Monthly Archives: January 2016

Binge Eating Disorder: Hunger for Food or Something Else?

The advertisement for a drug to treat B.E.D. kept appearing in commercials during our favorite TV series.

“What is B.E.D.? “ I asked but my spouse had no idea. “Bad Energy Day?” he responded. “No,” I answered, “it must have something to do with hunger because the drug is similar to amphetamine.“

Then it hit me. Binge Eating Disorder, that’s what it is. Interesting that a drug to take away hunger has been approved by the FDA. People who binge never eat only from physical hunger. Otherwise they would stop eating when the hunger is gone.“

I treated patients with binge eating disorder but insisted that I would do so only if they were also being seen by a psychotherapist. Even though the major symptom of binge eating disorder is the ingestion of enormous quantities of food in relatively few hours, the disorder is a psychiatric problem. Interventions focus on psychotherapy, along with nutritional advice to undo the weight gained from constant bingeing.

Binge eating disorder may affect as many as 1-5% of Americans, according to the National Eating Disorder Association. In fact it has its own association, BEDA, which offers Internet support and information as well as Internet contact with others who are living with this problem.  It is only relatively recently that the binges have been viewed as more than a derangement of appetite, or an inability to adhere to a rational eating plan. People with this disorder feel helpless to prevent themselves from gorging.  And because they do not compensate for their high calorie intake by starvation, laxative abuse, vomiting or excessive exercise, they may be morbidly obese.  Women are more prone to having this disorder than men and the bingeing is often accompanied with anxiety, depression, guilt and self-loathing.  Bingeing can occur several times a week, and sometimes a few times each day.

But bingeing is not the same as being very hungry and unable to stop eating until feeling stuffed. Teenage boys who can clean off a buffet table faster than a swarm of locusts are not bingeing; they just eat an enormous amount of food.  Diners on a cruise ship may feel an obligation to eat gigantic quantities of food to compensate for the price of their trip, but they are not bingeing either.

Bingers eat in secret and often they consume only tiny amounts of food when they are eating with others. Moreover, binges are often planned for the time when the eater is alone. The binger goes food shopping so there will be food in the house that the binger enjoys eating. Or she might go to several restaurants in a crowded food court. Ordering take-out food from several restaurants is also done because it is embarrassing to order a large amount of food from the same restaurant all the time. I had a patient who shopped on Thursdays for weekend binges. She turned off her phone, pulled down her shades, and spent from Friday evening to Sunday afternoon eating until her stomach could no longer hold food. Then she would sleep and upon awakening, start bingeing again. She was never hungry. How could she be?

Bariatric surgery might seem to be an obvious solution to halting bingeing and restore normal weight. But according to experts, reducing the size of the stomach, or bypassing it altogether, might cause extreme side effects. Physically limiting the amount of food consumed doesn’t reduce the emotional pain causing the overeating.  Without the psychiatric counseling before and following surgery to detect and help the underlying cause of binge eating, the bariatric patient is at risk for consuming much more food than the surgery allows and becoming extremely ill in the process.

In the winter of 2015, the FDA approved Vyvanse for the treatment of B.E.D. The drug is classified as a central nervous system stimulant like amphetamine, and had been already approved in 2007 to treat ADHD.  Vyvanse decreases hunger when used for ADHD, and this may have been the reason it was tested on binge eating disorder patients. Two studies were carried out, each for 12 weeks, among 700 people with binge eating disorder.  Compared with placebo treated subjects, the drug decreased the number of days each week people binged and also decreased the number of binges each day.

According to eating disorder experts, it is unclear how the drug works to reduce bingeing.(It is important to note that bingeing did not stop entirely in the studies.) Moreover, long-term results have not been reported. Questions to consider are… does the effect of the drug wear off or become even more effective over time? It is possible that the amphetamine-like drug removes the compulsion to eat, thus giving binge eaters a respite from their pathological focus on food. Instead of dealing with the constant bingeing with the guilt and shame of the aftermath, they  now have  emotional  time to deal with the reasons for their overeating. In a sense they are like binge drinkers who go into recovery and while they are abstinent, attempt to deal with the causes for their excessive alcohol intake. It is obvious that helping such people would be useless while they are drinking. And so too, it may be that helping the binge eaters, while they are still bingeing constantly, would also be futile.

Vyvanse is not a magic pill, and its ability to decrease binges does not mean it can decrease the emotional antecedents to the binges.  Replacing food as a coping mechanism will require more than a pill that takes away hunger. Eliminating binges is a long, complicated process requiring emotional healing and learning non-eating strategies to deal with future emotional upheavals. Removing hunger is necessary but not sufficient. But at least it is a beginning.

If There Were Doggy Bags at Catered Events, Would People Eat Less?

Have you ever gone to a pre-celebratory social event, tasting of foods e.g., a wedding or a fund-raising dinner?  A friend in charge of a fund-raising dinner for a local musical organization invited to me to join a group of six other ‘tasters’ to sample menu choices for such a meal. I was the token non-meat eater, and I think she wanted me there to make sure the vegetarian option was passably edible.

I wasn’t sure what the protocol was in this process. Does one eat and swallow, or eat and spit, or take tiny bites or eat everything (even if it doesn’t taste good)? There was no spitting, even of the various wines we were asked to sip. However, whether or not the taster ate every sample in its entirely or just nibbled was a matter of individual style.

The appetizer samples kept coming and coming, although I avoided eating many tidbits such as Brussels sprouts wrapped in bacon, lamb chunks on round squares of toasted rice, and spicy chicken wrapped in puff pastry. In view of the main courses and desserts we were about to sample, I kept to nibbling except when a couple of appetizers were too good not to gobble up.

Nevertheless, I was already stuffed, when the main courses were brought out. Though thankful they were served in small dishes, I was feeling like a judge on a food network competitive cooking show. I tried to taste all the components of each entrée, and eventually the desserts. Fortunately, these also came in tiny serving sizes.

But then, to my surprise, we were shown what our choices would look like plated for a meal, rather than a tasting. The serving sizes were gigantic. Not sure whether my full tummy magnified the size of the fish and the meat entrée, I asked the caterer about the weight of the entrees.  

“The fish is almost 8 ounces,” he told me, “and the meat, lamb loin, is about 7 ½ ounces.“ The first course, a cold soup, was about 8 ounces and accompanied by a large piece of crunchy cracker covered with a thick layer of whipped ricotta cheese. The serving of soup was sufficient to be a meal in itself, if eaten with some crusty bread and a salad.

“Why are you serving so much food?” I asked the caterer, but another taster chimed in to answer.

“Because when people come to a fund-raising event, they expect to get a lot of food,” the person told me. “If they think the portions are too small, they feel they are not getting their money’s worth.” The friend who invited me added, “And the guests will blame the caterer for not giving them enough to eat, not the committee who decided on the menu.”

“It’s too bad doggy bags aren’t given out at these affairs,” I mused. “That way, people could eat a reasonable amount of food, especially if their party clothes are a bit tight anyway, and then take home the rest. I was thinking of how much more I would have enjoyed the desserts had I been able to taste them when I still felt like eating.”

“It might be a bit awkward for women in long gowns and men in tuxedos to leave a fancy event carrying aluminum containers filled with filet of sea bass or chocolate mousse,” she replied, and added that she always feel stuffed after these events because she hated to leave food on her plate.

Most of us are not obligated to eat catered food frequently unless we are politicians, make a living as after-dinner speakers, work in the fund-raising development area, or have lots of friends and relatives who are getting married or celebrating major birthdays.  But when we do go to the lavish wedding or significant birthday or anniversary party, where the food is overly generous in quantity and variety, it is tempting to consume much more than we would eat at our kitchen table. Often the food selections include items that we would not ordinarily eat because of their expense or non-availability. We are tempted to fill our plates at the pre-dinner cocktail hour buffet, and go back for seconds at a sweet table served at the end of the meal. Who can resist a mountain of shrimp and lobster tails, or a chocolate fountain spilling its mouth-watering liquid over strawberries and chunks of cake?

Such offerings are irresistible; so we eat and eat and eat, and of course, drink too much as well.

There are many reasons to lament the excess of food at these events, not the least of which is the disparity between what is overeaten and/or thrown away, and the need for food among so many in our population.  (Some caterers are able to give away food that is not served to food pantries and shelters.) But consider as well the disparity between the need to eat less and more healthfully, a mantra repeated endlessly in the media and doctors’ offices; and the willingness of the guests to eat more and less healthfully. Obesity experts have gotten some to eat less in restaurants by promoting the doggy bag idea so half of the usual oversized portion is taken home for a meal the following day. Servers are always willing to take the uneaten portion from the diner and bring it back in a (usually too large) bag. But I suspect that servers will not do this at a wedding or bar or Bat Mitzvah, even if some guests would be delighted to go home with some of the delicacies they were too full to really enjoy at the event.

Maybe this should be the newest trend in catered dining.  Years ago, the idea of asking to take home one’s uneaten portion of food from a restaurant would have been considered dreadful manners. It just wasn’t done unless you were over 90, and put the rolls from the breadbasket in your voluminous purse because they would taste so good with coffee the next morning. But all it takes is a celebrity or two, squeezed into an outfit appropriate for a red carpet event and yet taking home a doggy bag of caviar, to start this trend.

Diets Don’t Work When You Are Stressed

“Why do you think you gained back the weight after your last diet?” I asked the new client sitting in my office.

“I like food, I guess, “she replied.

“Well, most of us like food,” I nodded, “but liking food and overeating food are not the same thing.”

She sighed and looked quizzically at me. Obviously my job was to tell her why she gained her weight.

“Do you remember what was going on in your life when you noticed yourself gaining weight?” I prodded.

And then the story came out: a new boss who imposed impossible deadlines, a nine year old son diagnosed with ADHD, as well as a mother who might need to enter an assisted living facility.

“Any one of these stresses would have been enough to cause weight gain,” I told her, “so I can understand why it was hard not to overeat when you experienced all three.”

My client, let’s call her Gail, was a repetitive dieter whose weight bounced up and down in response to whether her life was in control, or in chaos. She figuratively threw up her hands when facing problems without quick and effective solutions and decided, often unconsciously, to ignore her weight, her fitness, and her health. Gail’s situation was more difficult than many because she was a single mom, and although she had siblings, most of the responsibility for caring for her own mother fell upon her. As she described her situation it sounded as if she never got enough sleep, had to make up work time over the weekend because she took time off during the week for doctor’s appointments for her son and her mother, and ate too many take-out meals because she had too little time to shop for and then prepare food. As she told me, she spent her evenings worrying and eating. Sometimes she would binge on a large pizza or a quart of ice cream, or a frozen cheese cake. She did not seem to be able to stop.  But she added that she hoped going on a diet would give her back control over her life and perhaps (it must have been magical thinking) make her problems more manageable.

This is why she is a constant dieter.

Diets don’t take away stress. Indeed the necessity of following a meal plan with its attendant demands of food shopping, cooking, exercise, and a support group or private sessions may simply add to the burden of daily life. Some welcome a new diet because the need to count points, count calories, to eat only certain foods, or to cleanse or fast temporarily distracts the dieter from her problems. As long as her mind is focused on whether kale has fewer calories than spinach, or deciding to take a yoga class or a long walk; it is not focused on her mother, her mortgage, or her marriage. And as the pounds come off there is a feeling that at least something in my life is working.

But if the dieter, like Gail, handles stress by overeating, how lasting can her weight loss be? What good will it do to know that carrots are a better choice than carrot cake, when it is the carrot cake, not the carrots, that will be overeaten when the next stress enters her life?

I told Gail that she should not start yet another diet until she acknowledges her habit of solving unsolvable problems by bingeing, rather than looking for workable solutions. She had to accept that bingeing wasn’t going to ease her workload, but perhaps talking to her supervisor or someone from the HR department of her company might.  Bingeing would not help her son’s ADHD, but a qualified therapist could. Bingeing would not resolve her mother’s living arrangements, but a social worker might be able to help.

In a perfect weight loss world, dieters would have life coaches, therapists, career counselors, social workers, psychologists, and even matchmakers or divorce lawyers at their disposal to help them get through the stresses that might derail their diets. Since this world does not exist, the dieter, with the help of a weight loss advisor, must identify situations that trigger overeating: problems with work, family, friends, or changes in hormone levels (menopause),   seasons (winter depression), or medication. Unless effective strategies are found that replace eating as an automatic way of dealing with these stresses, the dieter will return to eating once the diet is over or abandoned.

Weight loss programs that advertise, ‘Permanent Weight Loss!’ or ’This Diet Will Succeed Even if Others Have Failed!’ or ‘You Will Change Your Lifestyle Forever!’ may work in the short run, but unless the dieter understands why he or she overeats, the weight will return. No change in the ratio of protein to carbohydrate to fat in a meal plan will change how the dieter responds to stress. No celebrity eating plan is going to impact the dieter’s personal response to unbearable and/or irresolvable problems. Eliminating gluten or adding anti-oxidants is not going to address the chronic issues that weaken willpower and make weight gain ultimately unavoidable.

January is the traditional time to start a weight loss program. And if the dieter knows how to avoid the overeating that so often accompanies stress, this January may be the last time a new diet has to commence.