ProSource (American Council on Exercise)
July 2015

Are We Exacerbating Binge Eating in Our Clients?
When Carol* began working with me, I assumed she was like many of my other clients who simply needed to make healthier lifestyle choices. But after working with her for several months and essentially seeing no changes in her body, I began to wonder if there was something deeper going on.

I initiated conversations with her about emotional eating and using food as comfort. She admitted to using food as a sort of security blanket and feeling out of control around food. If it was there, she’d eat it, even if she wasn’t hungry. There was a lot of shame surrounding her lack of control. She questioned why she didn’t have the willpower to stop these habits.

Turns out, for those with binge eating disorder (BED), willpower has nothing to do with it.

What Is Binge Eating Disorder?
“In 2013, the American Psychiatric Association identified Binge Eating Disorder as a distinct category of an eating disorder, alongside anorexia and bulimia,” explains Kari Anderson, Ph.D., L.C.M.H.C., C.E.D.S., clinical director at Green Mountain at Fox Run, Ludlow, Vt. “Interestingly, BED occurs in more people than anorexia and bulimia combined, and yet it often goes unrecognized and untreated.”

Over the past 20 years, there have been more than 1,000 published studies that have supported the idea that BED is a valid, specific diagnosis. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), key diagnostic features of BED include:
Recurrent and persistent episodes of binge eating. An episode of binge eating is characterized by both of the following:
– Eating, in a discrete period of time (for example, within any two-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
– A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating)
Binge eating episodes are associated with three (or more) of the following:
– Eating much more rapidly than normal
– Eating until feeling uncomfortably full
– Eating large amounts of food when not feeling physically hungry
– Eating alone because of being embarrassed by how much one is eating
– Feeling disgusted with oneself, depressed or very guilty after overeating
Marked distress regarding binge eating
The binge eating occurs, on average, at least once a week for three months
Absence of regular compensatory behaviors (such as purging—in other words, they don’t make themselves vomit after a binge, as would be the case with bulimia).

Why Can’t They Just Stop?
“Binge eating is associated with intense food cravings that override the brain’s signals of fullness and satisfaction and the rational intention for self-care,” says James Greenblatt, M.D., chief medical officer of Walden Behavioral Care in Waltham, Mass., and author of Answers to Appetite Control: New Hope for Binge Eating and Weight Management. “You keep eating even when you are not hungry and food satisfies you less and less.”

Greenblatt states that this is essentially food tolerance, a hallmark condition of addiction that requires more and more of the substance—in this case, food—to elicit the same sensation or response. “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry,” he explains. “Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations as the individual hyper-focuses on pursuing reward and relief by ingesting more of the addictive substance. Food addiction is specifically defined as a chronic, relapsing problem that encompasses three phases: one, binge intoxication; two, withdrawal; and three, craving.”

These cravings, says Greenblatt, are born out of a genetically based biochemical disorder that skews the body’s natural signals of hunger and satiety. He also explains that certain foods, such as refined sugars, gluten and dairy, can cause addiction-like symptoms and affect the ability to control food intake.

For instance, after being broken down in the body, casein, the protein found in dairy, and gluten, the protein found in certain grains, become peptides that are forms of morphine to the brain (casomorphin and gliadorphin, respectively). Have you ever wondered why comfort food is called comfort food? It’s not just a nostalgic thing. While you may have warm, fuzzy memories of your grandmother’s homemade macaroni and cheese, there is actually a very real, physiological reason why eating it makes you feel good. It is literally soothing to your brain.

There are also numerous studies that show that withdrawal from sugar causes symptoms that are similar to a drug addict going through withdrawal: shakiness, chattering teeth, tremors, agitation and hyperactivity.

How Does This Relate to BED?
“A pattern of chronic overeating alters the function of various centers in the brain, including the cortex, amygdala and limbic system, and also creates imbalances of dopamine, the ‘feel good’ neurotransmitter,” explains Greenblatt. “Consequently, deep physical cravings become so strong they are impossible to control simply by stubborn resolve or thought alone. Ruminations about food, regrets around meals and emotional connections to foods become constant and burdensome, fueling a chronic and relapsing addiction that mimics addictions to other substances.”

“Binge eating is often a way to attempt to manage uncomfortable or unpleasant emotions that have felt unmanageable,” explains Tiffany Phillips, M.A., L.M.F.T., clinical program manager at The Renfrew Center of Nashville. “It is a short-term solution to a long-term issue.

[There tend to be] underlying issues that leave the person feeling unable to cope with their feelings, relationships and stress without using food to comfort.”

“BED is more closely related to other eating disorders in that it is driven by an overvaluation of body weight and size in regards to self-worth,” adds Andersen. “Interestingly, it is also a counter-response to an internalized set of rules about food and eating, mainly restrictive in nature.”

Is it Safe to Work With Someone with BED?
Yes. While the client or student should have medical clearance from his or her healthcare provider and be under their continual care, there are usually no immediate, acute medical concerns, like there are with anorexia and bulimia. However, there certainly can be potential chronic complications to be aware of, such as hypertension, diabetes, heart disease and orthopedic issues.

Are We Making the Problem Worse?
Ironically, the exact advice those of us in the fitness industry give out is what exacerbates BED. This is disturbing, considering that according to Phillips, “Thirty to 40 percent of people in weight-loss programs at any given time would qualify for the clinical diagnosis of BED.”

Given that BED may affect such a potentially high percentage of your clients and students, how can you avoid exacerbating a client’s struggles?

“Fitness professionals should refrain from suggesting rule-based eating and rigid meal plans, as this often results in binge episodes and a sense of failure for those aiming to adhere to diet plans,” says Stuart Murray, DClinPsych, Ph.D., a postdoctoral fellow at the University of California and director of the National Association for Males with Eating Disorders.

“The focus should be on health and pleasurable fitness activities, rather than a specific weight goal or body size,” urges Kim Dennis, M.D., C.E.D.S., CEO and medical director of Timberline Knolls Residential Treatment Center in the Chicago area.

Andersen recommends encouraging intrinsic goals, “such as improving mobility and feeling better, rather than extrinsic measures, such as weight, body fat, calories or rigid food plans.”

“Even perceived restriction can trigger a counter-response of binge eating,” adds Andersen. “Strenuous exercise like CrossFit or competing in a long-distance event can also trigger a binge, as it generates feelings of deprivation when glycogen stores are depleted and blood sugar levels drop. We encourage more moderate activities until stable recovery is maintained.”

How Do I Know If Someone I’m Working With Might Have BED?
“Someone with BED has tendencies toward yo-yo dieting and exercising,” explains Anderson. “They may be very engaged in your classes and then they drop out for a while. When someone is in a binge cycle, they have a lot of shame and tend to isolate. Bingeing and exercising tend to not go together, because they tie dieting and exercise together. They may idealize a certain type of eating plan and be very rigid in following it.”

Do not be fooled into thinking that binge eaters are all obese. “Many of those who binge eat who are younger or in the early stages of the disorder are normal weight or only slightly overweight,” Andersen says. “Those who are older and have been bingeing for some time tend to be larger in size. Many in the later stages of the disorder do not tend to exercise publically due to their body shame. They may appear during a restrictive phase as I mentioned before, but then drop out if they resume bingeing.”
It can be difficult to uncover BED, because feelings of shame will prevent those with BED from readily sharing their behavior. For instance, clients with BED may resist keeping a food diary, especially if you have emphasized the need to be honest about what they’re eating. If you suspect a client may be struggling with BED, Andersen suggests asking gentle questions, such as:
Do you have a history of dieting?
Does your weight have rapid fluctuations?
Do you sometimes feel out of control with your eating or detached while eating?
Do you eat alone or feel you need to hide your eating behavior?
Andersen notes that their attitudes and behavior with food are more important than what they’re eating, so it is not necessary to discuss the food eaten.

If you suspect BED, validate the behavior as being normal for someone with disordered eating patterns and reinforce that dieting and other restrictive practices tend to aggravate the behavior. “Tell them that the behavior can be treated with the right interventions. Encourage them to find a trusted health professional to discuss their behaviors more in depth to rule out a serious eating disorder.”

And have a list of resources in your area to give to them. “The best-case scenario,” concludes Andersen, “would be working as a team member with the eating disorder specialist where the client has given permission for dialogue between providers. This would avoid any conflicting messages that the client might be getting from those involved in his or her care.”

By Carrie Myers

*Name has been changed to protect privacy.