Welcome to the ‘Navigating’ Series
As we continue exploring each eating disorder with more specificity, it’s clear that there are more things in common with each disorder than there are differences. The core of an eating disorder is coping - we all have things that occur in life that require coping skills and an eating disorder is one way we can learn to cope with stressful events or experiences. Living in diet culture requires coping, experiencing loss requires coping, and there are countless other human experiences that require coping skills to get through them. Contrary to what you might expect, eating disorders are actually incredibly effective coping strategies in the short term - they provide significant relief in the moment. The problem is, they are very ineffective and harmful in the long term. Pursuing treatment is a hard decision to make when it feels like the eating disorder is the only way to get through hard things. If you are currently struggling with the decision to pursue treatment, I am sending my support your way.
If you have any questions or additional considerations, please feel free to leave a comment!

Etiology
I’ll be honest, I have some gripes with binge eating disorder as a diagnosis and oftentimes find that there is a lot of fatphobia that exists in the process of giving a person this diagnosis.
It’s important to remind you that dietitians don’t diagnose - I am never the one giving a patient their diagnosis and also don’t change people’s diagnoses. These are my thoughts as a member of the healthcare team and not an attempt to overstate my role in the diagnostic process.
Why do I feel this way? I think of bingeing as a multifactorial behavior. There is a physical element and a mental element. I find that the diagnosis of binge eating disorder (BED) is really focused on the mental element without acknowledgement of the physical precursors that lead to bingeing. Let me explain.
Physically, bingeing is usually, almost always the product of restriction. When we aren’t getting enough nourishment throughout the day to meet our physical needs, our bodies have a couple options. One, in the case of anorexia nervosa without bingeing tendencies, we feel kind of good when undernourished and don’t have the biological drive to eat. Second, in the case of any diagnosis that includes bingeing, we have a biological drive that encourages us to eat when undernourished. When this biological drive kicks in it feels like what Evelyn Tribole and Elyse Resch, who co-wrote Intuitive Eating, coined “primal hunger”. This type of hunger overrides our rational part of our brains and feels more out of control. It is a survival instinct - your body doesn’t really care about your diet if it appears that you are living through a famine or food insecurity. This can also be why we tend to crave high energy density foods - if we are chronically undernourished, that is what your body needs! Bingeing in the context of undernutrition is a lifesaving mechanism. It is actually a healthy and necessary override in your systems to ensure that you can get enough food to stay alive.
Mentally, there can be a lot more to the puzzle to make things complicated. Our relationship with food is a significant factor influencing our bingeing behaviors. We have the case of physical restriction (literally not eating enough food) and mental restriction. Mental restriction is that tricky intersection where we can have food judgments, body judgments, fear of foods, residual diet thoughts, or arbitrary limitations on what is okay and what is too much. These mental restrictions unfortunately can be just as influential in feeling out of control around food as the physical restrictions. We also can use food to soothe, numb, or feel our emotions. People might binge to feel something when they otherwise feel numb, to feel numb when they are feeling too much, or to self-soothe when they are needing comfort. These mental drives for bingeing may still exist even after we address the undereating.
I can tell you that most of the people who come to me with a diagnosis of BED have absolutely no clue that they are restricting. They didn’t mention it to the healthcare provider who gave them the diagnosis and the healthcare provider didn’t ask. Which means that a lot of people with “BED” actually have a restrictive eating disorder with bingeing tendencies. My biggest issue with this is that this diagnosis almost exclusively is given to patients in larger bodies, but people in bigger bodies are just as likely to be restricting as anyone else. Maybe even more likely given that diet culture makes it everyone’s top priority to shrink your body. My second biggest issue is that bingeing is typically a scary behavior to my patients - it doesn’t align with the way they want to exist and it is oftentimes rooted in shame. Restriction usually feels like the “right” way to have an eating disorder - or even just the right way to feed yourself. So, when we give out a diagnosis like binge eating disorder without acknowledging the role and risk of restrictive behaviors in developing binge patterns, we are essentially agreeing that the worrisome aspect of the eating disorder is the bingeing.
Behaviors, signs, symptoms
To be diagnosed with binge eating disorder (BED) according to the DSM-5, the following criteria must be met:
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
A sense of lack of control with eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
The 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 feeling embarrassed by how much one is eating.
Feeling disgusted with oneself, depressed, or very guilty afterward.
Marked distress regarding binge eating is present.
The binge eating occurs, on average, at least once a week for 3 months.
The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors (e.g., purging) as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
Treatment
Treating binge eating disorder involves a lot of unlearning. Remembering that the root cause of the bingeing patterns is predominantly connected to restriction, we have to unlearn the dieting mentality that encourages restriction. We might need to explore the role of different macronutrients, micronutrients, fun foods, and convenience foods to be able to comfortably reintroduce them to the diet. Exposure to these foods that have been previously forbidden or restricted (and then subsequently binged), helps to facilitate the process of habitualization - the process by which repeated actions become a pattern and are seen as normal behavior. As we habitualize to previously off limit foods, we learn to eat in a way that is more intuitive and less chaotic. A dietitian may introduce a meal plan when someone has never had a healthy relationship with food to “get back” to, but for a person who previously had a positive relationship with eating they may not need as structured of guidance to get back on track. A meal plan is a tool to build trust between your mind and body. Having regular meals throughout the day, getting in enough energy and having variety and balance in food choices will help to re-establish eating cues for hunger and fullness and build comfortability with regular, appropriate nourishment.
It is unfortunately common that a person who binges has complete distrust for their body and eating. It is difficult to trust hunger and fullness cues, cravings, and desires when eating which means that we have to slowly work toward trusting the body to be on our side. It’s important to build self-efficacy and trust that we each have intrinsic knowledge about feeding ourselves in a compassionate, supportive way - without needing a dietitian to make all our food decisions for us! Meal plans should offer flexible structure to ensure you are eating throughout the day - not just sporadically. We learn so many disordered beliefs about food throughout our lives. Over time we develop sets of rules like when you are allowed to eat, how often you can eat certain foods, what foods are off limits, and where you are allowed to get food to eat. The team’s job is to help sift through these myths and challenge any disordered thoughts and encourage more nuance in food decisions.
It can be particularly helpful to participate in meals with the treatment team or even with groups. Meals with different themes or challenges can help bring up lingering biases or beliefs and help you explore them with others in the moment. It can also be incredibly healing to eat foods that you have believed are “bad” in front of others, working through the shame that has previously come up for you with a supportive group. Seeing a group of people eating normal, fun foods can also help to normalize the experience so the judgmental thoughts aren’t as severe.
Goals for Recovery
My favorite part of an initial session is asking what a person imagines for themself in recovery. I get a range of answers. Sometimes people are still very stuck in the disordered beliefs and their answers align mostly with their eating disorder. Other times people are already recognizing the unfulfilled promises of the eating disorder and are picturing a life without focus on weight and dieting. My role as a practitioner is to help facilitate the path to healing in a way that supports my client’s goals, values, and needs. The following goals are generally suitable and appropriate for anyone with an eating disorder, but someone may have more or fewer goals for themself depending on their own unique journey.
Overall, we need to resolve any restrictive eating practices to ensure adequate nourishment. If we aren’t meeting our needs, behaviors will continue and we start to risk poor health outcomes.
I want to make sure a client will walk away confident about their food preferences and the amount of variety in their diet. We each get to decide what our balance of fast food, restaurants, made-from-scratch, and convenience food looks like. Our lifestyles, preferences, kitchen skills, and budget will help influence what is reasonable on an individual basis.
I can all but guarantee a person struggling with bingeing has experienced some fatphobia in their life. Knowing this, it is particularly important to be talking about body image, a person’s body story, their relationship with exercise, and what it looks like to have a respectful and kind relationship with their body. If we can develop a positive relationship with the body that is fantastic, but body neutrality can be a really useful tool to take the pressure off of loving our bodies.
If an eating disorder is a coping skill, we know that we will always be experiencing things in our lives that require coping. This means that we will continually experience triggers to using behaviors and it can be incredibly useful to have awareness about what our triggers are and have a coping plan for how to deal with them when they come up. It isn’t reasonable to expect that recovery will be completely sunshine and rainbows forevermore, so building a toolbox of skills to use when life gets hard is an important and necessary part of the process.
I fully believe that awareness and understanding of the Health at Every Size principles is a key to supporting oneself in recovery and for advocating for good, appropriate care throughout life. Investing in your personhood as worthy of quality care, kindness, compassion, and positive experiences is a core aspect of long-term recovery.
An unconditional permission to eat food means that we are accepting that we may not always have an “answer” for why we are hungry or why we are craving a certain thing. Our permission to eat food is always there - when we need or want food, we have permission to have it. There are no rules for what is “too much” or “too high calorie” or “too frequent” for eating. Trusting ourselves and our bodies is a skill developed over time, but being able to believe in your body to look out for you and make sure you are adequately fed is an important task.
If you have binge eating disorder or are the caregiver to someone with BED, I hope this guide helps you in tailoring your treatment to your own needs and desires. I also hope it helps you in seeking out a professional to support you on your journey - ask questions and make sure the provider’s approaches are in line with your goals and needs. This is just an introduction to the basics of understanding and treating a complex mental and physical disorder. If you have more questions or want more information, please feel free to reach out via the comments or DM me!
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