What is the best advice for someone with hyperphagia (excessive eating) who finds it hard to stop?

Management of Hyperphagia (Excessive Eating with Difficulty Stopping)

The best approach for someone with hyperphagia depends critically on the underlying cause: if this is binge-eating disorder, start with eating disorder-focused cognitive-behavioral therapy as first-line treatment; if this is related to a medical condition (brain injury, dementia, genetic syndrome), address the underlying cause while implementing structured behavioral interventions and environmental controls. 1, 2

Step 1: Identify the Underlying Cause

The management strategy differs fundamentally based on etiology, so accurate diagnosis is essential:

Psychiatric Eating Disorders

• Binge-eating disorder is characterized by eating large amounts in discrete periods with loss of control and marked distress 1
• Screen for bulimia nervosa if there are compensatory behaviors (purging, excessive exercise) 1
• Evaluate for depression, anxiety, or other psychiatric comorbidities that may drive emotional eating 1

Medical/Neurological Causes

• Brain injury or stroke affecting right frontal/temporal lobes can cause morbid hunger and hyperphagia 2
• Dementia commonly causes hyperphagia in 23% of patients, typically during middle stages with median duration of 16 months 3
• Prader-Willi syndrome and other genetic conditions cause severe hyperphagia from leptin receptor or melanocortin pathway defects 1
• Medication-induced: Atypical antipsychotics (olanzapine, quetiapine, clozapine), some antidepressants, and glucocorticoids promote weight gain and increased appetite 1, 2

Metabolic/Endocrine Factors

• Diabetes with poor glycemic control can cause increased hunger 1
• Review all medications and minimize those promoting weight gain whenever possible 1

Step 2: Initial Assessment and Monitoring

Establish baseline measurements and identify complications:

• Weight, BMI, and vital signs including orthostatic measurements 1
• Laboratory testing: Complete blood count, comprehensive metabolic panel with electrolytes, liver and renal function 1
• Electrocardiogram if there is severe purging behavior or restrictive eating patterns 1
• Screen for complications: Diabetes, hypertension, cardiovascular disease, sleep apnea 1
• Assess eating patterns: Frequency, quantity, speed of eating, time spent preoccupied with food 1
• Evaluate psychosocial functioning: Impact on relationships, work, quality of life 1

Step 3: Treatment Based on Etiology

For Binge-Eating Disorder (Primary Recommendation)

Psychotherapy is the foundation of treatment:

• Eating disorder-focused cognitive-behavioral therapy is first-line treatment, delivered individually or in groups 1
• Interpersonal therapy is an effective alternative if CBT is unavailable or not preferred 1
• Therapy should address normalizing eating patterns, reducing binge episodes, and managing psychological triggers 1

Pharmacotherapy as adjunct or alternative:

• If psychotherapy alone is insufficient by 6 weeks or patient prefers medication, add lisdexamfetamine (FDA-approved for binge-eating disorder) 1
• Antidepressants (SSRIs) can be used, particularly if comorbid depression or anxiety is present 1
• GLP-1 receptor agonists (semaglutide, liraglutide) or dual GIP/GLP-1 agonists (tirzepatide) help regulate hunger and reduce binge episodes while improving metabolic parameters 1

For Neurological Causes (Brain Injury, Dementia)

Structured behavioral and environmental interventions:

• Meal structure: Provide 4-6 small, scheduled meals throughout the day with controlled portions 1
• Environmental modifications: Lock food storage areas, remove visible food cues, supervise meal times 1, 2
• Slow eating: Encourage thorough chewing (≥15 times per bite) and extended meal duration (≥15 minutes) 1
• Separate liquids from solids: Wait 15 minutes before meals and 30 minutes after to reduce total intake 1

Pharmacological options:

• Escitalopram (low-dose SSRI) showed benefit in a case of post-traumatic brain injury hyperphagia 2
• Switch antipsychotics if quetiapine or olanzapine is suspected of worsening hyperphagia 2
• For Prader-Willi syndrome, topiramate may help severe skin-picking but use cautiously 1

For Genetic Syndromes (Prader-Willi, Melanocortin Deficiency)

Strict dietary and environmental control is essential:

• Calorie restriction with dietitian supervision to prevent obesity while ensuring adequate nutrition 1
• Locked food access: All food must be secured and access completely supervised 1
• Setmelanotide (melanocortin 4 receptor agonist) is FDA-approved for rare genetic mutations causing severe hyperphagia (leptin receptor deficiency, POMC deficiency) 1
• Regular monitoring: Weight, diabetes screening, sleep apnea evaluation, behavioral management 1

For Medication-Induced Hyperphagia

Medication review and optimization:

• Discontinue or switch weight-promoting medications when clinically feasible 1
• Alternatives to consider: Switch from olanzapine/quetiapine to aripiprazole; from tricyclic antidepressants to SSRIs; from beta-blockers to ACE inhibitors 1
• If atypical antipsychotics are necessary, monitor weight, glucose, and lipids every 4 months initially, then annually 1

Step 4: Adjunctive Interventions for All Causes

Nutritional Counseling

• Work with registered dietitian to establish balanced meal plans 1
• Focus on nutrient-dense, lower-calorie foods rather than calorie-dense options 1
• Ensure adequate protein intake to prevent sarcopenia during weight loss 1

Physical Activity

• Incorporate regular physical activity, including resistance training to preserve muscle mass 1
• Address barriers to exercise (physical limitations, emotional factors) 4

Behavioral Strategies

• Mindful eating: Eat slowly, without distractions, paying attention to hunger and satiety cues 1, 4
• Avoid trigger foods: Limit simple sugars and high glycemic index foods that may trigger binge episodes 1
• Stress management: Address emotional eating through therapy, relaxation techniques 5, 4

Step 5: Monitoring and Reassessment

Regular follow-up is critical to prevent therapeutic inertia:

• Monthly visits for first 3 months when starting new interventions, then quarterly 1
• Weight trends: Early responders (>5% weight loss in 3 months) should continue treatment long-term 1
• Intensify treatment if goals are not met: Add medications to therapy, increase medication doses, or consider metabolic surgery for BMI ≥30 kg/m² 1
• Screen for complications: Depression recurrence, eating disorder relapse, metabolic syndrome 1

Critical Pitfalls to Avoid

• Do not label physiologic hunger from metabolic disruption as a psychiatric eating disorder - medication effects, diabetes, or neurological damage may drive hyperphagia 1
• Do not use appetite stimulants (megestrol acetate, dexamethasone) in hyperphagia - these are only for anorexia/cachexia 1, 6
• Do not ignore medication contributions - systematically review and optimize all medications 1, 2
• Do not delay treatment intensification - if initial approach fails by 6 weeks to 3 months, add or switch interventions 1
• Recognize increased pain tolerance in Prader-Willi syndrome - binge-eating can cause intestinal necrosis with minimal symptoms; vomiting is an ominous sign 1