Within the obese population, there is a subset of patients who first exhibit binge eating symptoms in their late twenties and thirties and who are increasingly recognized and treated by eating disorder professionals. However, these patients too often fall below the radar of the eating disorder community and remain unseen and untreated for long stretches of time. There are several components of this eating disorder that make both diagnosis and treatment more challenging and different.
Because people who binge eat are overweight, this disorder is often overlooked and lumped in with the general rise in obesity. The misdiagnosis leads to an ineffective and potentially dangerous course of treatment. A weight loss program is disastrous for someone who binges: the hunger triggered by calorie restriction only increases the urge to binge and the shame of binging. Even more damaging, these patients are considered candidates for Bariatric weight loss surgery. The screening process for these procedures should exclude people who binge eat, because even a physical restraint--gastric bypass or banding--will not curb their emotional and psychological need to binge. However, many find a doctor to perform the surgery anyway. The failure of this drastic surgery leads to even more hopelessness. The same treatment for binge eating disorders outlined in previous posts is equally effective for these patients, but the primary problem is accurate diagnosis.
The key difference for people who start binge eating later in life is that they have spent years as an adult at a normal weight. Typically, these patients have a long history of abnormal eating but were able to maintain normal weight and keep the disordered symptoms from fully disrupting their lives. As the binging escalates, they believe this is a short-lived phase and that they can regain control of their eating. In our culture of thinness, weight is seen as the central problem, and doctors often readily agree. This single-minded approach allows the eating disorder to stay hidden. As I have written several times, eating disorders are most powerful when they remain secret.
Typically, people who begin to binge at a later age have difficulty with the pressures and expectations in life that develop as they get older. In high school or college, students struggle with the early stages of independence and personal identity. In their twenties and thirties, people shift their focus to relationships, family and career development. Unfortunately, binge eating and gaining weight have a significant impact. People who are overweight report feeling invisible both personally and professionally. For someone terrified of intimacy and professional challenges, gaining weight reinforces feelings of inadequacy and worthlessness. The constant pressure to lose weight becomes life's central focus and supplants any other goals or dreams. If only they could lose weight, these patients say, their lives would be so different. After rounds of inaccurate diagnosis and ineffective treatment, patients retreat to the solace of food, lowered expectations and the veil of obesity. Often they seek psychiatric help as a last resort.
The key to diagnosis lies in the patient's own assessment of her problem with food and weight. Someone who overeats but does not binge will understand that food and weight are problems to be handled alongside her concerns in daily life. Patients with an eating disorder see food and weight as their only problems. They say their life is on hold until they lose weight. This obsession with weight loss is the most debilitating symptom because it takes over the patient's life. The result is a sense of paralysis and hopelessness simultaneously hated by the patient and coveted--because it helps her avoid the fear and anxiety daily life would otherwise trigger. The longer the disorder continues undiagnosed and untreated, the farther the patient is from fully addressing the issues at this stage of life.
Once the diagnosis is clear, the treatment is straightforward but challenging. First, the nutritional goal is normal eating with regular meals and snacks, with adequate--but not restricted--caloric intake. Patients will lose weight slowly because they aren't binging and will adjust to a sustainable meal plan. Once the binging has subsided, the treatment goal is to avoid restricting. Tempted to lose weight quickly, the patient will start cutting calories, get too hungry and then start binging again. That cycle allows the patient to remain focused on food and weight. When a patient can follow the meal plan, she will not have the distraction of the eating disorder. Then the patient will start to become aware of the initial triggers that started the binging and begin to tackle the fear of moving forward in life. This is the core treatment of the therapy, and what differentiates it from other obesity treatments: shifting the focus away from weight and towards helping the person feel grounded and content in her life.
The next post will shift the focus to address some of the medical consequences of eating disorders. It is easy to find a list of specific medical issues but little that explains what is happening to the body and metabolism in general. Stay tuned.