Binge Eating Disorder Is a Social Justice Issue: A Cross-Sectional Mixed-Methods Study of Binge Eating Disorder Experts’ Opinions

Background: Binge eating disorder is an autonomous DSM-V diagnosis characterized by discrete rapid consumption of objectively large amounts of food without compensation, associated with loss of control and distress. Environmental factors that contribute to binge eating disorder continue to evolve. This mixed-methods cross-sectional study assessed whether there is consensus among experts in the field about environmental factors that influence adult binge eating disorder pathology. Methods: Fourteen expert binge eating disorder researchers, clinicians, and healthcare administrators were identified internationally based on federal funding, PubMed-indexed publications, active practice in the field, leadership in relevant societies, and/or clinical and popular press distinction. Semi-structured interviews were recorded anonymously and analyzed by ≥2 investigators using reflexive thematic analysis and quantification. Results: Identified themes included: (1) systemic issues and systems of oppression (100%); (2) marginalized and under-represented populations (100%); (3) economic precarity and food/nutrition insecurity/scarcity (93%); (4) stigmatization and its psychological impacts (93%); (5) trauma and adversity (79%); (6) interpersonal factors (64%); (7) social messaging and social media (50%); (8) predatory food industry practices (29%); and (9) research/clinical gaps and directives (100%). Conclusions: Overall, experts call for policy changes around systemic factors that abet binge eating and for greater public education about who can have binge eating disorder. There is also a call to take and account for the narratives and life experiences of individuals with binge eating disorder to better inform our current understanding of the diagnosis and the environmental factors that impact it.


Introduction
Binge eating disorder is an autonomous DSM-V diagnosis characterized by discrete rapid consumption of objectively large amounts of food without compensation, associated with loss of control and distress [1]. The disorder has high lifetime prevalence rates (5%-13% [2,3]) and a complicated health sequelae [4,5] associated with genetic and environmental factors [6,7]. Several models of environmental factors for binge eating disorder have been proposed [7]. These models focus on behavioral genetic data that consistently support the contributions of both genetic and environmental influences to eating disorders and symptoms. For example, case-control family and twin-based studies have estimated heritability for binge eating disorder to be between 39% and 57% [8][9][10][11], with 42%-59% of variance attributed to unique environmental factors (not shared by co-twins) [9,12] and 13% attributed to common environmental factors [9]. These studies have not had complete agreement on whether shared environment plays a role in binge eating disorder [8]. Moreover, these studies were conducted between 2004-2010 [8][9][10][11] and are now outdated. Sociocultural models that focus on thinness ideals also have empirical support for increasing risk of eating disorder cognitions and behaviors in adolescents and women with eating disorders at large [7,13,14]. However, these models often lack empirical testing in populations of individuals with binge eating disorder, and in men and other minority populations.
More recently, social justice (equal distribution of opportunity, privileges, and wealth within a society [15]) has gained attention and traction socioculturally and in research broadly [16,17] as well as in the field of eating disorders specifically [18][19][20][21]. For example, the Coronavirus 19  pandemic has caused an increase in observational studies that have helped improve our understanding as a field of the experience of binge eating disorder from those who experience it [18,20] and tend to identify important social justice issues that seem highly relevant to binge eating disorder pathology [18][19][20][21]. These include eating disorder stigmatization and lack of diversity, inclusion, and representation for individuals with marginalized identities [20]. A recent review on binge eating disorder epidemiology [19] noted that less than half of adults with binge eating disorder are recognized in healthcare and minority status, deprivation, violence, trauma, and major mental health illnesses were identified as possible risk factors for binge eating disorder [19]. However, these proposed environmental risk factors lack empirical testing and more information on the contributions of environmental factors contributing to binge eating disorder is warranted and needed. Therefore, we interviewed 14 systematically identified expert binge eating disorder researchers, clinicians, and healthcare administrators on their perspectives of adult binge eating disorder pathology and treatment broadly. Here, we report on environmental factors identified as relevant to adult binge eating disorder pathology through reflexive thematic analysis of the semi-structured interviews that were conducted and recorded anonymously with the 14 systematically identified experts in the field.

Participants and Recruitment
This study recruited researchers, clinicians, and healthcare administrators with expertise in adult binge eating disorder. Eligibility criteria is shown in Table 1. Table 1. Participant eligibility criteria and number of participants who were recruited, and who consented and enrolled.

I. Eligibility criteria for researchers (18 recruited, 7 enrolled)
Eligibility criteria for researchers required meeting one of the following four criteria (I.1-4): 1.
Exclusion criteria: (A) grants not relevant to binge eating disorder, binge eating, compulsive eating, or overeating; (B) grants pertaining to anorexia nervosa or bulimia nervosa, without also pertaining to binge eating disorder; (C) grants pertaining to childhood or adolescence without also pertaining to adult binge eating disorder.

2.
Last author of ≥10 PubMed publications published 2010-2020 AND ≥5 PubMed publications in 2015-2020 relevant to binge eating disorder a. Retrieved January 2021 with the search term "binge eating disorder" in adults, young adults, and middle aged.

3.
Last author of ≥5 PubMed publications published in 2015-2020 relevant to food addiction a a. Retrieved January 2021 with the search term "food addiction" in adults, young adults, and middle aged.

Procedure
With approval from the National University of Natural Medicine (NUNM) IRB (# HZ12120), Dr. Bray sent eligible participants a scripted email study invitation. Respondents were interviewed anonymously on Zoom (Zoom.com; last accessed 19 May 2022) with verbal consent obtained at the start of each interview. Most interviews were scheduled for two hours, with abbreviated 30-60-min interviews conducted as needed. Table 2 shows interview questions pertaining to binge eating disorder pathology. Demographic information was collected at the end of each interview verbally or through follow-up email survey.

Question
n asked (n/14) Please describe your perspective on (or knowledge of) literature and research findings, current clinical guidelines, and your own personal experiences that relate to binge eating disorder pathology and treatment.

(100%)
How do you view the disease process in relation to the following possible aspects, and how important is it for treatment interventions to address these aspects ( Results expressed as n (%). n = number participants asked. Percentages expressed as n/14 times 100.

Data Analysis
Interview recordings were transcribed. Transcripts were de-identified and two investigators (BB and HZ) separately reviewed and qualitatively analyzed each transcript for common themes among interviews using a reflexive thematic analysis approach [29]. Interviews were independently coded by BB and HZ. Themes were identified independently then discussed and finalized through reflexive engagement with the data [29] with intentional involvement of BB and HZ. Transcripts were analyzed quantitatively by BB to identify the number of participants who expressed positive/supportive, negative/skeptical, or neutral perspectives on each of the identified themes. Additional investigators were consulted when quantitative analysis questions arose and for tiebreakers (HZ, CB).

Participant Response Rates and Characteristics
Thirty-eight experts met enrollment criteria and fourteen consented, enrolled, and participated in the study (Figure 1). This included six individuals who met the academic/research criteria (6/14, 43%), five who met the clinical criteria (5/14, 36%), one who met both the academic/research and clinical criteria (1/14, 7%), and two who met some criteria from the academic-and clinical categories so as to qualify for inclusion in a mixed option (2/14, 14%) ( Table 1). Characteristics for the 13/14 participants who provided their demographic information are provided in Table 3. Figure 1. Diagram of study flow, from participant identification to enrollment and follow-up. Thirtyeight experts met enrollment criteria and were invited to participate in the study. This included 18 experts who met the academic/research criteria (18/38, 47%), 18 experts who met the clinical criteria (18/38, 47%), and two who met the dual criteria (2/38, 5%; Table 1). Fourteen eligible experts consented, enrolled, and participated in the study (14/38, 37%), including six individuals who met the academic/research criteria (6/14, 43%), five who met the clinical criteria (5/14, 36%), one who met both the academic/research and clinical criteria (1/14, 7%), and two who met the dual criteria option (2/14, 14%). Thirteen participants (13/14, 93%) provided demographic information and were included in demographic analysis (Table 3). All 14 participant interviews were included in thematic analysis.  (Table 4). Twelve subthemes were identified that addressed singular or intersectional systems of oppression, all of which were described as causative or comorbid with binge eating disorder or impeding research, treatment, or remission ( Table 4). The subthemes were: (i) systematic discrimination (e.g., body weight/shape/size discrimination (see Theme 4), systematic racism, systematic sexism) (12/14, 82%); (ii) media messaging and sociocultural mandates (e.g., perpetuating stigmatization, body weight/shape/size ideals and discrimination, "diet culture," and movement and fitness ideals; see Theme 7; 12/14, 82%); (iii) insurance and healthcare systems (including insurance costs and coverage, treatment costs, systematic stigmatization from healthcare providers, geographic access to treatment, mandated movement for individuals in larger bodies, and provider scarcity; 9/14, 64%); (iv) "predatory" food industries/environments (see Theme 6; 4/14, 29%); (v) abuse (often domestic, including sexual, emotional, and/or physical; Theme 5, 4/14, 29%); (vi) geographical systems (e.g., geographical inequities in provider and treatment access, and in government assistance programs like the Supplemental Nutrition Assistance Program (SNAP) that can limit its effectiveness [30][31][32]; 4/14, 29%); (vii) eating disorder research as a field (e.g., operating from an anorexic-centric perspective/understanding; 3/14, 21%); (viii) research funding (e.g., lack of funds for eating disorder research relative to disorders of similar prevalence, lack of clarity regarding what agencies should fund eating disorder research; 2/14, 14%); (ix) economic exploitation (a relationship in economic wealth distribution wherein a worker does not receive proper compensation for his/her work [33]; 1/14, 7%); (x) school systems (e.g., individuals in larger bodies being less likely to be called on in class or receive college entrance; 1/14, 7%); (xi) legal systems (1/14, 7%); and (xii) police harassment (1/14 7%).  Themes 4 and 7) 12 (82%) Perpetuating stigmatization 12 (82%) Body weight/shape/size ideals (and discrimination) 12 (82%) "Diet culture" 3 (21%) Movement & fitness ideals 2 (14%) Insurance and healthcare systems 9 (64%) Insurance costs and coverage 6 (43%) Treatment costs 6 (43%) Systematic stigmatization from healthcare providers 6 (43%) Geographical access to treatment resources 4 (29%) Mandated movement for individuals in larger bodies 2 (14%) Provider scarcity 1 (7%) "Predatory" food industries/environment (see Section Theme 8) 4 (29%) Abuse (sexual, emotional, or physical) 4 (29%) Geographical systems 1 4 (29%) ) Eating disorder research as a field 2 3 (21%) ) Eating disorder research funding 3 2 (14%) Economic exploitation 4 1 (7%) School systems 1 (7%) Legal systems 1 (7%) Police harassment 1 (7%) All fourteen participants (14/14, 93%) acknowledged marginalized and minority populations that are disproportionately impacted, screened, treated, and represented in the field (Table 5). Subthemes pertaining to historically marginalized and overlooked populations included: (i) individuals with low socioeconomic status (13/14, 93%; see Theme 3.i below); (ii) individuals with food or nutrition scarcity (10/14, 71%; see Theme 3,ii-iii below); (iii) male sex/gender (8/14, 57%); (iv) racial and ethnic minorities, including black, indigenous, and people of color (5/14, 36%), (v) lesbian, gay, bisexual, transgender, and nonbinary populations (3/14, 21%), (vi) age (2/14, 14%); and (vii) religion (1/14, 7%). 1 (7%) Additional participant statements on minority-and marginalized populations "The number of people that I've seen and done evaluations on [who] are really surprised to learn that the way that they've been eating is actually considered disordered, and that they have an eating disorder, and I think that that's especially true for men, I think that's especially true for any individuals [who] don't fit that stereotypical mold of who has an eating disorder. . . . We know that unfortunately eating disorders have been hampered by these old stereotypes about who's affected, and that leaves millions of people undetected with an eating disorder. . . . There's a lot of emphasis these days on making sure that we're meeting the needs of underrepresented groups and so a lot of people are talking about how eating disorders don't discriminate, and that's certainly true, and I think it also makes sense to talk about the specific ways in which underrepresented groups might be struggling that are unique to them and their experiences versus just saying 'anyone can be affected." (P75) "So much of the eating disorder perspectives and history . . . that we attend to are very female-focused, . . . and come out of . . . the female gender orientation. . . . I think anorexia [nervosa] kind of set the stage [for a current understanding of eating disorder pathology and treatment], [and anorexia nervosa] is so dominantly female." (P16) "Certainly, there has been discussion in the eating disorder world . . . about whether different ethnicities have different levels of acceptance of overweight and obesity. So, one wonders whether that has impacts on . . . the frequency of the distress about binge eating disorder or the wish for treatment." (P46) "If you're a black woman, if you are somebody who lives in a larger body, if you are an older male, people aren't going to think that your eating habits [constitute] an eating disorder because you aren't . . . a young, thin, cis-gendered, white woman, and so I think that even just recognizing that binge eating disorder is 'a thing' is one of those things that gets in the way . . . I think it also makes sense to talk about the specific ways in which underrepresented groups might be struggling that are unique to them and their experiences versus just saying 'anyone can be affected.' . . . So knowing, for example, that if you are a sexual or gender minority you are at much greater risk of any kind of eating disorder behaviors, knowing that if you are a BIPOC member of a community you are very unlikely to get detected with an eating disorder, and that means you could struggle for a long time, and what do we do then to reach these communities in a way that's meaningful?" (P75) Thirteen participants addressed economic aspects of binge eating disorder (13/14, 93%); five (5/14, 36%) described direct connections between binge eating disorder pathology and economic status/precarity (Table 6). Seven factors were described as potentially mediating or moderating the relationship between economic precarity and binge eating pathology. These included: food insecurity (5/14, 36%); nutritional access/insecurity (5/14, 36%); food environment (3/14 participants, 21%), mental health risks (2/14, 14%), the COVID-19 pandemic (2/14, 14%), access to treatment resources (2/14, 14%), and weight biases (stating individuals in larger bodies experience economic discrimination) (1/14, 7%). Many of the economic factors-including the relationship between financial security, food scarcity/insecurity, and a pattern of forced restriction and binge eating-were endorsed as "systemic" public health issues.
"If [an individual's] economic status is not as good, their physical health status will be not as good and their mental health status will be not as good and we know that socioeconomic disadvantage is a major player in terms of risk for . . . perpetuation of illness, for maintenance of illness. And sometimes for, . . . the onset of illness as well. . . . socioeconomic disadvantaged groups in the community have poorer mental health, we know that. So, it is really important." (P93)
"I work with patients who have said, 'well yeah, I have binge eating. I binge eat the first two weeks of the month 'cause that's when we have food in the house and then there's no food in the house the last two weeks of the month.' That's a systemic issue that I think needs to be addressed and needs to be talked about in terms of people's vulnerability to eating disorders." (P75)
"The police are to black men as the medical establishment is to black women" (P72) "I have a patient with binge eating disorder whose doctor told her, 'you're fat every day, so you should exercise every day. '  Three participants (3/12, 25%) also discussed weight discrimination, described as one of the few remaining socially acceptable and legal forms of discrimination in the U.S., affecting college admission, job security, and healthcare treatment (Table 7).
"[There's] lots of research showing that traumatic early life experiences, sexual abuse, but also other forms of abuse, emotional and physical abuse, increased someone's risk for an eating disorder." (P93) "If the eating disorder has been associated with weight gain, then we know for a fact that they've been intruded upon by families, doctors, . . . institutions, and . . . there's trauma associated with that. There's trauma [associated] with . . . being told day in and day out that what you are is not acceptable or lovable or okay." (P7) " . . . trauma of physical activity . . . the idea that they don't want to work out, but it's really that their middle school teacher was screaming at them when they were trying to do their . . . whatever . . . PE class, or they got made fun of." (P37) "Trauma is so bad for the brain and what we're seeing around 'little t trauma,' if you are someone [who is] susceptible, and you are teased and bullied, I think there's a lifelong consequence for a lot of those individuals, and I think that absolutely sets up the trajectory around eating dysregulation, no question about it." (P72) 3.5.2. Subtheme ii: Relationship between Trauma/Adversity and Binge Eating Disorder Pathology (79%) Eleven participants (11/14, 79%) expressed views that trauma exposure is relevant to binge eating disorder pathology, with four participants referencing research findings (4/14, 29%) ( Table 8 Seven major trends were identified by which participants described trauma/adversity as being related to binge eating disorder pathology: (a) trauma/adversity as increasing risk for binge eating disorder (5/14, 36%; see Table 9 for supportive subthemes); (b) neurobiological impacts of trauma/adversity may prime binge eating disorder (2/14, 14%); (c) binge eating to cope with trauma/adversity or resulting mood regulation disturbances (2/14, 14%); (d) trauma/adversity as exacerbating or triggering binge eating disorder symptoms (2/14, 14%); (e) trauma/adversity as being comorbid with binge eating disorder (1/14, 7%); and (f) additional possible mechanistic pathways by which trauma/adversity may be linked to binge eating disorder (2/14, 14%), including the possibility that trauma/adversity can "make it harder to tolerate the distress that comes with doing treatment," (1/14, 7%). Table 9. Participant statements relating to Theme 6, "interpersonal factors".
"To what degree do we understand any trauma that somebody with binge eating disorder has experienced throughout their life, either singularly or multiple times? And how does that play a role in . . . their current experience? And [trauma] can be specific . . . traumatic events, it can be the ongoing impact of chronic stress related to either low level trauma or the trauma of chronic racism or the trauma of chronic weight stigma. And so how do we think about that and where does that fit into . . . our treatments?" (P60) 3.6. Theme 6: Interpersonal Factors (9/14, 64%) Nine participants (9/14, 64%) expressed views that interpersonal relationships, effectiveness, and deficits play important roles in binge eating disorder pathology (Table 9).
"Any form of interpersonal deficits or a struggle in terms of sustaining, maintaining good quality relationships in life and having people [to] confide in is an important vulnerability factor for an eating disorder, but also may probably help explain why interpersonal psychological therapy and addressing interpersonal deficits is an effective treatment in controlled trials." (P93)
"As a field . . . we neglect social anxiety disorder because we tend to think it's just about weight and shape, self-consciousness, I think we under-diagnose this. . . . we need to be looking specifically at Social Anxiety Disorder and I think based on Janet Treasurer's work, we're going to end up seeing that there's links in . . . sensitivity to social threat, . . . the extent to which that's causal, secondary to the eating disorder . . . understanding where anxieties sort of intersect and [understanding the] neurocognitive process . . . especially around threat sensitivity . . . is going to be really helpful." (P72) 3.6.3. Subtheme iii: Positive Relationships between Social Interaction and Binge Eating Disorder Pathology (21%) Three participants (3/14, 21%) also described positive relationships between social interaction and binge eating disorder pathology (outside of social media and social messaging). Two of these participants (2/14, 14%) referenced the positive impacts of community and one referenced the benefits of family (1/14, 7%). One participant expressed in a neutral, nonspecific manner, that social factors are important in binge eating disorder (1/14, 7%).
"[Social support] has an enormous impact not just on your behavior, but on you know, your brain functioning, honestly, I mean, it means you are in a community you are being cared for you are accountable." (P72) 3.7. Theme 7: Social Messaging and Social Media (7/14, 50%) Seven participants (7/14, 50%) described social messages (3/14, 21%) and social media (5/14, 15%) as being significantly relevant to binge eating disorder pathology (Table 10). Four participants (4/14, 28%) described the relationship as exclusively negative, primarily by reinforcing ideals around body weight/shape/size, food, eating, and fitness that contribute to stigmatization, social ranking, social interactions, and self-esteem/valuation/negative affect. Three participants (3/14, 21%) described the relationship as primarily negative, but also having some positive aspects or potential. Table 10. Participant statements relating to Theme 7, "social messaging and social media".

Social Messaging and Social Media 7 (50%)
Significantly relevant to binge eating disorder pathology 7 (50%) Social media as relevant 5 (36%) Social messages as relevant 3 (21%) Relationship described as exclusively negative 1 4 (28%) Relationship described as primarily negative but with some positive aspects or potential 3 (21%) Relationship described as exclusively positive 0 (0%) Additional participant statements regarding social messaging and social media: "Social media clearly does not replace [community]; it seems to lead to more comparisons and more loneliness." (P72) "When Meghan Trainor came out with 'All about that base,' . . . people around me were like, 'that's not going to make a difference,' [but] I was like, 'no, no, something's shifting,'." (P72) Results expressed as n (%), in which percentages are n/14 times 100. 1 Primarily by reinforcing ideals around body weight/shape/size, food, eating, and fitness that contribute to social ranking, social interactions, and self-esteem/valuation/negative affect.
"If you look at social media, the amount of blaming and stigmatizing and the link still . . . between . . . character and weight and shape and the role of thin privilege. I really do believe that if we can shift some of that it's going to have broader based implications around eating disorders, especially-frankly-binge eating, because people tend to be higher weighted." Four participants (4/14, 29%) described "predatory" food industry practices, such as hiring engineers to design foods that produce specific rewarding or emotional responses and promote consumption, potentially leading to over-consumption, and binge eating (Table 11). Table 11. Participant responses pertaining to Theme 8, "predatory food industry practices". Subthemes Related to Food Industry Practices 4 (29%) (i) "Predatory" food industry practices described 1 4 (29%) Describe foods intentionally designed to produce specific reward responses that promote excessive consumption 2 (14%) Comparisons made between "big tobacco" and "big food" industries 2 (14%) (ii) Food industry practices described as public policy issue 2 (14%) (iii) Call for public education 2 2 (14%) (iv) Express view that disordered eating behavior can be associated with specific foods, but can be extinguished 2 (14%) (v) Rewarding food properties acknowledged but not described as intentionally engineered 1 (7%) Table 11. Cont.

Additional statements describing "predatory" food industry practices and environments
"The evidence suggests that it's almost all ultra-processed, highly rewarding, potentially addictive foods that people are bingeing on, and in a really extreme manner and we kind of don't acknowledge that those foods potentially have this differential impact on our reward systems, inhibitory systems, emotion regulation systems." (P19) "We have . . . whole . . . city areas that are geared up around fast food. . . . [there are places where you can] very easily get a hold of fast food. You [can't] very easily get a hold of decent food." (P84) Additional statements describing food/eating extinction/normalization "What I'm worried about this notion of getting into it somehow the food's fault, or it's . . . an illness process that resides within the individual that's partly exhausting to make people get well. I've seen too many people do too well in binge eating disorder, to believe that there's some kind of genetic element or sometimes some kind of cue learning event going on that is unchangeable. Certainly, you get cue learning, but it's something we actually deal with all the time, then it seems to go away if you unlearn it, which is you basically oblivion conditioning stuff." (P84) Results expressed as n (%), in which percentages are n/14 times 100. 1 E.g., hiring engineers to design foods that produce specific rewarding or emotional responses and promote consumption, potentially leading to overconsumption and binge eating. 2 E.g., informing individuals with binge eating disorder of the nature of "hyperengineered foods" and food industry practices to provide a full picture of "[the foods and industries] they're dealing with", (P16).
"The question of political utility is something which we don't usually talk about in science, but I saw the nutritional epidemiology field paying attention to the emotional aspects of overeating and the emotional and physiological aspects of the way processed foods are created to promote overeating by tapping into physiological responses to fat, sugar, crunch, salt . . .
. . . There's so many processed foods that are designed to get people to overeat or to . . . trigger an emotional response that then [makes] someone prone to binge eating as a way of emotionally coping with things that are happening around them that feel out of their control or that are damaging to them. . . . There's so many different systems; the food system is one of them. This was often identified as an issue of political utility and public policy. Comparisons were made between "big food" and "big tobacco." One participant noted that: "With . . . tobacco, . . . we were working on these treatments, and pharmacology, and all these sorts of things, and we really didn't start to see drops in [ One participant also advocated for the importance of informing individuals with binge eating disorder of the nature of these foods/food industries and "what they're up against" to alleviate the sense of failure and guilt that often accompanies binge eating these foods.
"To ignore the fact that the food environment has changed, and that we are all kind of dealing with . . . predatory industry practices, but with very hyper-engineered, highly rewarding foods, to not acknowledge that in any way is problematic, and I think not giving people . One participant (1/14, 7%) acknowledged certain processed/engineered foods (e.g., brownies) can produce different reward-and behavioral responses than natural whole foods (e.g., broccoli), but did not describe these foods as being intentionally engineered to create specific consumer responses, or as contributing to the phenomenon of binge eating. One participant (1/14, 7%) acknowledged a variety of foods can be highly rewarding to a variety of consumers but did not identify these foods as being "processed" or intentionally "engineered." One additional participant (1/14, 7%) recognized disordered eating behavior can be associated with specific foods but attributed this to the internalization of specific "food rules," stating that normalizing mindful food consumption can extinguish "food rules" and the disordered eating behavior in turn.
"I have people [who] think that they're addicted to food. Once we normalize that food, though, then it's like, 'oh, okay, I can have cheesecake for my snack. Awesome,'." (P37)

Theme 9: Research Gaps and Future Directives (14/14, 100%)
Six subthemes were identified regarding gaps in the literature the experts would like to see closed and future research directives that pertain to the themes identified herein (Table 12).

That's a systemic issue that I think needs to be addressed and needs to be talked about in terms of people's vulnerability to eating disorders." (P75)
Results expressed as n (%), in which percentages are n/14 times 100. 1 Including need for more funding (equally proportionate to that available for research on other disorders of similar magnitude) and need for clarification on which funding agencies should fund eating disorder research. 2 E.g., structural racism and sexism, economic exploitation (see statements from P16 in section A), and "broader sociocultural issues". 3 "What do we do then to reach these [marginalized] communities in a way that's meaningful?" Abbreviations: BED, binge eating disorder.

Subtheme i: Systemic Changes (71%)
Ten participants identified a need for change in some of the systems that currently abet binge eating disorder (10/14, 71%). Spontaneously identified systems included: (a) the eating disorder field (5/14, 36%), including a need for increased funding for eating disorder research (equally proportionate to that available for research on other disorders of similar magnitude) and need for clarification on which funding agencies should fund eating disorder research (2/14, 14%), change in mandated movement perpetuated by the medical field that can be traumatic for individuals with binge eating (e.g., recommendations and mandates for movement-from PE instructors and medical doctors-given in ways that are insensitive to weight stigmatization and bullying, see Theme 4; 2/14, 14%), and recognition of implicit biases, stigmatizations, and discriminations toward individuals with binge eating and in larger bodies held among those in the field (1/14, 7%). (b) Food systems and availability (4/14, 29%), including food industry practices (2/14, 14%) and food stamp allotment (1/14, 7%). (c) Other systems of oppression (e.g., structural racism and sexism, economic exploitation (see statements from P16 in Theme 1), and "broader sociocultural issues," (P72)); and (d) economic aspects that prevent treatment access (1/14, 7%).
"I think we're very underfunded in terms of treatment trials, and . . . woefully underfunded when we compare ourselves with high weight disorders. . . . . . . and just generally, across the board, we need . . . more funding for research . . . " (P93) "I think that there's a professional socio-cultural administrative framework that is having trouble getting its arms around binge eating disorder . .  Table 9 and in Table 12.

Analysis Results
The environmental factors that impact adult binge eating disorder continue to change and evolve, as does our awareness of them as a field. The themes identified here represent new and emerging areas of research and recognition pertaining to environmental factors that impact adult binge eating disorder pathology.
Overall, expert recognition and emerging literature highlight the need for public education and policy change that can help reduce the oppression and discrimination inherent in these systems. Examples include: education and enforcement of equal eating disorder screening from healthcare providers across race, ethnicity, gender, sex, sexual orientation, weight-and socioeconomic status (as well as healthcare provider education on implicit biases and stigmatizations about binge eating disorder) [76]; inclusion of minority and marginalized populations in eating disorder research [65]; equal funding for binge eating disorder research relative to other disorders of similar prevalence [77,78]; as well as consensus on which agencies should provide such funding; and public education and policy change in food industry practices that target minorities and abet binge eating [64,[79][80][81][82][83][84][85][86][87][88] Many themes herein highlight a paradigm shift from an old view that ascribes eating disorders to thin, affluent, white cis-gendered females (the "SWAG: skinny, white, affluent, girl" stereotype [89]) to a new recognition of populations of individuals with binge eating disorder who have been historically overlooked in the field. These populations include racial, ethnic, and sexual minorities but also extend to other non-white, affluent, cis-gendered female populations (e.g., males [68], individuals in "normally" sized/weighted/shaped bodies [68], and individuals with low socioeconomic status [34,47,68,73,90], especially those with past or present histories of food/nutrition insecurity [34,47,[73][74][75][90][91][92][93], or use of government assistance programs like SNAP, food stamps, or welfare [47,75,91,93]). The experts recognize the historical mistake of overlooking these populations in research and clinically (theme 2) and recognize a need to include these populations going forward (themes 2, 9.iii,v).
Emerging literature supports the growing understanding that although white affluent cis-gendered females have traditionally saturated the treatment-seeking population (and thus research populations as a result), they do not exclusively represent all individuals who experience binge eating disorder. For example, studies have shown that 93.4-96.8% of individuals who meet DSM criteria for binge eating disorder never receive a formal diagnosis [68,94]; 67.3% do not perceive the need for treatment [68]; and 56.4-86.8% never receive or pursue treatment [2,68]. Moreover, individuals with eating disorder symptoms who are underweight, female, affluent, and/or white are more likely than their respective counterparts to perceive a need for treatment or receive a diagnosis or treatment [68].
The shortcomings in eating disorder recognition, screening, and treatment seem to affect specific minority populations more profoundly. For example, black, indigenous, and people of color have higher prevalence rates of binge eating disorder than their white peers [71,72,95], but make up <10% of participants in binge eating disorder research studies [65], are less likely to be screened by medical professionals for eating disorders [66,67], and are 50% less likely to be diagnosed or receive care [65,66,[69][70][71][72]. Emerging literature suggests sexual minorities are at an increased risk for eating disorders [96], with a nationally representative U.S.-based study finding greater prevalence of adult binge eating disorder in non-heterosexual participants (2.2%) than in heterosexual participants (0.8%) [97]. Literature on prevalence rates among agender, transgender, and non-binary individuals focuses primarily on youth [47,59] but demonstrates transgender young adults also have higher prevalence rates of binge eating disorder than their cis-gendered counterparts (28% in females, 64% in males, and 73% in non-binary respondents) [59], with transgender males having higher eating disorder pathology scores than transgender females [47].
These minority and marginalized populations often experience multiple factors associated by the experts as relevant to binge eating disorder pathology (e.g., economic precarity, food/nutrition scarcity, stigmatization, and discrimination) [59,71,72]. For example, rates of food insecurity are significantly higher in Black and Hispanic households (vs. White households) [48,49]. Transgender and nonbinary individuals experience higher rates of family rejection [45] and homelessness [45], have three times higher rates of adult unemployment (15% vs. the 5% national average) [46], and over two times higher rates of poverty and food insecurity than the national averages (poverty: 29% vs. 12% national average [46]; food insecurity: 21.2% vs. 10.5% national average [47,48]). These populations also experience high prevalence of stigmatization [56,[59][60][61][62][63], with higher levels of enacted stigma associated with higher odds of binge eating in transgender young adults [59]. More research is warranted to investigate other ways these independent factors may intersect to mediate or moderate the higher prevalence rates of binge eating disorder observed in minority populations.
Studies conducted at a food pantry in San Antonio, TX between 2015-2016 [34,73,90] found 51.5% of respondents reported deliberately trying to limit food consumption or going >8 h without food consumption [73], which was significantly correlated with overall level of eating disorder pathology (r = 0.25, p = 0.0001) and higher BMI [73]. Three main reasons for food minimization were lack of resources, SNAP or food stamps being insufficient, and family reasons [73]. Examples included "minimizing effects of hunger for other family members (e.g., children), 'stretching' food to make it last longer, and prioritizing medical expenses," [73].
These and other findings suggest limitations in current government assistance programs-or the way these programs are being used-may increase odds of recurrent binge eating, leading to binge eating disorder. While research continues to emerge on this relationship, some experts recognize this issue as systemic and likely requiring public education and policy change (themes 1-3). Additionally, it is important to include individuals with economic precarity and food scarcity/insecurity in research going forward, and to identify prevention and treatment options accessible to them.
Adverse childhood food experiences represent a specific form of adversity recognized by the experts that are also gaining recognition in the literature [74]. Coffino et. al. (2020) recognize childhood food neglect as "an ACE specially involving restricted food access" that increases odds of developing binge eating disorder (aOR: 2.95; 95% CI: 1.73-5.03])," [74]. While the experts call for a greater understanding of the specific forms of trauma and adversity that individuals with binge eating disorder experience and the ways these factors interact with binge eating disorder pathology (themes 5,9), it will also be important to evaluate existing literature that questions the internal validity of self-report measures of adverse childhood experiences [135,136] "Interpersonal," an adjective, refers to relationships or communication between people [137]. Experts and literature recognition of interpersonal factors as relevant to binge eating disorder pathology [138][139][140][141] are underscored by the success of interpersonal psychotherapy (IPT) in treating binge eating disorder [138][139][140][141][142][143][144][145][146][147]. National survey data collected between 2001-2003 [2] found 15.9% of individuals with binge eating disorder report severe impairment in their social lives, which exceeds reported prevalence rates for impairments in home-, work-, or personal lives [2]. Furthermore, individuals with binge eating disorder have significantly higher levels of interpersonal distrust [139], social insecurity [139]. attachment anxiety [139], and attachment avoidance [139] than non-clinical samples, as well as relational styles that are more domineering [141], cold [141], less-or non-assertive [138,140,141], more exploitable [140], and more socially withdrawn [138,141].
The lack of consensus among experts on the nature of the relationship between interpersonal deficits and binge eating pathology (e.g., directionality, possible mediators, moderators, and underlying mechanisms; Table 10) reflects an incomplete literature base. Ivanova et al.'s 2017 interpersonal model [138] found negative affect and affect instability mediate the relationship between interpersonal functioning and eating disorder psychopathology (p < 0.01-0.001) [138]. This model generally has the most support in the field [140,148,149] though incongruent findings exist [142,150].
Social ranking, social threat perception, and threat sensitivity have also been explored in the literature as being relevant to eating disorder pathology [151][152][153][154][155][156][157]. Work from Janet Treasure's lab finds individuals with anorexia-and bulimia nervosa have heightened sensitivity to social rank-related cues (but impaired self-evaluation at an automatic level of processing) [153], genetically-rooted attentional biases to social threat [152,155] (but deficits in emotion recognition and regulation) [152], and cognitive avoidance of threatrelated information [151,155], Currently, these findings remain largely untested [158] or unreplicated [157] in individuals with binge eating disorder.
Given the experts' comments on the traumatic ways in which individuals with binge eating disorder experience a variety of forms of stigmatization and discrimination-and the ways these experiences often extend to an individual's value and worth (theme 4)-it may not be surprising that individuals with binge eating disorder struggle with interpersonal communication and relationships. Possible connections between stigmatization, social bullying, adverse interpersonal experiences, and interpersonal deficits or even post-traumatic stress around interpersonal adversity certainly warrants future investigation.
The theme of social support is one that bridges the themes of interpersonal factors (theme 6) and social media engagement (theme 7). Literature shows individuals with binge eating have significantly greater levels of loneliness and lower levels of perceived social support relative to individuals without loss of control eating (p < 0.001) [159]. Furthermore, greater levels of social support are significantly associated with reductions in binge eating [139,160,161]. However, emerging literature demonstrates that not all forms of social support are equal for all individuals with binge eating disorder. For example, social support from family is associated with less likelihood of binge eating in African American women but greater likelihood of binge eating among white women [161]. A Chinese analysis of eating disorder treatment experiences further concluded "parents, friends, and partners were sources of social support, but participants largely felt misunderstood or blamed by these same entities," [162]. Overall, the literature supports participant 84 s statement that "other people can be part problem as well as part of the solution." The impacts of different forms of social support on different populations of individuals with binge eating disorder warrants further investigation, as does the nature of the relationship between interpersonal factors and binge eating (e.g., regarding directionality, existence of mediators, moderators, and underlying mechanisms).

Theme 7: Social Messaging and Social Media (50%)
The experts' recognition of negative impacts of social media use on binge eating disorder is reflected in the literature. In Chinese children, each additional hour of total screen time, social networking, texting, and/or watching/streaming television shows/movies per day is prospectively associated with significantly higher odds of binge eating disorder [163]. Increased photograph investment and investment in others' "selfies" on social media have both been associated with significantly increased odds of meeting criteria for binge eating disorder among Australian adolescents [164]. A 2022 integrative review of social media use and binge eating further concluded "the more participants use social media, the more likely they are to have increased appetite or intention to eat, which can lead to binge eating," [165].
Media messaging was perhaps one of the first factors explored as contributing to eating disorders broadly [166][167][168], supported by neuroimaging findings of neurobiological alterations related to body comparisons and distortions in individuals with anorexia nervosa [169][170][171]. Studies in binge eating disorder support the presence of body image disturbances (e.g., body weight/shape overvaluation), dissatisfaction, and body-related cognitive biases (but with accurate ratings of body shape) in individual with binge eating disorder [172]. However, the direct culpability of media-endorsed body images remains to be tested. Giordano (2015) suggests: "considering the portrait of thin models in the media industry as responsible for eating disorders is a misanalysis of the problem," and states, "media images, the public preference for extreme thinness, are, like eating disorders themselves, the expression of normative values" that relate thinness with "self-control, discipline, and austerity", [167].
While it may be true that sociocultural associations exist between thinness and selfcontrol (and-by default-between larger body sizes or loss of control eating and lack of self-control or discipline), these associations warrant investigative testing. The themes identified here suggest binge eating disorder is often associated with hardships that are outside of the control of the individuals who experience them (e.g., systematic oppression, marginalization, stigmatization, trauma, and adversity). The ways in which an individual's lack of control of external processes relates to lack of control of internal processes (and loss of control eating) warrant further investigation, as does an assessment of self-efficacy among individuals with binge eating disorder.
Overall, experts and literature suggest binge eating is often simultaneously normalized and stigmatized socioculturally. Sociocultural messages around binge eating and larger body sizes extend from advertisements that promote and glamorize food consumption while also reinforcing a drive for weight loss and thinness to Instagram selfies and tweets that emphasize thinness and conceal lack of control or hardships. An assessment of these messages may help explain why binge eating disorder itself is so minimalized [105], marginalized, and overlooked, despite its prevalence and gravity.
The experts' recognition of social media as an inadequate replacement for community and/or solution to loneliness and isolation (theme 6, e.g., P72) also bears further investigation. Despite many negative associations between social media engagement and binge eating disorder development [163][164][165], Nutley et al.'s qualitative analysis of Reddit use (www.reddit.com) among individuals with eating disorders during the COVID-19 pandemic concluded that many individuals used Reddit forums for support during the pandemic [173]. To this end, a variety of literature shows statistically significant associations between social support and reductions in binge eating [139,160,161]. Further investigation is warranted to determine the ways in which social support differ when achieved through different forms of online social mediums (e.g., engagement in Instagram/Facebook/Twitter vs. support-oriented Reddit forums or Facebook groups), online or in-person treatmentoriented mediums (e.g., treatment teams, professional-led support groups, or peer-led support groups such as overeaters anonymous), or in-person (e.g., in-person support from family and friends).

Theme 8: Predatory Food Industry Practices (29%)
Minority expert recognition of food industry practices designed to manipulate consumer choices (29%) is proportionately under-represented in peer reviewed journals and in the popular press [64,[79][80][81][82][83][84][85][86][87][88]. Experts and literature recognize that food environments and manufacturers can (and do) leverage food decisions by influencing variables known to control consumption that can also result in binge eating (e.g., marketing, packaging, container shape, portion size, product salience, and hedonic factors like salt, fat, sugar, and structure/texture) [80,86]. Literature also recognizes similarities in deceptive tobaccoand food industry marketing practices (e.g, intentionally emphasizing personal responsibility, paying research scientists to criticize opposing research as "junk science," lobbying with "massive resources to stifle government action," "manipulating and denying . . . the addictive nature of their products," and marketing to children to capture lifelong consumers) [85]. More recent findings identify direct tobacco industry involvement in food marketing strategies [64,87] that were not recognized by the experts. Examples include R J Reynolds' ownership of Hawaiian Punch [87], Philip Morris' ownership of Kool-Aid [87], Capri Sun [87], Tang [87], and General-and Kraft Foods [64], and Phillip Morris' direct transfer of "expertise, personnel, and resources from its tobacco to its food subsidiaries, creating a racial/ethnic minority-targeted food and beverage marketing program modeled on its successful cigarette program," [64]. This depth of tobacco-and food industry involvement highlights some of the ways oppressive tobacco and food systems directly target racial and ethnic minorities, possibly contributing to the systemic oppression that can increase the risk for developing binge eating disorder.
Literature-but not experts-also identifies food industry efforts to influence nutrition research and professional activities [82,83] through forming and funding "science-sounding" research institutes and journals used to develop and publish industry-supported studies and industry-benefiting guidelines on scientific integrity, conflict of interest, and publicprivate partnership, thus shaping the nature of the science that drives public policy to its benefit [82]. These practices are important to address because they influence food consumption in ways that can result in binge eating and specifically because they are not recognized by the majority of experts, suggesting they may not be known. Thus, the experts' call for public education and policy change around food industry practices (theme 6) seems particularly imperative. 4.1.9. Theme 9: Accounting for Narratives & Life Experiences through Open-Ended Research The themes identified herein emphasize the need for open-ended research that can access and include the~70% of individuals who experience binge eating disorder symptoms but may not recognize their need for treatment [68] as well as the~95% of individuals with binge eating disorder who never receive a formal diagnosis [68,94] and the~56-87% who never pursue or receive treatment [2,68]. It is equally important to identify research recruitment and dissemination tactics and treatment options that include minority and marginalized populations and receive and account for the unique treatment barriers these populations face. Specifically, these themes emphasize the value of taking and accounting for the narratives and life experiences of all individuals with binge eating disorder to better inform our current understanding of recurrent binge eating pathology and the systemic factors that impact it, as well as the unique challenges that historically underrepresented groups face. The experts recognize this need (theme 9), which is reflected in the literature [47,65,70,71,73,75] and shared by the authors.

Expert Demographics
While this study's sample provides an accurate demographic representation of eating disorder experts (92% white, 100% not Hispanic or Latino), it does not accurately represent the demographic profile of individuals who experience adult binge eating disorder, which has higher rates of Hispanics, Latinos and Blacks, Indigenous, and Peoples of Color [71,72,174]. The demographic discrepancies between those who study and treat adult binge eating disorder and those who experience it are not insignificant. These discrepancies highlight the importance of including marginalized populations in academic and clinical training opportunities for adult binge eating disorder research and care, and of emphasizing community-and narrative-based approaches to research.
Another important limitation (and oversight) of this study is that demographic data was collected for sex assigned at birth, but not for gender. This is a shortcoming for two reasons: (1) gender is relevant to this study question and sex assigned at birth is not, and (2) asking for sex assigned at birth follows an old convention (collecting information on sex assigned at birth by default rather than collecting only the most relevant information for the study question) that fails to include and account for equity and diversity. While the question of sex assigned at birth is not relevant to this study question, the question of gender is. It would also have been relevant and important to identify whether any study participants identify as agender or transgender since binge eating disorder has higher prevalence among transgender and gender non-binary individuals (at least in youth and young adults; to the authors' knowledge we are still lacking this information in adults) [47,59]. Overall, the field should work toward developing a base of researchers and clinicians who study and treat binge eating disorder that more accurately represents those who experience it.

Study Limitations
This research includes a small sample of individuals (n = 14). Thus, we cannot identify how accurately the themes and views identified here represent those of all binge eating disorder researchers, clinicians, and administrators. Moreover, NIH R01, T32, or P grant funding is one of four possible eligibility criteria that researchers were required to meet for participation eligibility (Table 3). Eligible participants were required to meet one of the four criteria presented in section I of Table 3 (not all four). Thus, our study did not limit researcher participation to U.S. researchers. However, this criterion did present a bias for inclusion of academics and researchers within the U.S. Although the study sample does include individuals from the UK, AU, and CA, 50% of study participants are American. Thus, the themes identified here must be interpreted with caution when done in the context of binge eating disorder pathology globally (vs. within the U.S.). Furthermore, the qualitative analysis of expert interviews were conducted by two individuals (BB and HZ with aid of CB). Thus, we cannot assess how accurately the themes identified here represent the true themes valued by expert binge eating disorder researchers (including those in this study and those at large). These limitations are standard in the field of reflexive thematic qualitative analysis and are not generally viewed as discounting the methodology as a whole [29].
It should also be noted the findings reported here come from a larger study that collected information from the fourteen experts reported here on their perspectives of adult binge eating disorder pathology and treatment broadly. Because of the robust commentary regarding binge eating disorder as a social justice issue, the authors felt the theme was substantive enough for a separate manuscript, even if not the exclusive focus of the interviews. If the interviews had focused solely on environmental factors relevant to adult binge eating disorder pathology, perhaps we could have delved further into the social justice issues deemed relevant to adult binge eating disorder.

Study Strengths
The study of social justice issues relative to their influences on behaviors is a relatively new contribution to "hard" science. This movement provides a new lens through which to view eating disorders. Our study aims to broaden the awareness of social justice issues that are both important and historically overlooked in the field of adult binge eating disorder. To the authors' knowledge, this study is also the first to synthesize expert opinion on environmental factors contributing to adult binge eating disorder pathology. The study's use of systematic inclusion criteria (Table 1) helps ensure as accurate population representation as possible of expert binge eating disorder researchers, clinicians, and healthcare administrators. A diverse group of experts were recruited internationally for the study and the study sample includes a balance of binge eating disorder experts involved in the field at all levels, including researchers (PhDs/ScDs, MD/PhDs), medical doctors (MDs, B\MBChBs), licensed therapists (LPs, R. Psychs, FRCPsychs), licensed and registered dieticians (LDs, RDs and certified eating disorder registered dieticians, CEDRDs), intuitive eating specialists, healthcare administrators, and public health and policy advocates (MPH) ( Table 3). The study's clinical criteria include clinicians with high clinical and academic affiliations as well as those likely to be most accessible to individuals with binge eating disorder (e.g., most commonly identified through a google search or through reading a popular press book on binge eating disorder). The latter criteria are met by including clinicians with high popular press distinction and online directory listings. Thus, this study includes clinicians who are active in the clinical space both academically and commercially. The study's academic inclusion criteria ensure academics with the greatest amount of funding and publication output both recently and historically are included. Thus, the academics included in this study are those who drive and influence the field and its literature base. Although the NIH funding criteria presents a bias for inclusion of academics within the U.S., the study sample does include a balanced geographic representation, with individuals across the U.S. (East Coast, Midwest, and West Coast), as well as in countries outside of the U.S.

Conclusions
Interviewed experts conveyed a growing awareness of systemic issues related to binge eating disorder. These issues include systems that disproportionately affect marginalized and minority populations who have historically been overlooked, under-diagnosed, and under-treated in the field. Examples of these issues include predatory food industry practices and food environments, body weight/shape/size discrimination, insurance and healthcare systems, and the eating disorder research field and eating disorder funding agencies. Interviewed experts recognize a need for public policy changes that take responsibility for changing systemic factors influencing binge eating disorder (e.g., food industry practices and food environments). The experts also recognize the need for including these populations in research, and for "taking account of people's narrative[s] and life experiences" to better inform our current understanding of binge eating disorder and the systemic factors that impact it.

Institutional Review Board Statement:
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of THE NATIONAL UNIVERSITY OF NATURAL MEDICINE (protocol code HZ12120 approved 12-01-2020).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.