Over the years I’ve narrowed my private practice to focus mostly on people with binge eating disorder (BED) or similar symptoms such as “overeating,” “mindless eating” and “emotional eating.” (I put these in quotes purposely because these symptoms are often not what people think they are). I’ve learned so much from working with people with BED, it is the most common eating disorder, and yet I feel like it’s so completely misunderstood by the general population and also clinicians (usually doctors and non-ED professionals).
Many people think this is a problem of eating to excess. Even the DSM-5 diagnosis criteria seems to assume this. Weight stigma and diet culture probably both have a lot to do with that.
So I thought it was high time I shared what I’ve learned over the years in hopes of clearing up some misconceptions.
In 2013, Binge Eating Disorder made it into the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria.
According to the DSM-5, diagnostic criteria for binge eating disorder include:
Weight or body size is not a part of the diagnosis. Like any eating disorder, a person of any size can be diagnosed with binge eating disorder. Unfortunately, other diagnosis criteria like Anorexia Nervosa do include a weight component. This is a big problem because, again, anyone of any size can have anorexia or any other eating disorder.
I am so glad that the DSM has included this ED as its own diagnosis, but I think these criteria need to evolve. Specifically, I take issue with #5, “The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, or avoidant/restrictive food intake disorder.” I believe that if clinicians were relying on that criterion for diagnosis, few people would fit into this category.
I think this criterion leads to a lot of ineffective treatment because it assumes a person is bingeing while eating normally the rest of the time. It makes BED all about “eating too much.” In all my years treating BED, I’ve met very few people with BED who are eating enough food through the day before they binge. But because dieting is seen as “normal,” especially for higher weight people, this compensatory behavior (e.g. eating but not enough, eating foods that aren’t satisfying or enjoyable) isn’t seen as problematic. Trust me, it is.
The few people I have met who may be eating enough through the day have other things going on that are creating mental restriction. They feel shame about their weight, about the types of food they eat, about the quantity or the quality. They live in a shame bubble that tells them they are always doing eating wrong. That can translate in the brain to “the diet starts tomorrow and this food is going away.” They are always striving for compensation, in a way. Deprivation eating may follow in the form of a binge.
I haven’t yet met the client who binges without some form of past or current restriction or desire to lose weight. Compensatory actions are almost always present in the form of skipping meals the next day, “eating light” or planning the next diet.
I imagine there is some leeway in diagnosing and often clinicians are just doing their best to help their clients. But either diagnosing clinicians are ignoring this particular criterion to give a client a diagnosis that could help them get treatment (and I am fine with this because I think this criterion is not helpful) OR they may not be aware of the small-but-important compensatory behaviors the person is engaging in. That’s why a dietitian is crucial in the treatment of binge eating disorder.
The bottom line: Any compensatory behavior in the way of eating less, exercising more, or planning the next diet to control weight will just keep a person trapped in the binge cycle.
Many people with BED assume that any weight gain they experience is due to the act of bingeing. While this is always a possibility, in my experience it’s almost impossible to know what weight gain is due to if someone has a history of dieting (or worse restriction) and weight cycling. The act of dieting/restriction/weight loss destabilizes weight to varying degrees. Even without bingeing or overeating, a person who stops restricting may gain a drastic amount of weight while eating normally. Some may gain no weight at all. Genetics plays a huge role in this.
So when my clients don’t lose weight once their bingeing stops, there is sometimes disappointment. They’ve been told their entire lives that their eating made them fat, and they learn that not eating enough is “normal” (it is not). So finally eating enough may feel like “too much” for a long time, and they may feel like they are still doing eating wrong. It’s useful to have some training in helping clients learn to tolerate their bodies, a first step in improving body image. Anyone promising weight loss as a part of treatment for BED should be avoided at all costs.
I have heard (literally while in a treatment center) some clinicians express concern that a higher weight person is gaining more weight in treatment. This is a big problem. Weight is often gained in recovery and that’s not different for someone who has been restricting as a part of their binge eating disorder. They may have been suppressing their weight with the amount of restricting they were doing even while bingeing. Any focus on suppressing weight in ED treatment, including BED, is counterproductive and will worsen the ED. We also can’t control weight easily and any dietitian who has tried to get a hypermetabolic anorexic person to gain weight with food alone will attest to that. More training is needed for therapists to understand the meaning of “weight neutral” in treatment and how any focus on suppressing weight is damaging.
Treatment for BED must be aligned with the principles of HAES®. Weight control cannot be any part of treatment nor should we encourage the idea that weight control efforts should resume after treatment because this will most likely ensure a relapse.
From a nutrition standpoint, our first priority is to make sure biological hunger is met by ensuring adequate energy intake. This can be really challenging when clients often don’t experience “clear” hunger signals. It can help clients to learn that a compelling drive to eat may be a hunger signal and this is their body’s way of saving them in the absence of enough food.
The majority of my clients with BED often simply do not eat enough earlier in the day. Why? Because they’ve been taught that eating the least amount of food possible is what they should be doing to control their weights, often a lifetime effort starting in childhood.
A first line of treatment will be to start what is sometimes called “mechanical eating.” That’s eating regular meals and snacks in the absence of hunger – because hunger signals are not accurate to guide eating early on in EDs! This is often not fun or pleasant but it is effective as hell when it comes to stopping binge behaviors AND urges.
Which is an important point: the goal of binge eating disorder treatment is not to “control” binge urges but to have the binge urges cease completely so you can live a life free of food anxiety.
Working towards internally regulated eating, such as with the intuitive eating and eating competence models, is a good goal. That can take a long time as the body relearns normal hunger and fullness cues but everyone recovers at different rates.
There also may be psychological factors that trigger a binge, but in my experience, once you are adequately fed, meeting biological hunger and giving yourself permission to eat, it’s easier to work with your therapist on those restrict/binge triggers. Having both a therapist and dietitian gives you the team you need to support your recovery.
Even if you don’t qualify for a binge eating disorder diagnosis, if you suffer from several of the same symptoms, it’s worth it to seek out help.
I have many binge eating clients and the relief they experience when they see that they can learn how to be good, relaxed eaters is such a privilege to observe.
If you’re looking for more tools to help with binges or overeating problems, I have put some of my best ones, the ones I use first with clients, in this free guide, 7 Strategies to Stop Overeating.
If you’re in need of help with your eating, set up a 30 minute free call with me and we’ll see what could be most helpful.
My Peaceful Eating Jumpstart may also be a great place to start in helping you heal from binge eating and other eating problems. Group begins February 7th and spaces are filling up and I would love to have you join us!
Welcome to food freedom! Dare to Not Diet LLC is owned by Glenys Oyston, Registered Dietitian and Nutrition Therapist and Certified Intuitive Eating Counselor. It's time to feel good about eating, your body, and your health.