in these descriptions—whether it’s binge eating, nighttime eating, or other patterns that feel out of control—know this: you are not alone, and you are not to blame. These are medical conditions with biological, psychological, and social contributors, not a reflection of willpower or character.

When you go to a medical visit, it’s okay to bring these concerns up with your healthcare provider. Asking about eating patterns, even if it feels uncomfortable, is an important act of self-care. Having a proper diagnosis opens the door to effective therapy, relief from distress, and better long-term health outcomes.

Your health journey deserves compassion, not shame. By speaking up, you give your medical team the opportunity to help you heal not just your metabolism, but your relationship with food—and in turn, support your overall vitality and longevity.