Binge Eating Disorder: A Need for Parity

The societal understanding of Binge Eating Disorder (BED) has had an impact on medical diagnosis and treatment. Binges are seen largely as a clinical term to describe overeating rather than the symptom of eating very quickly an amount of food much larger than a meal in a very short period of time. The distinction is very significant. Even though BED is now one of only three eating disorder diagnoses, most people mistakenly view this illness as justified gluttony. 

The increase in binging in recent decades stems from two changes in our daily lives: sanctioned starvation through dieting and the abundance of addictive, processed foods. Starvation through restricting leads to excessive, uncontrolled hunger in many people. Even once better nourished, the hunger frequently takes months or years to diminish, and regular dieting without cease can mean the intense hunger never goes away. Also many people are susceptible to the addictive qualities of processed foods, namely added sugars and fats, which increase the likelihood of binging. 

In a society searching for a pharmaceutical cure to human limitations, many people seeking help for BED simply want a medication to fix what most people call the "chemical" cause for their illness. The pharmaceutical industry has added to this belief by viewing BED as a new frontier, approving Vyvanse last year despite minimal evidence of long-term benefit. Rather than look for a treatment plan for recovery, people with BED more than any other eating disorder have been primed to only seek a quick fix, as if their symptoms are just a chemical deficit rather than a full-fledged eating disorder. 

The reality is that people with BED need a comprehensive treatment plan including therapy, nutrition counseling and medication just as anyone else with an eating disorder. Distorted views about binging and about the fantasy of a magical cure seem more accepted for BED, but that belief leaves these patients much more hopeless and without reasonable expectations for treatment. It's crucial for patients with BED to be treated as thoroughly as anyone else with an eating disorder.

The Psychiatric Symptoms Caused by an Eating Disorder

People with eating disorders are often diagnosed with comorbid psychiatric illnesses including depression, panic disorder, and obsessive-compulsive disorder in addition to many others. Clinicians do not often attempt to differentiate between the diagnoses and clarify the interplay between them, much to the detriment of the patient. 

It is rare that another diagnosis is the primary diagnosis; usually the eating disorder is the central issue. People with other primary diagnoses may have eating symptoms as a part of their struggle, but a full-fledged eating disorder inevitably takes over a person's life. 

A list of diagnoses, rather than just one, only makes someone feel sicker and untreatable. An explanation of what the diagnoses mean and how they reflect the person's current state and likelihood of successful treatment is a much kinder and more helpful way to approach the path to recovery. 

What is rarely discussed with patients is that starvation and binge/purge cycles themselves can cause psychiatric syndromes. In other words, one effect of chronic eating disorder symptoms is to create a new psychiatric diagnosis hat resolves with normalized eating. 

Starvation and binging are known to lead to depressed mood. Chronic, severe hunger begins to feel like anxiety much of the time, especially because people who are starved lose the ability to identify hunger. In addition, low blood sugar, a common long-term effect of an eating disorder, creates the feeling of a panic attack. Anyone starved over time develops OCD symptoms no matter how susceptible they are to this illness. 

Having a series of psychiatric diagnoses is different from realizing that the eating disorder causes a host of psychiatric symptoms that mimic other diagnoses. This fact also explains why medications tend not to be as helpful in treating psychiatric symptomatology associated with an eating disorder. If starvation or binging causes the symptoms, then medication will be much less effective than food, the only real medication that helps with recovery. 

This idea also brings up the idea that food is a mind-altering substance. It can lead to emotional stability, clarity and mental acuity. Starvation can lead to volatility, confused thoughts and dullness. Eating disorders are illnesses that affect our entire bodies, our minds and emotions included.

The Meaning of Weight in Weight Loss

The concept of weight in medicine and especially in the diet and weight loss industries is very confusing. So much attention is given to the number on the scale and so little to the meaning of that data point in metabolism and health. 

Shifting the focus away from weight and to changes in daily routine around food and activity is much more effective for long-term change. If all importance is placed on the number on the scale, success is marked solely by continued downward changes. Any leeway based fluid shifts, metabolic changes and the many other things that affect weight is nonexistent: it is simply a failure. However, if success relates to consistent lifestyle changes, which also are a better marker of health, the person can embrace the positive, and weight changes will follow as one of several key markers. 

There are three ways to understand weight as a valuable source of data: the current weight, the local weight range and the set point. Each reflects very different information of varying usefulness. Understanding the nuances of body weight also makes clear the limited value of these data for health. 

It's most clear to start with set point, the most longitudinal information, and proceed to the more specific. The set point is a wide range of weight, typically about 15% of total body weight, that anyone can shift within quite naturally. The body is comfortable and not in danger anywhere in this range. Any pressure to go above or below this range leads to a strong metabolic response to attempt to stay within this range. The brain and hormonal system has determined that this range is ideal for health and will therefore protect the range for survival. If enough pressure through starvation or overeating persists, the range can shift down or up over a period of months to years. Then the new range becomes the norm. 

The local weight range is a variation of about 2-5 lbs that the body can vary day to day. This weight change is almost completely due to fluid shifts from retained water or dehydration. Fluid shifts can be significant. One salty meal may increase weight the next day by up to 5 lbs. Monitoring weight too often simply reflects these fluid shifts. Body mass changes rarely constitute more than a pound per week and typically much less. Very fast weight loss on diets is almost exclusively water loss. 

Any specific data point of weight has very little medical value. This number will rest in the current local range and will be up or down based on the current fluid state of one's body. 

Weight data only has value longitudinally. This information over a period of weeks to months will clarify the general set point and range for someone and further history can clarify how long it has been set. Recent eating history and weight change can give a clinician an idea of where the person's weight lies in that range. Longer term history will dictate a plan for lifestyle improvement and how health and then weight may change over time. 

A true shift in the concept of weight loss needs to reflect the limited utility of weight data and take attention off of the number on the scale and instead to sustained lifestyle changes.

Diets Don't Work 101

The news this week about the Biggest Loser contestants gaining back most if not more of the weight they lost is no surprise to clinicians who treat people with eating disorders, nor is it surprising to anyone who has read this blog. 

The initial cause in the rise of obesity is related to several changes in lifestyle over the last few decades. The abundance of processed, non-nutritious foods which are highly caloric and also quite addictive has wreaked havoc on the average person's diet and exposed weaknesses in the human ability to navigate hunger and fullness. In addition, changes in transportation and careers have led to much more sedentary lives. These two facts have led to a spike in obesity and diseases that follow such as diabetes, high blood pressure and heart disease. 

Treating obesity, however, is not about changing these variables but instead addressing a metabolic disorder caused by excessive weight gain. Attacking the problem head on with swift weight loss is never successful, as decades of research have shown: nothing new in the Biggest Loser data. The only form of success involves long term, permanent lifestyle changes and slow, steady weight loss. The key is that the changes are not temporary: the diet paradigm does not work. 

The psychological manifestations of weight gain in our current society make weight loss seem urgent. Many people feel that obesity must be fixed before facing any challenges in life, professional, personal and emotional, a condition I have called pathological obesity. These people spend years focusing solely on quick fixes for weight loss and forgo all other components of their life. The urgency leads to a variety of unsuccessful diets that result in higher and higher weights. 

The cure for obesity involves slow and steady changes that require an enormous amount of patience. It also requires psychological help to face life's challenges concurrently to accept the thought that life must continue and progress, even if one is still overweight. 

In honor of this news about the Biggest Loser, I will repost the most read article about obesity from this blog as well. Meanwhile, the next post will address the underlying metabolic problem in treating obesity in words everyone can understand. It will truly explain the role of weight in weight loss.

Chronic Dieting: The Third Pillar of Obesity