Thursday, December 5, 2019

Binge Eating: How the Health at Every Size Approach Can Transform Treatm

Binge Eating: How the Health at Every Size Approach Can Transform Treatment

By Jennie J. Kramer, LCSW-R, Executive Director of Metro Behavioral Health Associates and Ashley Seruya, Social Work graduate intern and HAES Educator and Content Specialist
How can clinicians, clients experiencing eating disorders, and loved ones of those struggling all contribute to the changing culture of eating disorders? At our centers, we believe it starts with tackling the weight stigma that is so embedded within the diagnosis and treatment of BED and the entire eating disorder diagnostic category.
So let’s start with some simple definitions: what is a binge?
Compulsive Overeating is akin to what some call “grazing”. It is often eating all day, perhaps not too mindfully, almost by rote and certainly not in response to intuitive hunger cues. An example is someone who keeps a supply of a food in a desk drawer at work and eats from it rather frequently all day long. One is often not aware that she/he/they is doing it.
Emotional Eating is also not in response to intuitive hunger cues but much more episodic in nature. It is most often in response to or in anticipation of some emotions or events that cause anxiety, worry, upset or any other unpleasant feelings. There’s also usually a great awareness that it is happening but one feels helpless to do anything else in the moment in an attempt to self soothe.
These are not binges per se. Bingeing certainly has components of emotional and compulsive overeating but it is most often much more copious amounts of food in one sitting, stopped only by either physical discomfort, pain or falling asleep. It is most often alone and accompanied by a sense of great personal shame.
It is also important to note that all categories are quite fluid. Many who struggle actually utilize multiple behaviors across the spectrum, including bingeing, restricting, and purging. Though an individual may lean more heavily on one behavior or another, it is important to acknowledge that these categories are not as black and white as clinical procedure might suggest. With BED specifically, it is unusual to experience bingeing without also engaging in restrictive behavior of some kind, though this is not always acknowledged diagnostically.
There is inherent weight bias within the DSM-5 or Diagnostic Statistical Manual, the present standard for all psychiatric diagnoses, including those related to one’s relationship to food and body. For example, the diagnosis of Anorexia Nervosa (AN) requires an individual to be of low weight while those with BED are often assumed to be of higher weight. These general weight class assumptions are rooted in weight stigma. In truth, many individuals struggling with anorexia are in average-sized or larger bodies.
As a result, many individuals have a difficult time being properly diagnosed, especially those in higher-weight bodies exhibiting restrictive symptoms. Their experience may not be taken as seriously, despite existing research that indicates that how much weight is lost in short period of time is much more indicative of the severity of a restrictive eating disorder than weight itself. Someone who, for example, is of a higher weight and loses a large amount of weight in a short period of time via restriction but is still considered “overweight” or “obese” by the BMI scale will likely be misdiagnosed and their restrictive behaviors are likely to not be believed by providers because of the stereotypes surrounding eating disorders and the ways in which the DMS-5 perpetuates these stereotypes. Furthermore, insurance reimbursement often relies on DSM-5 diagnoses. Being diagnosed improperly can lead to improper treatment and an inability to pay for that treatment.
In terms of treatment, this means embracing a Health at Every Size (HAES) approach to recovery for all eating disorders. HAES, a body of work that began in the 60s and has been popularized by Dr. Linda Bacon, is an approach to health and wellbeing that is weight inclusive rather than weight centric. Instead of pathologizing larger bodies, HAES proposes that all people are deserving of respect and quality of care, no matter their size. HAES proponents believe all people in all bodies should be able to pursue health if that is something they desire and are committed to creating a world in which we divorce health status from weight.
Let’s say that again – divorcing health status from weight. Quite the task when we are all steeped in diet culture at every turn.
Here are some statistics to ponder:
  • Often referred to as the “obesity paradox,” people in the “overweight” and “obese” categories on the BMI scale have a lower morbidity rate than those in the “normal” and “underweight” BMI categories;
  • No current research can show sustained intentional weight loss on a long-term basis;
  • Health gains are maintained with or without maintaining weight loss when health behaviors are maintained;
  • Those who do engage in intentional weight loss are more likely to end up heavier than when they initially began attempting to lose weight;
  • Weight cycling, the most likely result of attempts at intentional weight loss, may be more metabolically dangerous than remaining at a stable higher weight.
With all of this information in mind, it becomes clear that what we think we know about weight isn’t quite as black and white as previously believed. For eating disorders, this becomes an important factor in diagnosing and treating those in higher-weight bodies. Too many well intended treatment models continue to pathologize larger bodies, not believing people when they report their experiences of restriction simply because they are not “underweight.” Many then get wrongly treated via weight loss clinics, highlighting the misunderstanding of how BED functions.
Instead, let’s start by acknowledging bingeing behavior as one of several coping mechanisms meant to self soothe. We also need to begin acknowledging the role that restriction plays in BED, and the role of internalized fat-phobia in all eating disorder development and maintenance. Understanding more about the society in which we live and how it continues to treat larger-bodied individuals as second-class citizens (hiring managers are less likely to hire someone who is “overweight;” it is legal to fire someone for being in a larger body in the majority of states; peer-to-peer bullying related to weight is a pervasive problem in our schools; stereotypes about larger people persist, including beliefs about laziness and poor personal hygiene), is essential to understanding how eating disorders function and some of the barriers individuals face when attempting to recover. How can we truly expect people to let go of their eating disorder behaviors when we live within a world that tells us that in order to be valuable, we must be thin? How can we expect people to even understand their behavior is disordered when we don’t recognize the restriction that takes place in bingeing-type eating disorders? These are important questions to be asking ourselves as professionals, sufferers and those who support loved ones who suffer.

The Power of What We See: An Examination of Weight Bias in Television Programming

The Power of What We See: An Examination of Weight Bias in Television Programming

By Kristine Vazzano, PhD
The human brain processes images 60,000 times faster than words.
This data is not only powerful, but pivotal in illustrating the many ways the media can impact how we see and feel about our bodies as well as those around us. Living in our culture, we are exposed to numerous images each day dictating how we “should” look. Inherent in these messages can be the notion that fat is bad and thin is good. Although these messages are prevalent in countless media streams, television continues to be a primary media outlet. When we look closely at how body shapes and sizes are characterized in television, several trends and patterns of weight stigma become apparent.
These trends include:
  • Reality shows focusing on weight loss, featuring weight loss as a game and something solely in someone’s control. These shows ignore the harmful consequences of dieting and reinforce the dangerous idea that becoming thinner means positive things for someone’s overall happiness, health, and appearance.
  • Mischaracterizing people based on their size. Television shows commonly depict certain characters in a negative light, appearing unintelligent, unhappy, or mean. In fact, in 40% of children’s movies, a character of a higher weight is disliked as a part of the story line.
  • Featuring characters in larger bodies as the sources of humor or someone to make fun of. These trends are particularly evident in children’s movies and video games.
  • Misrepresenting size diversity by showing more women that are underweight and fewer women in higher weight bodies.
What are the implications?
The messages in television programming misrepresenting size diversity and people in higher weight bodies contributes to harmful and inaccurate stereotypes. These patterns imply that a person’s character or personality is negatively linked to their body shape and size.  Laughing at individuals in higher weight bodies and casting them in a negative light reinforces weight bias that is already common in our culture. It perpetuates weight-based stigma, the harmful notion that it is acceptable to make fun of those in a larger body.
Furthermore, by stigmatizing individuals with a higher body weight in these ways, TV programming is reinforcing the thin ideal making it seem as though thinner bodies are something we must strive for in order to be happier, healthier, well liked, and successful.
Much of the programming is geared toward a younger audience, one particularly vulnerable to developing attitudes and beliefs about others and their own bodies as well.
What can we do?
  • Be aware and critical of what you see. Challenge messages reinforcing weight stigma. Educate yourself and those around you about the importance of treating all people with respect.
  • We have the power to choose some of what we consume. Turn off the shows that reinforce weight bias. Seek out shows, social media accounts and other media that challenges the thin ideal and provides healthier, flexible messages.
  • Speak out about weight bias. Stand up to the discriminatory messages you see and hear. Reinforce the message that size does not demonstrate someone’s worth, personality or health.

Network Analysis of Males and Eating Disorder Symptoms

Network Analysis of Males and Eating Disorder Symptoms

By Lauren Forrest, MA
When you think of the term “eating disorder”, what words come to mind? Perhaps you think of descriptors like girls, women, thin, body image, and lean. If you read a case description of someone with an eating disorder, how often would you guess the case description described a female vs. a male? It’s likely your mind would have a stronger association between eating disorder girls/women/female, as compared to eating disorder + boys/men/male. And it’s true: girls and women are more likely to be affected by eating disorders than boys and men. However, the gender gap of eating disorder prevalence is closer than you may think—males account for roughly 20–25% of affected individuals (Hudson et al., 2007; Mohler-Kuo et al., 2016; Udo & Grilo, 2018). Importantly, one reason why male eating disorders are lesser known than female eating disorders may be because of differences in core eating disorder symptoms (for a thorough review, see Murray et al., 2017). In collaboration with a team of excellent colleagues (Natalie Perkins, Jason Lavender, and April Smith), I led a study that identified core eating disorder symptoms among men, and I’m excited to tell you more about it.
This study used something called network analysis to identify core eating disorder symptoms. Network analysis is a statistical technique that identifies how individual symptoms interact with one another. Through empirical methods, network analysis specifically identifies the symptom(s) that have the strongest connections to other symptoms in the network, which is important because these highly-connected symptoms may be those that cause the development of several other symptoms in the network. For example, network analysis findings among women indicate that eating disorder symptoms like shape and weight overvaluation—where people feel like their shape or weight is extremely important to how they judge themselves as people—are highly related to several other symptoms, like fearing weight gain and dieting.
Even though network analysis shows promise to better understand core symptoms of eating disorders, males have been very under-represented in eating disorder network studies. Without including boys and men in our research studies, we can’t know whether the symptom-level interactions identified among women are operating similarly for boys and men. Our study identified specific eating disorder symptoms that may be the main drivers of eating disorders in men. To do this, our symptom network included items that are typically used to assess eating disorders, while also including items that capture experiences that seem to be important to men’s experiences, such as items related to male (vs. female) body ideals.
In western society, the male body ideal is muscular and lean. This is in contrast to the female body ideal, which is thin and marked by having a low weight. To achieve these different body ideals, males and females may engage in specific eating disorder behaviors. Dietary restriction and purging may be used to lose weight and achieve a thin body ideal, whereas eating large quantities of specific foods (e.g., those high in protein), lifting weights, and exercising intensely may be used to gain muscle mass and achieve a muscular body ideal. Most of the measures that are commonly used to assess eating disorders do an excellent job of assessing attitudes and behaviors associated with achieving a thin body ideal, but few incorporate items that assess attitudes and behaviors associated with achieving a muscular body ideal (please see the great work of Dr. Kelsie Forbush for an exception). In our study, we used a “both–and” approach, where we included items in the network that are commonly used in eating disorder research (but lack male/muscularity specificity) while also including items that capture muscularity-related body ideals, dissatisfaction, and behaviors.
The results of our study were quite interesting. We found the items with the greatest importance in the network—i.e., items that were most strongly associated with all other items—were shape overvaluation (believing a person’s body shape is one of their most important qualities), wanting to lose weight, fearing losing control over eating, feeling guilty for missing a weight training session, and using dietary supplements. The first three symptoms (shape overvaluation, wanting to lose weight, and fear of losing control over eating) were expected to be important, based on previous research. But the most interesting part of the results was that the last two symptoms (feeling guilty for missing weight training and using dietary supplements) came from measures assessing male/muscularity-specific eating disorder symptoms. This may mean that to most accurately diagnose, understand, and treat eating disorders among males, we need to be paying attention to some of the things we already pay attention to for female eating disorders (e.g., shape overvaluation, valuing weight loss) while also increasing the attention we pay to things like dissatisfaction about one’s body not being “muscular enough” or “lean enough” and the behaviors that may arise from this dissatisfaction (e.g., intense and strict weight lifting schedules, supplement use).
More broadly, one implication of these results is that as a field we may need to expand our theoretical models of eating disorders. Rather than our models specifying that pursuit of a thin body is the driver of all eating disorder symptoms (which is a belief ranging from implicit to explicit in current theoretical models of eating disorders), we may better conceptualize male and female symptoms by specifying that pursuit of any body ideal (thin, muscular, lean, etc.) could lead people to engage in specific eating and exercise behaviors to achieve that ideal. For some people, these experiences may result in clinically significant eating pathology. Such an expansion could bring necessary growth and diversity to our field, and ultimately help us impact more people through more accurately assessing, diagnosing, treating, and preventing eating disorders.
To my mind, one of the most problematic stereotypes about eating disorders is that they are “female diseases.” There is a kernel of truth to this stereotype, as eating disorders do affect more females than males. However, the fact that a sex difference exists doesn’t mean that males don’t develop eating disorders, and it also doesn’t mean that eating disorders present exactly the same in men and women. My hope is that by conducting research like what my colleagues and I did here, we can help the eating disorders field better recognize the similarities and differences between male and female eating disorders, so that we can make sure that we’re providing the most thorough and effective assessment and treatment for all affected individuals. 

Eating Disorders Coalition Celebrates Latest Federal Guidance on Implementation of Mental Health Parity to Promote Compliance and Enforce Eating Disorders Coverage

WASHINGTON, D.C. (October 28, 2019) – The US Department of Labor, US Department of Health and Humans Services, and the US Department of the Treasury released guidance last month entitled, “FAQs About Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act Part 39,” providing additional direction to insurance plans, issuers, and outside stakeholders in an effort to promote compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The Eating Disorders Coalition for Research, Policy & Action (EDC) applauds the Departments additional guidance, including new clarifications that will enhance insurance coverage for eating disorders as a result of the Anna Westin Act provisions included within the 21st Century Cures Act (P.L. 114-255). 

The EDC has worked tirelessly to educate federal agencies on the barriers to care for individuals and families with eating disorders. This work has included submission of public comments on previous federal guidance documents in September 2017 and June 2018; Congressional letters of support in 2017 (House/Senate) and 2018 (House/Senate); and participation in a July 2018 and a January 2019 federally hosted forums with stakeholders and federal agencies to discuss MHPAEA implementation. The most recent guidance from the Departments includes victories for our community regarding the following: 

  • Coverage of Sub-group Disorders: When a plan or issuer provides benefits for a mental health condition/substance use disorder, benefits for that condition or disorder must be provided in every classification in which medical/surgical benefits are provided. Insurance plans are in violation of MHPAEA if coverage for eating disorders does not extend to all sub-types including, anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and other specified feeding or eating disorders (OSFED). 

  • Shifting the Burden of Proof for Fail-First Policies to Payers: It is incumbent upon the insurance company, not the patient, to prove they’re in compliance with step therapy protocols and are able to demonstrate evidentiary standards were utilized comparably to develop step therapy requirements between mental health/substance use disorder benefits and medical/surgical benefits. 

  • Residential Care Classified as Inpatient, Covered Benefit: Residential eating disorders treatment is classified as a sub-category of inpatient care to ensure the patient receives their inpatient covered benefit just as skilled nursing facilities, nursing home care, and hospice are considered sub-categories of inpatient care. 

  • Rights to Receive Medical Necessity and Denial Information: Insurance plans must provide current/potential patients and contracted providers with free of charge information regarding claim denials and related documents on medical necessity requirements to file within 30 days of a participant’s request. 

“The recent guidance from the Departments provides further clarity to individuals and families with eating disorders, treatment providers, and insurance companies to fully comply with the Mental Health Parity and Addiction Equity Act as intended,” said EDC Board President Chase Bannister, MDIV, MSW, LCSW, CEDS. “Our coalition has worked diligently to fight for equitable treatment under the law. We will remain steadfast in our mission to continue having a seat at the table as we educate the Departments on MHPAEA violations and work together to drive change for those in need of treatment.” 

The EDC recognizes that parity enforcement and compliance both remain a work in progress, therefore we will continue to use our collective voice to provide expertise to the Departments as they release additional implementation guidance on a rolling basis. 

The Eating Disorders Coalition for Research, Policy & Action (EDC) is a Washington, DC-based, federal advocacy organization comprised of advocacy organizations, academics, treatment providers, family/loved ones of children with eating disorders and people experiencing eating disorders nationwide. The EDC advances the recognition of eating disorders as a public health priority throughout the United States. Additional resources can also be found at

When People with Anorexia Injure Themselves

Vol. 29 / No. 6  

Difficulty regulating emotions is a common component of an eating disorder, and self-injury  may act as a coping mechanism for dealing with overwhelming emotions. This was one finding from a recent study of patients with anorexia nervosa or eating disorders not otherwise specified (J Eat Disord. 2018; 6:26).
Dr. Linda Smithius and colleagues at Parnassus Psychiatric Institute, Rotterdam, used a cross-sectional design and a self-report questionnaire to measure the prevalence and characteristics of self-harm behavior among 136 patients with eating disorders. The authors found that 41% of their study subjects had injured themselves during the previous 30 days. Those who injured themselves had been in treatment longer and were more likely to have a secondary psychiatric diagnosis, suggesting more severe illness than those who did not injure themselves. These patients also stated they a reduction in negative feelings and increased relief after hurting themselves. Afterwards they also could articulate the emotions that led them to injure themselves. The Dutch researchers were also able to isolate the intensity of two emotions in particular, “feeling angry at myself” and “feeling angry at others.”
The authors noted that emotion regulation appears to differ between subtypes of anorexia nervosa, so that patients with the purging subtype have reported greater difficulty regulating their emotions than do patients with restrictive-type anorexia nervosa (J Eat Disord. 2016; 4:17). The findings replicate work using intensive self-monitoring strategies such as ecological momentary assessment to measure the impact of self-injury on emotion regulation

EATING DISORDERS Large Study Analyzes Compulsive Exercise and Eating Disorders

Vol. 29 / No. 6  

One finding: Nearly half of eating disorders patients were compulsive exercisers.
In the largest study to date of compulsive exercise in adults with eating disorders, more than 9,000 female and male patients were examined for tell-tale symptoms (J Eat Disord. 2018; 6:11). Dr. Elin Monell and colleagues at the Karolinska Institute and the Stockholm Health Care Services, both in Stockholm, Sweden, gathered their data from the Stockholm database, a clinical database for specialized eating disorders treatment centers throughout Sweden. The database includes all treatment modalities, including medical, psychosocial and nutritional data and records the length and intensity of treatment.
In Sweden, about 60% of treatment is given as outpatient care; approximately 25% of patients receive day treatment and residential care. Records of patients registered from March 2005 to October 2017, were identified, and 9,117 patients with histories of eating disorders were included in the final study. All participants were studied with semi-structured interviews and questionnaires, including the Structured Eating Disorder Interview, the Eating Disorder Examination questionnaire(EDE-Q), The Structural Analysis of Social Behavior,and the Structural Clinical Interview for DSM-IV-Axis 1 Disorders(SCID-1).
Compulsive exercise at admission
Of the total sample of 9,117 patients, 96.3% were female, and the patients’ ages ranged between 18 and 81 years. Compulsive exercise was noted in 48.2% of female patients at admission and in 45.5% of male patients, where it was most often linked to eating disorders not otherwise specified or to bulimia nervosa. Both males and females who compulsively exercised had more general eating disorders pathology and restraint than did those who did not compulsively exercise. Females with compulsive exercise diagnoses were slightly younger, had a fairly shorter duration of eating disorders, and a slightly lower body mass index than did non-compulsive exercisers.
Compulsive exercise predicted a slightly lower remission rate in men, and women who had never engaged in compulsive exercise or had ceased using it remitted twice as quickly as those who continued to use compulsive exercise during treatment.
The authors noted that compulsive exercise was a transdiagnostic symptom in their study. Their results are similar to those of a prior study of adolescents with eating disorders. This growing body of literature suggests that while exercise has received relatively little attention, it deserves greater focus, both in research and in clinical practice.

Collegiate Female Athletes’ Knowledge About Eating Disorders

Vol. 29 / No. 6  

Knowing the signs and symptoms of an eating disorder brought the lowest scores.
Athletes are a group at high risk for disordered eating, and one would hope they would be knowledgeable about eating disorders. In fact, athletic organizations such as the National Association of Intercollegiate Athletics (NCAA) have engaged in raising awareness about eating disorders (these efforts may focus on larger athletic programs). When a team of American and Swedish researchers compared general knowledge about eating disorders and confidence in that knowledge among a group of female athletes, they were surprised to learn that despite the women’s confidence in their knowledge of eating disorders, their actual understanding fell far short.
Dr. Megan E. Rosa-Caldwell and colleagues recruited 51 women from an NCAA Intercollegiate Athletics university and asked them to complete a 30-question exam assessing 5 different categories related to eating disorders (Peer J. 2018; doi 10.7717/peer). 5868).
Most scores were unsatisfactory
Fifty-one female college athletes (mean age: 19.7 years) completed the study. The average score was 69.1%. Only 23% achieved an adequate score of >80% correct, despite the fact that most thought their level of knowledge was good. Most could identify risk factors but scored the worst on identifying signs and symptoms. As the authors noted, most of the athletes lacked knowledge about eating disorders.
Some possible explanations
While there is a substantial amount of research on eating disorders risk and prevalence of this among athletes at large universities, little research has been done at smaller athletic programs, which often lack the resources that are present at the larger universities, such as access to team physicians, team-specific athletic trainers, or dietitians.
The authors note that overconfidence may also play a role, citing the Dunning Kruger effect, first outlined in the 1990s (J Personality Soc Psychol. 1999; 77:1121). An individual may have high confidence in his or her knowledge of a subject but in fact does not have the ability to see the limitations of their knowledge. Coaches or teammates who cannot recognize problematic eating behavior but who are also confident in their ability to do so can have serious ramifications.
This study points to potential challenges in small collegiate athletic programs and may also identify an overlooked need for increased efforts to improve awareness efforts. An individual may lack the knowledge to identify signs and symptoms of disordered eating among his or her peers, yet have high confidence in the ability to do so. Improving knowledge about eating disorders in these athletes could thus have a large impact.