Portions Uncontrolled: The New World of Binge Eating

Portions Uncontrolled: The New World of Binge Eating
How supersized portions, out-of-control eating, and depression tie to the new disorder of binge eating.

by Maia Svalavitz for MSN Health & Fitness

Chevese Turner remembers her first food binge. She was only 5 years old and had discovered a box of ice cream cones in a kitchen drawer at home. She sneaked them up to her bedroom.

“Just the cones, no ice cream,” she says. She later ate all of the cones in one sitting, feeling unable to stop herself.

Back then, there was no name for the eating disorder that she would soon develop. Though binge eating is part of bulimia, in that condition, the eating is followed by purging, which Turner did not engage in.

Now 42 and in recovery, Turner heads the Binge Eating Disorders Association, which supports the inclusion of what is now called binge eating disorder (BED) in the next edition of psychiatry’s diagnostic manual (DSM). In a draft released in February, BED is among the new disorders recommended for inclusion in the final publication.

But with oversized portions and a growing supersized population, could including BED in the manual mean that the majority of Americans—the 67 percent who are overweight or obese—could be diagnosed as mentally ill? Isn’t binge eating just another way of labeling and stigmatizing how overweight people behave? Could more than two-thirds of U.S. adults be about to become mentally ill and not even know it?

Not just a weight problem

In fact, studies show that only about 3.5 percent of women and 2 percent of men meet the criteria being proposed for BED, which is distinguished from normal eating because it involves periods of loss of control over food intake, typically followed by intense shame and guilt. This makes it more common than anorexia or bulimia, but nowhere near as common as being overweight.

About 70 percent of people with BED are overweight or obese—a clear majority, but the condition doesn’t always lead to unhealthy weight. Overweight people who do binge eat, however, are at greater risk for ongoing weight gain and related health problems than those who do not.

Further, obesity itself isn’t usually characterized by binge eating, says Stephen Wonderlich, Ph.D., professor of clinical neuroscience at the University of North Dakota School of Medicine and the lead author of a paper reviewing the research on the disorder for the DSM draft proposal. “If you go into places where people are seeking treatment to lose weight, around a third of them will have significant binge eating. But lots of obese people do not binge, the majority in fact,” he says.

What is BED and how do you know if you have it?

“The official definition [of a binge] is eating an unusually large amount of food by social comparison in a brief period of time, usually under two hours,” says Cindy Bulik, Ph.D., director of the Eating Disorders Program at the University of North Carolina. “But the kicker is feeling out of control. This is not the Super Bowl or Thanksgiving—it has to include that out-of-control feeling.”

For Turner, the loss of control was driven by distress related to growing up in a broken family, with a mother who herself suffered from an eating disorder and alcoholism. “I was preoccupied and obsessed with food in my head,” she says. “I would try to restrict my diet and then the binges would unleash and there was no going back.”

Losing control

Turner recalls binge eating in childhood and starting to diet as early as 8 or 9. However, the age when BED is most likely to develop is not yet known. Marian Tanofsky-Kraff, an assistant professor at the Uniformed Services University of the Health Sciences and a researcher in the unit on growth and obesity at the National Institute of Child Health and Human Development, is studying children with “loss-of-control eating,” which may be a precursor to BED. “We rarely see the full syndrome in little kids, but we start to see it in adolescents a bit,” she says.

The cause is also unknown, but there are already signs of a significant genetic contribution.

“Forty-one percent of liability to BED is due to genetic factors,” Bulik says. “The rest is due to the environment—it’s clearly not either/or.”

About half of people with BED also suffer from another mental illness, commonly depression, anxiety disorders or addictions to alcohol and/or other drugs. In fact, the condition seems to share a lot of the same psychology as substance-abuse problems, which also tend to occur with depression and other mental illnesses.

For example, both addictions and BED are defined by a loss of control over a particular behavior, and both are marked by difficulty stopping that behavior once it has started. The compulsive behavior tends to be triggered in both cases by an attempt to cope with difficult emotions.

Emotional eating

“I've left after a huge meal with my family and gone to McDonald's an hour later,” Turner says. “It has nothing to do with the taste of the food, and I am certainly not hungry. I need something to fill that hole that never can be filled.” She says she used such binges to avoid uncomfortable feelings.

Another major reason why eating-disorder experts have fought for the inclusion of the disorder in the DSM is that it usually can’t be treated by behavioral approaches to weight loss the way obesity without BED can be. Interestingly, people with BED respond as well—or as poorly—as other overweight people do to weight-loss treatments.

“If you put a whole bunch of people into a weight-loss program and half have BED and half don’t, the people with BED do as well at losing weight as people without BED. It’s not a marker for poor response to weight-loss treatment,” Wonderlich says.

However, the shame, distress and life disruption caused by periods of uncontrollable binges don’t ease with weight loss alone. For people with BED, getting a handle on “emotional eating” is what matters. While this alone will often not cause weight loss, it improves quality of life tremendously.

Stopping the binges

For some, self-help books that teach cognitive strategies to avoid binges can treat the problem successfully. Bulik wrote one such book, Crave: Why You Binge Eat and How to Stop.

Understanding the feelings and situations that trigger binges is an important step to taking control. Learning to distinguish between a desire to eat driven by desire for escape and one that represents real hunger is also important. “There are very few situations when the body needs a whole pan of brownies,” Bulik notes wryly. “I can’t think of single nutritional deficiency that requires that.”

While people may need to avoid the highly palatable sweet, salty or fatty foods that they have binged on at first, “The goal is to have there not be forbidden foods,” Bulik says. “The idea is to train people so that they can have more power over food than food has over them.”

Getting a handle on appropriate portion size also matters. “The buzz word is portion distortion,” Bulik says. “It’s even hard for people without BED to figure out. People become astonished when they read nutrition labels to see what a portion size really is.” She recommends the Agriculture Department Web site; this guide uses household items to allow easy visualization of appropriate portions.

For those who need more than self-help, cognitive behavioral therapy is the treatment of choice, with evidence showing significant improvements in BED. Another approach being researched—like cognitive behavioral therapy, originally designed to treat depression—is called interpersonal therapy.

Tanofsky-Kraff, who is using it for teens with loss-of-control eating, says, “I personally like IPT because it addresses the things that adolescents care about most: getting along with their parents better, improving friendships, romantic relationships. Although this is just an impression, I find that they love it.” She is conducting a large trial to see if it works.

Recovery

Turner has been recovery for around 10 years now. “I use an intuitive eating model,” she says. “I’ve continually lost weight by listening to my body. It’s a very slow process, but it helps with the binges.” She notes, however, that weight loss isn’t what matters most.

“Exercise is part of my life, but I don’t beat myself up about it. And yes, I’m going to enjoy a piece of birthday cake with my kids, but I’m not going to sneak down in the middle of the night and have two more pieces.”

She adds, “People might look at me and still see an overweight person, but it’s important to know that the weight is not the recovery. It’s addressing the underlying issue and being OK in your own skin.”