Vyvanse Approved for Binge Eating Disorder

A medication, Vyvanse, approved in the last few weeks for Binge Eating Disorder (BED), ought to be cause for celebration. There just are not many options to treat binging. Yet my first reaction is concern and trepidation. 

This medication is a stimulant initially marketed and approved for Attention Deficit Disorder. It is effective and safe for this disorder. A once daily, long-acting alternative to Adderall and Ritalin, Vyvanse was a welcome addition to this class of psychiatric drugs. 

One of the most common side effects of stimulants is appetite suppression, the purported effectiveness of Vyvanse in BED. Since children often take stimulants, decreased appetite can lead to weight loss, malnutrition and medical issues. Adults often see this side effect as an added bonus, which only increases the appeal and risk of stimulant usage. 

My first concern is that the side effect of appetite suppression is now touted as a potential cure for binge eating, which is patently untrue. These medications can be used to stop binging that is particularly dangerous in the short-term but no more.

Like most side effects, loss of appetite tends to wear off as someone takes Vyvanse regularly.  The binging returns soon enough as appetite returns to normal, unless the patient receives alternative treatment. Vyvanse is a bandaid in this instance, not a cure. 

My other concern is that Vyvanse is an addictive medication. In other words, people develop a tolerance to the drug so that they will experience withdrawal if it is stopped abruptly. Also the initial effect tends to wear off and necessitates an increased dose for the same effect. 

When used for ADD, the doctor can increase the dose until it is effective. Since Vyvanse actually treats the symptoms, the effects will usually be long-lasting. When used for BED, Vyvanse diminishes appetite only as a temporary side effect, so increasing the dose is inevitable when appetite returns to normal.

Continually searching for an effective dose will lead some people to seek higher doses, increasing the chance of taking too much medication. There is no benefit to replacing binging with prescription medication abuse. 

The shortage of effective medications for BED is clear to patients and physicians. However, a government agency cannot justify approving an addictive medication with extremely limited use for binge eating as a viable treatment alternative.

It's better to increase awareness and develop more treatment options than propagate false hope. 


The Miracle of Human Metabolism

The other topic of the radio show I mentioned a few posts ago is concerned with digestion and metabolism of processed foods. The doctor in that show speaks with authority about how digestion and metabolism are different with these foods as opposed to foods found or grown in the environment.

Specifically, he describes how processed foods are immediately available for digestion and absorption which leads to instant changes in blood energy levels. There is increasing evidence that the complex hormonal regulation of blood energy struggles to adapt to these new foods. More natural foods provide a buffer to delay and slow absorption, something our digestive system depends upon for normal regulation of blood energy. 

The doctor's step towards vilifying processed food and added sugars though is unrealistic. From his vaunted perch, it would be more helpful to discuss how to live in a world with our current food supply. Being able to eat processed foods in moderation is a cornerstone in modern life, but it's also crucial to understand why the majority of one's diet needs to be real food for our bodies to function normally. 

People generally think about metabolism in terms of burning energy. The goal in this rubric is to maintain a high metabolism to keep weight down; however, this is not the true definition. The pressures from the food and diet industry intend to place blame on the individual while hawking products that lead to weight gain. 

Metabolism is the bodily function that digests food, turns it into usable energy and transports the energy to parts of the body that need it. It is a complex interplay of the endocrine and gastrointestinal system which maintains healthy function throughout the body.

Our conscious part in this system is to eat regularly and eat predominantly a varied diet of real food. People like the NYU nutritionist Marion Nestle have written at length about what that means, but it's not about following the most recent fad, just following logical conclusions. 

The purpose of reflecting regularly in this blog about metabolism is for readers to understand and admire the way our bodies use food and energy in complex and amazing ways. With that knowledge, we can try to avoid the current trends and pressures about food and just do the basics each day. That's true for everyone, those with or without an eating disorder.


Putting Weight where it Belongs in Recovery

One main focus of eating disorder thoughts is weight. It feels like a huge success to seemingly master weight with disordered behaviors, restricting, binging, purging, laxatives, etc. The positive feedback weight loss elicits is often intoxicating and only fuels the eating disorder thoughts. Just when someone starts to question the symptoms, that person finds herself trapped between the possibility of recovery and the terror of gaining weight. 

Treatment programs and clinicians often focus too much energy on weight for many reasons. Insurance companies limit treatment after weight normalization as a way to keep down costs. The pressure of patients to focus on weight can be hard for treatment providers to resist. And weight provides a concrete, if limited, measure of improvement, something otherwise difficult to quantify. 

The focus on weight in treatment only strengthens the eating disorder because weight gain feels most terrifying to someone in recovery. Losing the false sense of security that the eating disorder provides with weight is an enormous change in identity. 

Recovery needs to put weight in context. The number on the scale is only one marker of improvement in health and quality of life. Medically, heart rate, blood pressure, improved organ function, normalized brain function and increased energy all are signs of improved health. Similarly, a broadened personal life through work, family and friends represents changes only possible with improved health. 

If weight becomes a battle between recovery and the illness, the illness always wins. Treatment needs to minimize the value of weight and refocus instead on health and living a full life. There is so much more to being in this world than the number on a scale.

The fact that women sick with a disease receive so many compliments for a core part of an eating disorder is a sad comment on modern day living.


Focusing on the Place of Weight and Metabolism in Eating Disorder Recovery

The radio show "Good Food" was a favorite of mine when I lived in Los Angeles. The show covered somewhat light topics such as the farmer's market and new restaurants, so it was a surprise to see the host use her platform to address issues around food politics and health in this episode. She interviews two people in particular who discuss central concerns for people with eating disorders. 

The first presents the struggle about how to define health with respect to weight, a topic critical in eating disorder recovery. Much of the treatment world focuses too much on weight normalization as the sign of improved health rather than the many other markers of recovery: energy, improved cognitive function, repair of organ damage and reengagement with the world.

This piece talks specifically about improving the health of people who are overweight without focusing on weight loss. It's a novel approach to treat the overweight medically and not hone in on the number on the scale. The eating disorder community could take a hard look hard at this research. 

The second piece is an interview of a doctor from UCSF. He focuses on the effect of processed food on body metabolism, namely that insulin production and the endocrine balance of digestion are dysregulated by processed foods.

Our bodies are designed to eat real food and function at their best when fed appropriately. This information is crucial for people with eating disorders, whose metabolism often stops working with abnormal eating patterns. 

Unfortunately, this incredibly useful research allows the doctor to get on his soapbox and vilify a new food, sugar. He may have a point but his standing is better used to counter food industry myths than waste his breath on a new food villain. It's too easy to ignore the important information about food and health when given the specter of a new horrible food to avoid at all costs. 

Here is the link to the radio show. 


I will write about more about the role of weight and metabolism, respectively, in eating disorder recovery in the next two posts. 


Kindness and Compassion: The First Step for Families

The central tenet families need to understand is that kindness, compassion and patience are necessary to help someone get better from an eating disorder. Firmness, criticism and judgment only harden the illness and isolate the loved one from support. 

Understanding why this is so important is linked with familiarity with the thought process of an eating disorder. 

The internal world of someone with an eating disorder is harsh, critical and judgmental. The standards are always too high. Any respite feels impossible.

Because reality never matches up with unreachable expectations, the person endures the endless shame of never being good enough. 

These thoughts are not always in the forefront of one's mind. Often they run as a loop in the background all day and influence every decision and interaction. It makes for a tortured existence. 

The possibility of entering real treatment and recovery means lowering the bar from impossible to reasonable. The steps to get well can be slow and deliberate. Entering back into meaningful family relationships needs to be enveloped in kindness and caring. The key message, above all, is acceptance. 

Rather than searching for the best solution, families need to reconsider their efforts. Starting with a thoughtful, compassionate approach to the suffering of a loved one opens up the possibility for conversation and closeness.

There is no immediate concrete plan that will work. Through the door of compassion lies some of the answers to begin steps towards recovery.


Partial Recovery: Differing Views

I have written in this blog many times about the concept of having one foot in and one foot out of the eating disorder. The article linked below explains very clearly the risks of that state of living and why it inevitably leads to a small life followed by relapse. 

I also think it misses two key points. 

First, not everyone's path to recovery goes from two feet in to two feet out. For some, the perspective gained from having one foot out of the eating disorder is a significant step. Only recognizing the negative part of this state of recovery acts to take that progress away, which is not helpful.

It's crucial to understand that being only half out of the eating disorder is not an endpoint. Without continuing to press for recovery, the road from there is only towards relapse. 

The other concern about this article is that the message about weight restoration is somewhat heavy handed. It's clear through all the research that weight restoration increases the chance of full recovery significantly. But that research has limitations since the subjects are mainly at inpatient programs, thus ignoring a large part of the eating disorder population.

Rather than relegate these other people with eating disorders to chronic illness, I prefer to see their road as more complex. Their path will have to include improved nourishment and health, but immediate weight restoration without sufficient psychological progress also often leads to relapse, also shown through research. 

Preparing to step fully out of the eating disorder may need psychological and emotional attention first. Both parts of treatment are necessary for full recovery. 



Families must Start with Understanding, not Action

Someone savvier about blogs than me suggested I forgo a longer biweekly post for shorter, more frequent updates. That will start with today's post. 

The last post explored possible ways for powerless parents to approach an adult child with a chronic eating disorder. There is one central reason these approaches won't work that I will explain in this post. 

The logic families rely on to understand an eating disorder has one fatal misstep. It assumes that eating and health are the top priorities of the child. Either pulling back from the child or forcing her into treatment will not affect the underlying thought process, something crucial to start a path to recovery.

The driving force of the eating disorder is the use of symptoms to manage the trials of daily life. Starving, binging, overeating and any other symptom serve a powerful purpose as one's central coping mechanism. Any repercussions from the eating disorder pale in comparison. 

The first step for any family to understand the challenge of recovery lies with this crucial piece of knowledge. 

I often suggest that loved ones imagine what it would feel like if their most useful coping skill were suddenly ripped away. For those who can empathize even slightly with that scenario, the mental challenge of recovery becomes much clearer. 

The next post will start to review other options families can consider.