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. Author manuscript; available in PMC: 2023 Dec 1.
Published in final edited form as: Curr Psychiatry Rep. 2022 Nov 12;24(12):757–766. doi: 10.1007/s11920-022-01383-8

A Review of Binge Eating Disorder in Black Women: Treatment Recommendations and Implications for Healthcare Providers

Rachel W Goode 1,2, C Kashonna Webster 3, Rebecca E Gwira 4
PMCID: PMC9789195  NIHMSID: NIHMS1851204  PMID: 36370263

Abstract

Purpose of Review.

We review relevant factors and barriers to care for binge-eating disorder (BED) in Black women. We examine evidence for the treatment of BED and provide recommendations to improve cultural relevance for assessing and treating BED in Black women.

Recent Findings.

BED is the most common eating disorder among Black women. Moreover, evidence supports alternative factors that contribute to the onset of BED in Black women, including stress, trauma, and food insecurity. Furthermore, though there are evidence-based treatments for BED, disparities persist in access to care and treatment retention. Recommendations for increasing the cultural relevance of assessments and treatments are provided.

Summary.

Gaps in the literature remain on the use of evidence-based treatments for BED among Black women. As such, healthcare providers should include Black women as co-collaborators in their care and seek out training and consultation to aid in providing culturally affirming treatment.

Introduction

Binge eating disorder (BED) is a DSM-5 diagnosed eating disorder that causes impairments to daily functioning including mood symptoms, negative views of one’s body, and low quality of overall life functioning [1, 2]. BED is marked by recurrent episodes of binge eating (i.e., once per week for at least 3 months) that involve a loss of control, and marked distress, without regular compensatory behaviors [3]. BED is the most common eating disorder across racial and ethnic groups in the United States (U.S.) [4, 5] and has been estimated to affect approximately .90 – 3% of the U.S. population [4, 6]. Additionally, BED is comorbid to other psychopathology, including personality pathology, substance use, and mood disorders [5, 7-10], and is associated with obesity, type 2 diabetes, hypertension, asthma, menstrual and pregnancy complications, pain, sleep, and gastrointestinal conditions [11]. Indeed, a recent systematic review found that individuals with BED experienced decreased mental and physical health-related quality of life and increased healthcare utilization and costs compared to those without an eating disorder [12].

Binge eating in Black Americans

Although eating disorders are stereotypically believed to affect skinny, white, affluent, cis-gender women, recent studies report similar rates of BED across racial and ethnic groups in the U.S., and, in particular, among Black women [4, 13]. BED is the most common eating disorder among Black Americans, with lifetime prevalence estimated between .62 – 1.48% [4, 7]. Furthermore, rates of binge eating, defined as eating in a discrete period (within 2 hours), an amount of food that is larger than what someone would typically consume under normal circumstances, are similar or higher, than compared to other racial/ethnic groups [3]. For example, binge eating prevalence among Black women was found to be nearly 5% compared with 2.5% among non-Hispanic White women [13-15]. This prevalence may be even higher among Black women with obesity, around 30% of whom also report binge eating [16, 17].

Black women not only experience BED at rates different from white women; they also often experience different pathways to BED. Namely, while traditional conceptions of disordered eating behaviors have tended to attribute these behaviors to an individual’s overevaluation of their shape or weight [18], disordered eating behaviors among Black women have been theorized as behaviors that function as means of coping with stress and oppression, including but not limited to trauma and negative affect [19, 20].

Despite the availability of evidence-based interventions to treat binge eating and improve body image [21], vast disparities persist in treatment access and retention among Black women. In fact, Black women have some of the lowest rates of access to care for eating disorders, with fewer than 8% of Black women with BED seeking treatment compared to 20% of White women with BED [22, 23]. Moreover, Black women who begin eating disorder treatment are more likely than White women to drop out of treatment [24]. Though reasons for this disparity vary, Black women have causes of disordered eating behaviors that are unique from those of other populations, and interventions may not be appropriately designed to engage this population.

Current paper

In light of the prevalence of BED and binge eating among Black women and the barriers they face to accessing treatment, the aims of this article are: (1) to review the unique factors that contribute to binge eating among Black women; (2) to identify the most salient barriers to treatment faced by Black women; and (3) to provide treatment recommendations for best practices when working with Black women with or at risk for BED. To this end, this review will first examine cultural factors contributing to the development of binge eating among Black Americans broadly, followed by barriers that that may influence access to care among Black women specifically. We then conclude by offering treatment recommendations and best practices that recognize key factors affecting BE treatment outcomes among Black women. By distilling the evidence-based treatments to-date for binge eating and BED treatment in Black women, this review aims to better equip clinicians to provide culturally relevant care.

Factors affecting Binge Eating

To date, much of what researchers and interventionists know about eating disorders has been generated by studies of samples that do not include Black Americans. Historically, prevailing conceptualizations of eating disorders frame them as occurring because of individual pathologies [18, 25]. By contrast, more recent evidence grounded in studies of Black women highlights the function of poverty, mental health, racism, and microaggressions as additional contributing factors in eating disorders, productively expanding the scope of contributing factors to be addressed by researchers and interventionists focusing on eating disorders [25, 26].

Food Insecurity

Food insecurity (i.e., not having enough food to meet the needs of household members) affects approximately 37 million Americans, and Black-headed households are among those most likely to experience food insecurity [27]. In several recent studies, people with the highest levels of food insecurity reported higher levels of binge eating behaviors and disordered eating behavior [28, 29]. Goode et al. [30] found that even before adjusting for sociodemographic factors, Black adults experiencing severe food insecurity were more likely to report lifetime binge eating, compared to those who were food secure. Food insecurity is also associated with elevated anxiety and weight stigma, which are known to positively correlate with disordered eating. [28]. Moreover, food insecurity may also have a lasting impact on those with past or childhood experiences of poor access to food [31]. Collectively, these research findings warrant greater attention to food insecurity as a critical factor in binge eating among adults.

Stress and Discriminatory Stress

Another factor that may contribute to binge eating behavior among Black women is stress [19, 32, 33]. Indeed, stress is well-documented as an important factor in the onset and maintenance of binge eating. For example, a study of a sample of 178 Black and White participants found that stress, assessed by examining the extent and response to daily life hassles, as well as how frequently participants were unable to control certain things in their lives, was associated with binge eating [19]. Furthermore, discriminatory stress, measured by examining the frequency of specific racial events over the past year and during the lifetime, is also associated with binge eating among Black Americans [34]. In a study using data from the National Survey of American Life examining the relationship between perceived discrimination, gender and BED, perceived discrimination was associated with higher odds of BED [34].

Trauma

Though limitations of retrospective reports of trauma have been established [35], exposure to trauma or the experience of traumatic events is associated with the development of disordered eating among Black women [19]. For example, in a controlled case study by Striegel-Moore and colleagues [36], Black and White women diagnosed with BED had higher rates of physical and sexual abuse than those in the healthy comparison group. Indeed, in a recent systematic review examining 70 studies on adverse life experiences and BED, approximately 90% of included studies verified the relationship between trauma and the development of BED [37]. For Black women, part that relationship may be explained by the internalization of a strong black woman ideology (further discussed in a later section), which entails the obligation to show strength at all costs [38, 39]. Being exposed to trauma influences how intensely strong black woman ideology is internalized, and survivors may find it difficult to regulate emotions and in turn, use eating to meet psychological needs [32]. In sum, binge eating may be a means of regulating negative affect among those with past trauma.

Depressive symptoms

Nearly 20% of adults in the U.S. have experienced depression in their lifetime. Eating disorders are frequently co-morbid with depressive symptoms and are associated with binge eating in Black women. Indeed, depressive symptoms are associated with binge eating cross-sectionally among Black undergraduate students [40], those pursuing bariatric surgery [41], and community-based samples [33]. Further, the association between binge eating and depressive symptoms endures over time; for example, in a longitudinal study of Black young adults, embarrassment over the amount eaten and binge-eating related concerns still predicted depressive symptoms seven years later [42].

Views on Body Image

Although various factors influence the risk of binge eating, body dissatisfaction is a core behavior of concern [43]. Among Black women, body image dissatisfaction is a strong predictor of binge eating [44]. In fact, greater weight is associated with increased body image concerns and binge eating in Black women [45].

Historically, discussions of Black women’s body image have been situated in a framework that contrasts their behavior to that of White women and the compulsion with achieving the thin ideal [46-48]. Previous research has suggested Black women have higher rates of body satisfaction and experience less pressure to achieve societal standards of thinness in comparison to White women [47, 49, 50]. Certainly, Black women have generated alternative cultural norms related to body satisfaction (e.g., reporting that their views of body image are influenced by factors other than just weight, including hair, skin tone, and attitude) [51-54]. However, while some Black women may prefer a curvier figure compared to White women, this does not imply that these Black women experience body satisfaction or an increased desire to remain in a larger body [55]. Black women still report feeling dissatisfied with their weight and self-conscious about their bodies [56-58], with greater dissatisfaction observed among women with higher BMI values [59]. For example, among Black women seeking treatment for eating disorders, various studies report high rates of body dissatisfaction and shape or weight concerns [60, 61]. In fact, recent evidence from a qualitative study of Black women indicated that 76% of participants were dissatisfied with their body weight, and 80% wanted help to achieve a body size that would not be characterized as overweight or obese [55].

Strong Black Woman Role

A strong black woman (or superwoman) can be characterized as a woman who, out of the necessity for survival, is able to assume multiple roles of caretaking, financial provision, and emotional support [38, 39]. Being a superwoman entails an obligation to suppress emotions, help other people, show strength, and avoid showing weakness or asking for help [38]. Internalizing the pressure to be “strong” also has increased levels of selflessness, self-silencing, and powerlessness among Black American women [39]. This archetype, and the presumption of strength among Black women may push Black women to develop disordered eating behaviors [32, 39]. For example, in a sample of 179 Black American women who were trauma survivors, assuming the strong black woman role was associated with difficulties with emotion regulation, eating for psychological reasons, and binge eating [32].

Barriers to Treatment for Eating Disorders

Currently, there is a dearth of literature studying treatments for binge eating using samples of Black women [26]. Though Black women have comparable (or higher) rates of binge eating to White women [13, 62, 63], vast racial disparities in treatment access persist, meaning that Black women remain greatly underrepresented in clinical studies for the treatment of binge eating [63, 64]. Understanding the barriers to treatment for BED will serve as an essential foundation for creating effective, tailored intervention programming for Black women with eating disorders.

Limited recognition

One challenge to the treatment of eating disorders among Black women is these women’s limited recognition of symptoms and/or knowledge of what may be considered disordered eating. Indeed, Black women have reported limited awareness of the symptoms of BED, and/or surprised that their eating behavior may be considered “disordered” or something for which they could receive support [23].

Bias

Black women may also experience bias in their encounters with medical providers. In fact, Black women are less likely than White women to be referred to or to seek eating disorder treatment [13, 65, 66], and evidence suggests that racial stereotyping may contribute to this disparity. Several studies have demonstrated that Black women are considered far less likely to be affected by eating disorders, are less likely than Whites to be receive a recommendation or referral for further evaluation of care for an eating disorder, and/or less likely than White women to be asked by their doctor about eating disorder symptoms [65, 67, 68]. Additionally, while BED may be common among patients in primary care settings given its association with increased medical problems and service utilization, many medical providers remain unfamiliar with BED symptoms and thus may miss opportunities for diagnosis [63, 69].

Multiple Caregiver Role

Another barrier to seeking and obtaining care for disordered eating among Black women may be their performance of a multiple caregiver role (i.e., being responsible for providing emotional and/or tangible aid to extended family and friends) [70], a role often assumed by Black women. Similar to the strong woman syndrome/superwoman schema [38], this role may inhibit Black women’s participation in activities to improve their health and physical activity because its extensive physical and mental demands may result in their disengagement from self-care and development of maladaptive coping strategies (e.g., overeating, binge eating) [71].

Treatment Needs

Conceptualization of Eating Disorders

According to the cognitive behavioral model of eating disorders, the overevaluation of shape or weight is a core driver of the development of disordered eating behaviors [72]. However, body image ideals differ by race and ethnicity, and Black women have often rejected mainstream cultural norms pursuing the thin ideal [19]. Thus, a model focusing on the pursuit of thinness may not fully capture and explain eating pathology among Black women [19].

One alternative model posits that eating disturbances among women of color often begin as strategies to cope with various stressors and traumas, including racism, oppression, poverty, sexism, and sexual abuse [73]. In interviews with nearly 20 multi-ethnic women, Thompson et al. [74] identified the interlocking nature of different forms of oppression experienced by women, and how this intersectionality (e.g., racism and sexism and/or poverty) anchored some of the interviewed women’s choices and use of coping strategies [19]. Notably, although the women interviewed reported being hurt by the culture of thinness, they did not report that it was the core reason for their disordered eating behaviors. Instead, they reported their eating strategies were tools to cope with various traumas.

This finding is consistent with the affect regulation model of binge eating which suggests that binge eating is the consequence of the desire to regulate negative affect or emotion [75], as well as reports by Black women of using binge eating to cope with stress, respond to trauma, and find comfort when experiencing negative moods [23]. Encouragingly, studies have already yielded findings supporting the use of this model among Black women [23, 32].

Treatment Factors and Considerations

Black Patients in Treatment for BED

Though clear racial disparities persist in access to care for BED, the literature has yielded mixed findings regarding the presence of racial differences in the presentation of eating disorder symptoms [62, 76, 77]. For example, a study of Black and White BED participants seeking care in a primary care clinic found no significant differences in the clinical presentation of eating disorders or psychosocial functioning between Black (n = 53) and White participants (n = 56) with BED [77]. Similarly, other studies have found no significant racial differences in eating disorder pathology levels among between Black and White participants [26, 62]. However, in another study of treatment-seeking adults, Black patients with BED had significantly higher BMI and higher binge eating frequency compared to White patients with BED and had significantly lower depression compared to Hispanic and White patients with BED [62]. Additionally, even as racial disparities persist in treatment access, some evidence indicates that the beneficial treatment outcomes of established treatments for BED are not similarly disparate. Indeed, in a study of 592 adults (19% Black), Black participants had comparable or better outcomes (i.e., fewer binge-eating, lower depression) in treatments for BED compared to White participants, except that they were less likely to have attained a 5% per weight loss by the end of the study [76]. Notably, the authors concluded that disseminating evidence-based treatments for BED may be sufficiently effective and that these treatments may not require further adaptation for specific populations [76].

Despite this study’s conclusions, researchers and interventionists need culturally relevant strategies to ensure equitable, adequate access to care and to design treatment environments that appeal to Black women. Previous research has already shown that group-style interventions, a supportive facilitator, and cognitive-behavioral interventions may make BED treatments more effective for Black women [26]. Further, studies of the effectiveness of interventions for binge-type disorders for women of color support the use of accessible behavioral interventions to increase physical activity and raise appetite and satiety awareness [15, 78]. With this empirical foundation, researchers and interventionists are well-positioned to create and enhance programming for binge-type disorders among specific populations. The following sections detail evidence-based best practices for providers seeking to provide culturally congruent and effective care for Black women with BED.

Treatment Facilitators

Psychoeducation about Eating Disorders

One challenge to the treatment of eating disorders among Black women is the lack of awareness of BED and/or knowledge of what may be considered disordered eating. Although Black women have reported being distressed by the symptoms of BED, they may not view their binge eating as a clinically significant problem [23].Thus, when assessing Black women's disordered eating behaviors as part of treatment, it may be particularly important for clinicians to provide psychoeducation on relevant symptoms of BED, explore cultural views of shape and weight, and disseminate information on the nature of disordered eating, relevant treatments, and steps one may take to improve eating behaviors [23].

Culturally Relevant Assessments

When working with Black women, providers need to recognize how this population’s disordered eating terminology and motivations for disordered eating may differ from those of White patients. Importantly, Black women are not monolithic; this makes it critical for providers to consider the multi-dimensionality of questions being used to assess disordered eating for Black women [79] . Given the factors affecting binge eating among Black women often expand beyond shape and weight concerns, to adequately capture disordered eating in this population clinicians may need to ask additional culturally relevant questions designed to capture data on the life experiences potentially affecting the client’s eating behaviors. For example, Small [79] encourages providers to ask questions related to Black women clients’ past experiences with racism and microaggressions, along with questions about the influence of skin color, hair, acculturative stress, and gender on eating behaviors. Questions assessing past or present experiences of food insecurity, depression, identification with the strong woman syndrome, [38] trauma and/or sexual abuse may also be useful means of gathering data on the causes and presentation of disordered eating behaviors. Certainly, providing space to question and discuss the roles of historical oppression, colorism, class, gender identity, religion, poverty, and past relationships will be essential to creating an effective context and provider-client relationship for treating eating disorders among Black women [25]. Table 1 provides additional recommendations of culturally relevant assessment questions for providers.

Table 1.

Culturally relevant assessment questions to ask Black women clients with disordered eating. Adapted from Treating Black Women with Eating Disorders: A Clinician’s Guide (Edited by Small & Fuller, 2021; p. 25-26, 170).

Potential Assessment Questions for Black-Identifying Clients with Eating Disorders
How has your race/ethnicity affected the way you think about body and/or your relationship with food?
What has it been like for you growing up in a culture where racism and microaggressions are present?
Do you find yourself in environments where you are one of the only people of color? How have those experiences affected your relationship with food and your body?
What messages from society have you received regarding your figure?
Have you had periods of your life when you did not feel you had access to enough food to eat? How have those experiences affected your relationship with food and your body?
What role does food serve in helping you manage your emotions?
Do you feel pressure to have to be strong and/or be “all things” to certain people in your life?
What messages about food have you received from your culture?
What messages do you tell yourself about your food and eating patterns?
What are your triggers to eat?
What strengths help you deal with your eating disorder?
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Assessment Tools for Binge Eating

A recent systematic review found that most screening measures for eating disorders (i.e., Eating Disorder Examination (EDE), EDE-Q, Binge Eating Scale (BES)) yielded similar scores among Black and White participants [26]. For example, in a study examining two common eating disorder assessments (EDE and EDE-Q), Black (n = 119) and White (n = 119) participants exhibited similar convergence between the EDE and the EDE-Q. Scores were correlated, but higher on the self-report measure than in the interview for Black and White participants. The authors concluded that Black patients with BED can be evaluated similarly to White patients with BED, even though the assessment tools they considered were developed using predominately White samples [80]. However, subsequent research has highlighted the importance of using formal measures that assess specific and culturally relevant eating behaviors/attitudes, societal experiences, and racism to optimize assessment accuracy [81].

Helping Clients Manage Stress and Negative Emotions

Due to Black American cultural norms that may recognize eating as a legitimate means of managing negative emotions [81], it may be vital for clinicians to help Black women find new ways to effectively cope with stress and negative emotions [82]. Binge eating may be a way to self-soothe, particularly if clients are feeling pressured to perform the strong black women or superwoman role by manifesting strength and suppressing emotions regardless of personal stress [38]. Thus, trainings for ways to manage negative affect and to develop healthy non-eating coping skills will provide essential tools for Black women experiencing disordered eating.

Role of Race in Clinician Relationship

Importantly, one critical factor in the treatment of BED and other eating disorders in Black women is to understand and/or provide space to examine the client’s experiences of racism, sexism, and gender identity concerns. Indeed, recommendations have been made for clinicians, particularly those identifying as White to take the time to understand their own racial identity and to invite clients to share on the impact of racism in their lives. It may further improve therapeutic rapport to acknowledge the limited understanding of the lived experiences of Black women and position oneself as a “learner” to create an atmosphere when the client may feel safe to share. Though all clients may not find it necessary to examine the role of racism and microaggressions, including this in an assessment allows this determination to be made by the client.

Finally, for clinicians who identify as Black, it will be important to bracket one’s own racial identity development experience during the examination of the client’s racial identity. Recommendations have been made to not assume that shared racial identity equates to similar racial history and experiences with clients [83, 84]. Certainly, all are susceptible to be influenced by narratives from stereotypes; clinicians may find benefit in examining personal narratives of racial identity as well as working with the client to create an image that is healthy and not limited to ideas created by others and/or the larger society [84].

Conclusions

Though there is a growing literature to further the understanding of eating disorders, and specifically BED in Black women, gaps in the empirical literature remain. First, evidence remains limited on the use of evidence-based treatments for BED in samples of Black women [26]. Though we have some data to suggest these treatments may be beneficial, without additional evidence of their use in samples of Black women, clear answers remain in question. Next, there is little evidence to evaluate the use of culturally relevant treatments for BED, and whether the use of these treatments, customized in respect to cultural factors/values influencing disordered eating may improve long-term BED outcomes among Black women. Additional evidence is also needed to understand the barriers and facilitators to treatments for BED in samples of Black women. Though disparities are clearly noted, research is limited on facilitators that may improve access to care. Certainly, it will be critical for future clinicians to recognize the importance of cultural factors, socioeconomic and environmental factors, racism, and the intersections of these factors for creating effective treatments for BED among Black women [85].

Importantly, clinicians should also take steps to recognize any of their own implicit biases that may affect the type and quality of care they provide [86]. Doing so will allow the provider to build the patient/provider alliance through an affirmative therapeutic approach, and hopefully reduce early termination and increase patient willingness to seek services and adhere to treatment. Clinicians should also ensure that they assess and attend to the full spectrum of disordered eating behaviors in Black women patients. Although binge spectrum disorders appear to be more common than anorexia nervosa among Black women, clinicians must nonetheless screen for restricting patterns among Black women clients presenting with disordered eating to ensure that these clients receive appropriate treatment and support.

Future Directions

Currently, there is a dearth of eating disorder screening tools and treatment modalities designed for use with Black women. As such, existing measures used for assessing eating disorders that have not yet been tested using Black samples should test their psychometric utility for Black women. Future research should also investigate ways of adapting current modalities to better align with Black clients’ needs. Taking these steps will require researchers to prioritize creating new measures and treatments that are grounded in the expressed disordered eating behaviors, attitudes, needs, and motivations of Black women.

Funding:

Dr. Goode acknowledges grant support from K23129832, ADA-11-21-ICTSHD-12, and the Substance Abuse and Mental Health Administration (H79 SM081924).

Footnotes

Conflict of Interest: The authors have no existing conflicts of interest to report.

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