Category: Eating Disorders

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BY: Anna Guerdjikova, PhD, LISW, CCRC, Lindner Center of HOPE, Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program University of Cincinnati, Department of Psychiatry, Research Assistant Professor

 

An estimated 45 million Americans diet each year and spend $33 billion annually on weight loss products. WebMD lists over 100 different diets, starting with the African Mango diet, moving on to the South Beach and Mediterranean diets and ending up with the Zone. Most diets, regardless of their particular nature, result in short-term weight loss that is not sustainable. Weight cycling or recurrent weight loss through dieting and subsequent weight gain (yo-yo effect) can be harmful for mental and physical health for both healthy weight and overweight individuals. Furthermore, weight fluctuations have been related to increased risk of development of cardiovascular disease, Type 2 diabetes, and high blood pressure.

What is Dieting

The word “diet” originates from the Greek word “diaita”, literally meaning “manner of living”. In the contemporary language, dieting is synonymous with a quick fix solution for an overwhelming obesity epidemic. Dieting implies restriction, limitation of pleasurable foods and drinks, and despite of having no benefits, the omnipresent dieting mentality remains to be the norm.

Most diets fail most of the time. Repeated diet failure is a negative predictor for successful long term weight loss. Chronic dieters consistently report guilt and self-blame, irritability, anxiety and depression, difficulty concentrating and fatigue. Their self-esteem is decreased by continuous feelings of failure related to “messing my diet up again”, leading to feelings of lack of control over one’s food choices and further … life in general. Dieting can be particularly problematic in adolescents and it remains a major precursor to disordered eating, with moderate dieters being five times more likely to develop an eating disorder than those who do not diet at all.

Diets imply restriction. Psychologically, dietary restraint can lead to greater reactivity to food cues, increased cravings and disinhibition, and overeating and binge eating. Biologically, dieting can lead to unhealthy changes in body composition, hormonal changes, reduced bone density, menstrual disturbances, and lower resting energy expenditure.

The Potential Harmful Effects of Dieting

Aggressive dieting lowers the base metabolic rate, meaning one burns less energy when resting, resulting in significantly lower daily needs in order to sustain achieved weight after the diet is over. Returning to normalized eating habits at this lower base metabolic rate results in commonly seen post dieting weight gain. Biologically, dieting is perceived as harmful and physiology readjusts trying to get back to initial weight even after years since the initial rapid weight loss. Recent data examining 14 participants in the “Biggest Loser” contest showed they lost on average 128 pounds and their baseline resting metabolic rates dropped from 2,607 +/-649 kilocalories/ day to 1,996 +/- 358 kcal/day at the end of the 30 weeks contest. Those that lost the most weight saw the biggest drops in their metabolic rate. Six years after the show, only one of the 14 contestants weighed less than they did after the competition; five contestants regained almost all of or more than the weight they lost, but despite the weight gain, their metabolic rates stayed low, with a mean of 1,903 +/- 466 kcal/day. Proportional to their individual weights the contestants were burning a mean of ~500 fewer kilocalories a day than would be expected of people their sizes leading to steady weight gain over the years. Metabolic adaptation related to rapid weight loss thus persisted over time suggesting a proportional, but incomplete, response to contemporaneous efforts to reduce body weight from its defined “set point”.

Dieting emphasizes food as “good” or “bad”, as a reward or punishment, and increases food obsessions. It does not teach healthy eating habits and rarely focuses on the nutritional value of foods and the benefit of regulated eating. Unsatisfied hunger increases mood swings and risk of overeating. Restricting food, despite drinking enough fluids, can leads to dehydration and further complications, like constipation. Dieting and chronic hunger tend to exacerbate dysfunctional behaviors like smoking cigarettes or drinking alcohol.

Complex entities like health and wellness cannot be reduced to the one isolated number of what we weigh or to what body mass index (BMI) is. Purpose and worth cannot be measured in weight. Dieting mentality tempts us into “If I am thin- I will be happy” or “If I am not thin-I am a failure” way of thinking but only provides a short term fictitious solution with long term harmful physical and mental consequences. Focusing on sustainable long term strategies for implementing regulated eating habits with a variety of food choices without unnecessary restrictions will make a comprehensive diet and maintaining healthy weight a true part of our “manner of living”.

 

Reference: Obesity (Silver Spring). 2016 May ;Persistent metabolic adaptation 6 years after “The Biggest Loser” competition.; Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, Chen KY, Skarulis MC, Walter M, Walter PJ, Hall KD.

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By: Heather Connor, LISW-S

At times it can feel like it’s impossible to have a positive relationship with our body image. We are inundated with ads that encourage us to lose weight via this supplement or that diet/wellness program, guaranteed to give you results. Diet Culture is a multibillion-dollar industry and it’s been around for generations. However, a fact to consider is that diets do not work. In a large-scale 2015 study of 278,000 people, it showed within 5 years, 95-98% regained all the lost weight (or more) (Fildes et al, 2015). Diets are designed to fail and instead of taking responsibility for that failure, they turn the blame onto the dieter. The reality too, is that even when the weight is lost, most of us still don’t feel confident in our bodies. Fatphobia is a driving force for the diet culture industry. The more afraid we are of fat bodies, the more we subscribe and pay into the thin ideal. Fatphobia is woven into the fabric of our culture, and it’s become so commonplace, we may not even notice when it’s present. For years we have rarely seen fat bodies on television or in ads and when we do, these characters are shown as the butt of the joke, the silly friend, or the lazy one who is always eating but almost never the main character or the one who finds love. We live in a world in which certain seats or devices do not accommodate larger bodies. We have until very recently, forced those in larger bodies to shop at specialty stores or online for clothes that can accommodate their size.

 

It’s become commonplace to gab to our friends about which “program” we are trying this week and we might even find community in joining along. We regularly talk negatively about our bodies or praise others for looking “great” after some noticeable weight loss without stopping to consider how this weight loss was achieved. We make unprovoked comments about other people’s bodies and children and even adults are often bullied relentlessly if they exist in a larger body. And with each time we make these comments we reinforce the narrative again and again that fat is bad and thin is the goal.

And it’s not just our culture that contributes to our unhappiness with our bodies. With our healthcare system waging war on obesity, it’s no surprise that many of us will search out any means to lose weight in the name of health. The BMI continues to be used to determine who is at risk even though BMI only accounts for our height and weight and no other measurement of health. While thin is often promoted at “healthy” for a large portion of the population, working tirelessly to achieve this goal, is anything but health-promoting. If we consider the steps we often take to achieve the thin ideal, we have to acknowledge that most of these involve hurting our bodies. These include everything from denying ourselves basic needs like nutrition to invasive surgeries, all in the name of health. Not to mention the shame and ridicule we often experience not only from others but from our own internal dialogue as well.

“While it is well established that obesity is associated with increased risk for many diseases, causation is less well-established. Epidemiological studies rarely acknowledge factors like fitness, activity, nutrient intake, weight cycling, or socioeconomic status when considering connections between weight and disease. Yet all play a role in determining health risk. When studies do control for these factors, increased risk of disease disappears or is significantly reduced.” (Bacon & Aphramor, 2011) In other words, living in a larger body does not automatically mean that one is “unhealthy”.

While we are on the topic of health, let’s also consider that dieting is a major risk factor for the development of eating disorders. The National Association of Anorexia Nervosa and Associated Disorders (ANAD) reports that 9% of the US population will develop an eating disorder in their lifetime and only 6% of those who are diagnosed are considered “underweight”. Eating disorders also have the highest mortality rate of all other mental health disorders, 2nd only to opioid overdoses and this is true for people, regardless of their size.

As a result of these experiences, we all have certain internalized biases surrounding weight which also contribute to our body image. We might make assumptions of someone’s health, intelligence, willpower, or overall lifestyle based solely on their body shape and size. The reality is however that we cannot determine any of these above traits just by looking at someone.

So if we can accept that all bodies are not meant to be thin and thinness does not equal health, then perhaps we could forge a different relationship with our bodies. When we focus on listening to our bodies instead of on external rules, we naturally lean into behaviors that are health promoting. Such behaviors include eating a variety of foods, engaging in joyful moment, and practicing a relationship with our bodies that prioritizes taking care of ourselves in the way we might care for a good friend. When we are not focused on losing weight, we are able to make decisions based on trust and our own internal wisdom.

The following are some strategies one might consider to begin the journey of moving away from diet culture and fatphobia and into a place of peace, trust, and an overall more friendly relationship with our bodies.

  1. Grieve the “ideal” body. In order to improve your relationship with your body, we have to first begin to let go of the “ideal” and accept the wonderful body you have. This may involve some of the phases of grief such as denial, anger, bargaining, and depression, before achieving acceptance.
  2. Ditch the negative self-talk. Every time you notice yourself calling yourself names and making negative comments about your appearance, stop, put your hand on your heart, and give yourself a compliment, body-focused or otherwise. You might even consider writing a few compliments down and posting them up as easy reminders that you are more than your body. A good rule of thumb here is begin to talk to yourself in the same manner you would a good friend.
  3. Practice Body Gratitude. Take 5 minutes each day, find a quiet place, close your eyes, and scan down through your body. Notice any sensations, thoughts, or feelings that you notice as you bring awareness to your body. If you are finding a lot of negative energy around one or more parts of your body, begin to shift that focus to what that part of your body does for you. Begin relating to your body as a good friend who trying to take care of you.
  4. Listen to your body and start rebuilding body trust. Start making it habit to begin to check in with your body regularly. This is a practice that is often lost for those that have been chronic dieters because dieting relies on rules rather than our body for what we can eat or how to move. As you check in, begin to respond according to your body’s signals such as eating when you are hungry, moving when you feel restless, or resting when you are tired.

If you continue to struggle with your relationship with your body, consider talking to a therapist who has experience with body image and who is familiar with Health At Every Size (HAES) or the practice of Intuitive Eating in order to help guide you even further in your journey towards body acceptance.

References:

Anorexia Nervosa and Associated Disorders (n.d.) Eating Disorder Statistics. https://anad.org/eating-disorders-statistics/

Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10, 9.

Fildes, A., Charlton, J., Rudisill, C., Littlejohns, P., Prevost, A.T., &Gulliford. M.C. (2015). Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. Am J Public Health, 105, 9, e54-9. doi: 10.2105/AJPH.2015.302773. Epub 2015 Jul 16. PMID: 26180980; PMCID: PMC4539812

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One of the greatest challenges in the treatment of bipolar disorder (BD) is the significant weight gain associated with psychotropic medications.  Mood stabilizer medications with antimanic activity, which include lithium, valproate as well as atypical antipsychotics, remain the mainstay of treatment despite being associated with different degrees of significant weight gain.  This is particularly notable for antipsychotic medications, which are furthermore associated with metabolic disturbances.  Accelerated weight gain is concerning because it is associated with increased cardiovascular risk, and particularly important in patients with BD because of their increased risk for cardiac and metabolic disease.  Furthermore, excessive weight gain is distressing and often plays a role in dissatisfaction with treatment and early discontinuation.  A growing body of evidence suggests that weight gain, weight cycling, and central obesity are linked with exacerbation of bipolar symptoms and less favorable course of illness.  A comprehensive treatment plan for bipolar disorder should include interventions to prevent or mitigate excessive weight gain.  Let’s examine the available options and identify areas for further research.

Until recently, interventions for weight gain were mostly limited to lifestyle interventions.  Inactivity and dietary choices are significant contributors to metabolic abnormalities seen in patients with BD, and although dietary and lifestyle changes have the potential for improving the overall quality of life, the results from these interventions often fail to keep up with the accelerated weight gain seen with psychotropics.  Clinicians have also attempted to select medications with lesser potential for metabolic dysfunction and increased appetite, but this is not always a viable option.  Bariatric surgery has the greatest potential impact as an intervention for obesity in BD.  Although there is evidence that weight loss resulting from bariatric surgery is associated with improvements in mood, there is no data specific to patients with BD and this is only an option for stable, euthymic patients.

The use of off-label adjunctive medications for mitigating weight gain has had mixed results:  Weight mitigation has been modest, efficacious medications have produced significant adverse events leading to discontinuation or the cost to the patient has been prohibitive. Topiramate and zonisamide are antiepileptic drugs with data suggesting efficacy in weight mitigation.  Topiramate has shown significant efficacy in weight mitigation (3.1kg over 6-26 week, according to a meta-analysis), but it is poorly tolerated and is associated with significant cognitive adverse events and paresthesia.  The estimated cost for a month’s supply of topiramate ranges from $40-$250.  Data suggest that zonisamide also has a significant effect on weight gain mitigation with similar, but milder adverse events.  Opioid receptor antagonists like naltrexone and samidorphan have demonstrated modest efficacy in mitigating weight gain associated with olanzapine.  Samidorphan, the best-studied opioid antagonist, is associated with modest weight mitigation (1kg with olanzapine), is well-tolerated and is available on the market as part of a proprietary combination with olanzapine with an estimated cost of $1000/month.

Antidiabetic drugs like metformin and glucagon-like peptide-1(GLP-1 RA) receptor agonists have  potential for weight mitigation and improvement of metabolic parameters such as dyslipidemia and insulin resistance.  Metformin is a popular option for medication-induced weight gain.  In patients treated with atypical antipsychotics, the estimated weight mitigation with metformin is 2-3kg and it is generally, well-tolerated.  The average estimated monthly cost of Metformin ER 2000mg/daily ranges from $27 to $50.  GLP-1 RAs and similar drugs have the potential for significant mitigation of weight gain associated with psychotropics, and in some cases, weight loss.  These drugs are better tolerated than topiramate but additional research on the effects of these drugs on patients with BD is needed to determine efficacy and safety.  GLP-1 RAs decrease glucagon secretion, have the potential for decreasing insulin resistance and delay gastric emptying, therefore decreasing appetite.  In addition, GLP-1 RAs have been shown to improve glucose regulation, lipid levels, and reduce cardiovascular risk.  Although GLP-1 agonists have demonstrated effectiveness in inducing weight loss and improving metabolic parameters in type 2 diabetes mellitus and obesity, data shows that only 10% patients eligible for treatment do not take these medications due to the high cost.

As we have seen, there are a few options for treatment of excessive weight gain associated with psychotropics, which can be used in addition to lifestyle interventions.  Limitations the modest results seen with some interventions, intolerable adverse events with more effective options or high cost.  Additional, affordable treatment options are needed.

For more information about Bipolar Disorder research at the Lindner Center of HOPE:

https://lindnercenterofhope.org/research/clinical-trials/#1619574722103-ad16b647-fc35

Works consulted:

Laguado SA, Saklad SR. Opioid antagonists to prevent olanzapine-induced weight gain: A systematic review. Ment Health Clin. 2022 Aug 23;12(4):254-262. doi: 10.9740/mhc.2022.08.254. PMID: 36071739; PMCID: PMC9405627.

Mangge H, Bengesser S, Dalkner N, Birner A, Fellendorf F, Platzer M, Queissner R, Pilz R, Maget A, Reininghaus B, Hamm C, Bauer K, Rieger A, Zelzer S, Fuchs D, Reininghaus E. Weight Gain During Treatment of Bipolar Disorder (BD)-Facts and Therapeutic Options. Front Nutr. 2019 Jun 11;6:76. doi: 10.3389/fnut.2019.00076. PMID: 31245376; PMCID: PMC6579840.

Wang Y, Wang D, Cheng J, Fang X, Chen Y, Yu L, Ren J, Tian Y, Zhang C. Efficacy and tolerability of pharmacological interventions on metabolic disturbance induced by atypical antipsychotics in adults: A systematic review and network meta-analysis. J Psychopharmacol. 2021 Sep;35(9):1111-1119. doi: 10.1177/02698811211035391. Epub 2021 Jul 27. PMID: 34311625.

 

By Nicole Mori, RN, MSN, APRN-BC, Lindner Center of HOPE Psychiatric Nurse Practitioner

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Elizabeth Mariutto, PsyD, CEDS

 

 

 

 

When the average person is asked to describe eating disorders, body image concerns are one of the most identified symptoms.  However, not everyone with an eating disorder struggles with body image.  Those with Avoidant and Restrictive Food Intake Disorder (ARFID) avoid or restrict certain foods, but do not do so out of fear of weight gain, desire to lose weight, or body dissatisfaction. Instead, those with ARFID limit their eating based on sensory features of the food, fear of something bad happening when one eats, or a lack of interest in eating (Thomas & Eddy, 2019).

However, ARFID is more than picky eating. Those with ARFID are highly selective in what they eat, and this selectivity leads to some type of impairment in their lives (American Psychiatric Association, 2013). Children or teenagers may not grow as expected, leading to pediatricians being concerned that they have not followed the typical growth curve that had been evidenced earlier in their lives. Those with ARFID may lose a significant amount of weight unintentionally. Others end up needing to rely on oral supplements or nasogastric tube feedings to get in sufficient energy, and those with ARFID may display nutritional deficiencies.  Additionally, many with ARFID struggle socially (American Psychiatric Association, 2013). Many get-togethers, holidays, and celebrations with family and friends revolve around food, which can be anxiety and shame-inducing for those that eat more selectively, often leading to avoidance of such social gatherings and consequently, problems in relationships.

The same factors that lead to the onset of ARFID are worsened by its symptoms, which creates a cyclical pattern. Those who develop ARFID may experience more intense sensory experiences (Thomas & Eddy, 2019). They may be more sensitive to textures and/or may be a “supertaster” and pick up on more subtle variations of flavor than others. However, eating the same few foods repeatedly can lead to sensory-specific satiety, leading to those few foods becoming more aversive with time. Furthermore, if nutritional deficiencies develop, the taste of new foods can be altered, thus leaving someone to feel they have very few tolerable options. Others with ARFID may start out simply not having much interest in eating. When they eat less as a natural result, their fullness cues start kicking in prematurely and hunger cues dissipate, leading to eating even less.  Lastly, those who develop ARFID after having some type of aversive experience around food (i.e., choking) start to avoid the food that led to the negative experience hoping to avoid the same event. This expands into avoidance of similar foods as well.  The avoidance of these foods reinforces the fear, as these individuals do not have recent fear-countering experiences to teach them that they can safely consume these foods. Avoidance leads to increased anxiety, making the fear more entrenched.

ARFID treatment approaches resemble those for other forms of eating disorders but may include some modifications that more closely resemble the exposure treatment that is often used for obsessive compulsive disorder and anxiety disorders.  A treatment provider will likely do a thorough evaluation and case formulation of what factors need addressed in treatment.  First and foremost, patients may require medical stabilization to manage any of the acute health concerns that have risen with malnutrition.  Second, to prevent further medical problems from occurring and to begin the process of nutritional stabilization, clients often need to increase the overall volume of food.

There has not been much research on treatment for ARFID, although a modified version of cognitive behavioral therapy, CBT-AR, is being researched for ARFID and is showing promise (Thomas et al., 2020; Thomas et al., 2021). CBT-AR pulls from existing eating disorder, obsessive compulsive disorder, and anxiety disorder treatments and extensively educates the patient on how the disorder develops and is maintained, nutritional deficiencies and the importance of volume and variety, then gradually helps patients expose themselves to the foods that they have been avoiding (Thomas & Eddy, 2019).  Furthermore, Family-Based Treatment, which is a front-line treatment for adolescents with eating disorders, has been recently modified to address ARFID more specifically, also showing promising results (Lock, Sadeh-Sharvit, & L’Insalata, 2019). This treatment, which addresses the eating behaviors directly and conveys the seriousness of the eating disorder, empowers parents to refeed their child, takes a non-blaming approach to the illness, and helps parents and patients separate the illness from their identity (Lock et al., 2018).

Getting professional support can help patients with ARFID improve medically, nutritionally, psychologically, and socially. While therapists can provide support and teach specific techniques, the patient ultimately has a significant say into what foods to incorporate, when, and how.  With persistence, those with ARFID can eat with much greater variety and flexibility.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.

Lock. J., Robinson, A., Sadeh-Sharvit, S., Rosania, K., Osipov, L et al. (2018). Applying family-based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa. International Journal of Eating Disorders, 52, 439-446. doi: 10.1002/eat.22994

Lock, J., Sadeh-Sharvit, S., L’Insalata, A. (2019). Feasibility of conducting a randomized clinical trial using family-based treatment for avoidant/restrictive food intake disorder. International Journal of Eating Disorders, 52, 6, 746-751. doi: 10.1002/eat.23077

Thomas, J. J., Becker, K. R., Kuhnle, M. C., Jo, J. H., Harshman, S. G. et al (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder (CBT-AR): Feasibility, acceptability, and proof-of-concept for children and adolescents. International Journal of Eating Disorders, 53, 10, 1636-1646. doi: 10.1002/eat.23355

Thomas, J. J., Becker, K. R., Breithaupt, L., Burton Murray, H., Jo, J. H., et al. (2021). Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder. Journal of Behavioral and Cognitive Therapy, 31, 1, 47-55. doi: 10.1016/j.jbct.2020.10.004

Thomas, J. J., & Eddy, K. T. (2019). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Cambridge: University Printing House.

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Julie Foster, LISW-S, RN, MEd

There are many types of eating disorders. The most commonly talked about eating disorders are anorexia nervosa, bulimia nervosa, binge-eating disorder, and avoidant restrictive food intake disorder. National Eating Disorders Awareness Week (NEDAW) is an observance to bring awareness to the seriousness of eating disorders across the United States. It is estimated that over 28 million Americans will have an eating disorder in their lifetime. (https://www.womenshealth.gov/nedaw).

So, what can employers and leaders do to help?

Fatphobia and body shaming are so woven into our workplaces that often it goes unchecked. In fact, it is a microaggression normalized by “wellness” programs in the workplace that encourage weight and calorie tracking, weight loss incentives, and “Biggest Loser” competitions.

There is “evidence that weight stigma is a bigger risk to people’s health than weight itself and what they eat.” (Harrison, 2021)

Weight-loss challenges can actually be one manifestation of a hostile work environment.

And anyway, dieting does not work! 95% of those who diet may lose weight in the short term, but they gain that weight back and more within 1 to 5 years. (Fildes et al., 2015)

Instead of weight loss competitions, how about implementing “No diet/body talk zones” and including weight discrimination in workplace diversity and inclusion efforts. Workplace leaders can start to change the office culture by modeling zero tolerance for body shaming and also by  supporting employees who are actively fighting against diet culture. Leaders can fight weight discrimination by examining their hiring practices and normalize not just Health at Every Size (HAES) but also leaning into the truth that size has no bearing on one’s intelligence or work ethic.

How can you shut down body-shaming? Start with yourself. What kind of things do you say, out loud, at work, about your body and what you are, and are not, eating? Change the narrative and speak up when others are making fatphobic comments. What others are eating or not eating is no one’s business. Commenting on someone’s weight in any fashion is not appropriate any more than commenting on anything else about their body.

You wouldn’t agree with   a colleague  making racist or homophobic remarks, so the same should be true if employees are body shaming. Here’s how you could respond:

“Why would you think it’s okay to say something fatphobic like that?” Or, “Why do you think it’s okay to discuss ______’s body?”

Another important part of creating a body-size inclusive culture is to conduct a physical audit of your environment. Are there chairs and workstations to accommodate all sizes of bodies? Are your waiting areas or lobbies welcoming to all sizes of bodies? Do your vending machines sell regular and low-calorie drinks for the same price?

Just like “love is love”, “food is food.” Food is neutral, not good or bad. What you eat does not define you as good or bad or qualify as being good or bad. And it’s no one’s business what or how much someone else is eating, so request employees keep their commentary (which is probably related to their own insecurities) to themselves. It is important for leadership to recognize that it is likely that a percentage of their workforce has, or has had, and eating disorder, and comments about food and size can be very triggering for them. What might seem like a neutral comment (“I can’t believe how bad I was! I ate that whole piece of cake!”) reinforces to someone with an eating disorder that food and eating is bad or shameful.  Or talking about how you haven’t eaten all day as some badge of honor reinforces to others that they are somehow weak or wrong for eating regularly.

It is also important to remember that an eating disorder is a disability, therefore the Equality Act 2010 applies. Eating disorders are the most lethal of all mental illnesses. Managers and colleagues should be aware that individuals with eating disorders, as with any long-term health condition, may have changes their performance.

Reasonable adjustments for those suffering with an eating sidorder could include: flexibility in allowing time off for appointments, working hours or extended lunch or other breaks, consideration of factors such as a place to eat in private or avoiding lunch meetings or other work events involving eating socially.

Compliment people without bringing their weight or bodies into it. Find ways to bond, connect and have conversations with people in the workplace that do not involve food, bodies, or weight loss.

Encourage movement for fun, for change of scenery, for better productivity. Play music, normalize dance breaks.

Why not create a routine where everyone has the opportunity to  get up from their desk at least once every hour and takes a 2 minute walk. But avoid tracking steps or putting a lot of emphasis on competition.

The best way for people to be released from diet culture is to have a community of support. The workplace can become a safe space. If you are concerned an employee may have an eating disorder, there is help at the Lindner Center of Hope 513-536-HOPE.

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Binge eating disorder (BED) is the most prevalent eating disorder but remains largely undiagnosed and untreated.  BED is characterized by recurrent episodes of loss of control and consumption of unusually large amounts of food within a short period of time (<=2h).  Episodes are associated with significant emotional distress but are not followed by purging behaviors (vomiting, misuse of laxatives, etc.), which differentiates BED from Bulimia Nervosa.  In addition to psychological distress, BED is associated with medical complications including accelerated weight gain, metabolic abnormalities, functional impairment, and decreased quality of life.  Untreated BED leads to worse clinical outcomes in a variety of medical and psychiatric conditions and poor treatment response in hypertension, diabetes, dyslipidemia, and obesity, which are commonly seen in primary care.  Patients with BED stand to benefit from increased screening, diagnosis, and treatment, particularly patients with type 2 diabetes mellitus (T2DM).

Screening for BED is particularly important in patients with T2DM.  While the prevalence of BED in the general population is estimated around 3%, prevalence is significantly higher in T2DM, where the prevalence of BED is estimated around thirteen times higher than in the general population.  In fact, eating disorders are frequently encountered among patients with T2DM, with prevalence estimated around 20%.  Diagnosis and treatment are important because the presence of binge eating greatly complicates management and is associated with worsened outcomes such as impaired glycemic control, dyslipidemia, and accelerated weight gain.  BED is associated with decreased response to weight loss interventions (including dietary and bariatric surgical procedures), impaired glycemic control, dyslipidemia, and exacerbation of insulin resistance.  Moreover, common pharmacotherapies for diabetes (such as insulin, sulfonylureas, and dietary restraint) have been implicated in the exacerbation of binge eating.

As we have seen, BED is a barrier to achieving treatment goals in T2DM.  It is important to take binge eating into account when selecting treatment.  Reducing the frequency and severity of binge eating can facilitate the achievement of treatment goals in T2DM.  Primary care providers manage most patients with T2DM, but screening and management of BED is still overlooked.  It is necessary to treat patients to decrease the frequency and severity of binge eating to help patients achieve treatment goals for diabetes.  Optimal outcomes in treatment are not possible with untreated BED.  Primary care providers face the challenge of identifying and initiating treatment for this population with complex needs.

Even though BED is an important comorbidity in T2DM, significant barriers to diagnosis and treatment persist.  First, eating disorders are associated with significant stigma and patients may not readily disclose disordered eating behaviors due to shame.  In many cases, patients are aware that some of their eating behaviors are abnormal, but they do not know that they are suffering from a treatable eating disorder.  In addition, primary care providers may overlook binge eating as a possible factor when patients fail to achieve treatment goals despite intensification of treatment.  In addition, primary care providers face time and financial constraints which limit their ability to diagnose, refer and treat.  Finally, there are not enough trained clinicians who can offer specialized medication management, dietary counselling, and psychotherapy for BED.  Medication options are still limited to an FDA approved agent (lisdexamphetamine), plus a couple of drugs used off-label.  However, providers still have options to start addressing the needs of patients with T2DM and BED, including:

Further research is needed to understand the needs of patients with comorbid T2DM and BED as well as to develop treatments to lessen the occurrence of binge eating episodes clinical care guidelines.

The Research Institute at the Lindner Center of HOPE is conducting a clinical trial of an experimental medication for Binge Eating disorder.  No prior diagnosis is required.  For additional information, contact us at 513-536-0700 or visit:  https://redcap.research.cchmc.org/surveys/?s=TP3C4TEA8J

Bibliography

Harris SR, Carrillo M, Fujioka K. Binge-Eating Disorder and Type 2 Diabetes: A Review. Endocr Pract. 2021 Feb;27(2):158-164. doi: 10.1016/j.eprac.2020.10.005. Epub 2020 Dec 13. PMID: 33554873.

Keshen A, Kaplan AS, Masson P, Ivanova I, Simon B, Ward R, Ali SI, Carter JC. Binge eating disorder: Updated overview for primary care practitioners. Can Fam Physician. 2022 Jun;68(6):416-421. English. doi: 10.46747/cfp.6806416. PMID: 35701190; PMCID: PMC9197289.

Winston AP. Eating Disorders and Diabetes. Curr Diab Rep. 2020 Jun 15;20(8):32. doi: 10.1007/s11892-020-01320-0. PMID: 32537669.

Nicole Mori, RN, MSN, APRN-BC, Lindner Center of HOPE Psychiatric Nurse Practitioner

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By: Annie Ward, MSN, PMHNP-BC
Psychiatric Nurse Practitioner, Lindner Center of HOPE

When we think of eating disorders, our society tends to think of individuals in emaciated bodies. Disordered eating is more common than not, and does not discriminate against body size, gender or race. The line between dieting and disordered eating is blurred in our society. There are narratives tightly woven into our culture which lead to disordered eating habits being encouraged, and unfortunately often praised. Sadly, they are only acknowledged as problematic when the physical manifestations become unignorable and when they can no longer be labeled under the guise of “healthy diets”.

One of the most common disordered eating patterns that I encounter in clients (whether they are seeking help for an eating disorder or not) is the binge-restrict cycle. This pattern can start with either binge eating or restricting. Essentially, when we restrict nutrition, our bodies increase our hunger cues as they search for sustenance, to alert you that your body needs food. This can often end up in a binge-eating episode which involves eating a large quantity of food while feeling out of control. Unfortunately, the feeling of lack of control often results in shame, which may then lead to subsequent restriction of nutrition. This may be due to feeling full after a binge or primarily due to shame, but unfortunately fuels the cycle of binge-eating and restricting.

It can be helpful to think about how this cycle was useful for our hunter and gatherer ancestors. They may have gone several days without food, and when they found it, the body wanted to obtain as much nutrition possible, because it didn’t know how long it would have to survive without food again. Their bodies pumped out hunger hormones to protect them and sustain them. Your body works the same way– it cannot identify why it is not getting food. I hope that you wouldn’t expect our ancestors to feel shameful for eating more when they found food- and hope this helps you understand why you should not feel shameful for eating more after a period of restrictive eating. Additionally, our bodies have natural weight settling points and when we restrict, to conserve the energy we have, we slow down our metabolism to conserve resources. This is one reason why diets are overwhelmingly unsuccessful.

In order to learn what your body needs and wants, one of the best things that you can do for yourself is structure regular nutrition throughout the day- regardless of what your eating looked like the day before. Our society certainly defaults to making us believe that we should eat less if we “overdid it” the day before, but this is simply not true. Your body needs and deserves consistent nutrition every day.

If you struggle with fatigue, poor concentration, mood swings, headaches or lightheadedness—these are a few of the ways that inadequate nutrition can present. They can present quickly after your body realizes it needs more fuel, and may not get better until your body can trust that you will consistently give it the nutrition it needs. I would encourage you to explore your relationship with nutrition and how it may be affecting you physically— and mentally.

What should we learn from this? 

  1. If you feel you ate too much of a meal or snack, you should forgive and forget. You deserve to eat all meals and snacks the next day. Returning to a consistent pattern of nutrition will help break the binge-restrict cycle.
  2. Our society promotes “health” but this often gets twisted into unhealthy recommendations which can lead to the binge-restrict cycle. This can then lead to guilt, shame, and eating disorders. Be wary of “healthy” diets.
  3. Consistent nutrition is self-care, and it is not helpful to use nutrition as a form or judgment of self-control

If you are struggling with this, reach out for help with an eating disorder specialist who is knowledgeable about Health at Every Size- you do not have to look a certain way to have an eating disorder or be “sick enough” to get help

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The role of the circadian system in obesity and disordered eating

By Nicole Mori Psychiatric Mental Health Nurse Practitioner

The circadian system is the body’s endogenous timekeeper, a network of hierarchically-organized structures (“clocks” or “oscillators”) in nucleated cells, which regulates a variety of biological processes (including the cell cycle, metabolism, growth, development and sleep/activity cycles) by generating outputs in a rhythmical manner. The suprachiasmatic nucleus (SCN) in the hypothalamus acts as the “master” pacemaker by generating periodic outputs targeting clocks in peripheral cells. The endogenous SCN period is greater than 24 hours, but it resets every day in response to environmental signals.  The main  synchronizer for the SCN is the periodical light/dark signal over the course of 24 hours.  Additional environmental synchronizers include feeding and social activity.  The circadian system enables  organisms to adapt to environmental changes and optimize function, playing a central role in the maintenance of health and illness.  Research has linked circadian dysregulation to a variety of disorders including cancer, cardiovascular disease, metabolic abnormalities and obesity in humans and animals.

Recent studies support the role of circadian dysfunction in the development and maintenance of obesity.  Circadian misalignment can manifest as metabolic abnormalities, sleep disturbances, delayed sleep phase (evening preference), abnormalities in daily rest/activity rhythms and disordered eating patterns. Both endogenous (e.g., genetic) and exogenous factors are involved in circadian dysfunction. External factors include decreased sleep duration, jet lag, frequent snacking and nighttime eating and exposure to bright light. Epidemiological data show shift work is an independent risk factor for obesity and increased metabolic risk. Decreased sleep duration is associated with increased risk for obesity and metabolic disease. Among children, sleep loss is associated with the development of obesity and is a predictor of lifelong obesity. The increasing prevalence of obesity in recent decades has coincided with trends such as shortened sleep duration, light pollution, increased nighttime exposure to bright light and increasing shift work.

Sleep pattern changes affect appetite and eating behaviors and vice versa. Sleep restriction has been associated with changes in circadian hormonal patterns, which result in increased appetite, hunger and food choices such as increased preference for sweets.  In turn, alterations in eating patterns have a dysregulating effect on the circadian system. For instance, overeating has been associated with decreased sleep duration, high dietary fat and carbohydrate intake with decreased short wave sleep and high increased nighttime arousal respectively.

The timing of food consumption plays an important role in metabolism and body weight. Nighttime eating leads to increased insulin resistance and worsened glucose tolerance and lipid levels than meals consumed during the daytime. Among bariatric patients, eating late in the day has been associated with less post-operative weight loss.  In addition, irregular eating patterns are associated with abnormal weight gain, increased binge eating and greater eating disorder severity. Conversely, appropriate timing of eating and regularization of meal times appear to have a beneficial effect. Animal studies show that time restricted feeding (limiting feedings to a timeframe appropriate to the species’ diurnal/nocturnal pattern) is associated with decreased obesity. Among humans, an app study showed an association between time-restricted feeding and sustained weight loss.

As we have seen, the regulation of metabolism and body weight appear to depend on the optimal function of the circadian system, which requires appropriately timed exposure to synchronizing stimuli. Interventional studies suggest that manipulation of synchronizers may be beneficial in treating disordered eating behaviors, metabolic abnormalities and obesity. Potential interventions for circadian dysfunction would optimize the timing of synchronizers (such as bright light therapy, timing of food intake and time-restricting feeding), regularize rest/activity circadian rhythms (by increasing regular exercise, maintain a consistent waking up schedule), or the administration of medications according to circadian phase. The treatment of circadian dysfunction promises improved outcomes in the prevention and treatment of obesity, but further research is needed.  New technologies and methods will enable a thorough characterization of circadian function is obesity and eating disorders and determine whether the circadian system is a potential target for chronotherapeutic interventions.

The Lindner Center of HOPE is conducting a comprehensive study of circadian function in adults with obesity with and without binge eating disorder.  For more information, contact Brian or George at (513) 536-0707 or visit http://www.lcoh.info

Bibliography

Broussard, J. L., & Van Cauter, E. (2016). Disturbances of sleep and circadian rhythms: novel risk factors for obesity. Current opinion in endocrinology, diabetes, and obesity, 23(5), 353-359.

Garaulet, M., Gómez-Abellán, P., Alburquerque-Béjar, J. J., Lee, Y. C., Ordovás, J. M., & Scheer, F. A. (2013). Timing of food intake predicts weight loss effectiveness. International journal of obesity, 37(4),
604-611.

self-esteem and self-worth in our youth will bring about numerous long-lasting, positive changes that Cupid’s arrow could only dream of creating.

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By Elizabeth Mariutto, PsyD, CEDS, Clinical Director of Eating Disorder Services

“How do I encourage mindful eating for my kids?” I often have patients come in with histories of well-intended parents who promoted diets or restrictive eating in the attempts to help their kids become “healthy.” When they come to me to rewire their brains against the diet culture so prevalent in our society, they feel like they don’t know where to start in promoting more beneficial attitudes towards food in their own kids. Here are ten tips for promoting positive food habits in kids.

  1. Set up your home to promote balanced nutrition. Buy a variety of produce, serve meals with a balance of proteins, fats, and carbohydrates, and while you can definitely have some sweets and packaged snack foods, having too many of these options can lead to turning to these items often. Serve unfamiliar foods with familiar foods, and introduce new foods multiple times. Encourage family mealtimes at the table without electronics.
  2. Allow them to trust their bodies. Think about how we feed babies and small children. Every 3 to 4 hours, they cry and tell us they are hungry. We feed them until they stop eating. If children tell you they are full after a meal, don’t force them to finish their plate. This only teaches them that it’s pointless to follow hunger and fullness cues.
  3. Avoid labeling foods as “good” or “bad” or “healthy” or “unhealthy.” Avoid overtly controlling food messages, such as putting pressure on kids to eat fruits and vegetables or telling them they can’t have sweets, as these practices lead to unhealthy eating habits for kids (Scaglioni, Arrizza, Vecchni, & Tedeschmi, 2011).
  4. Serve items for meals that you would like kids to eat at regular times, making sure there is something you know they like on the table. Don’t worry about what they end up choosing to eat.
  5. Avoid rewarding, bribing, or soothing kids with food. Yes, that includes bribing kids for eating their veggies with dessert! Research has found kids consume less of a food and rate them as less tasty if they were presented as instrumental to a goal (Maimaran & Fishback, 2014), and rewarding with food is associated with emotional eating later in childhood (Farrow, Haycraft, & Blisset, 2015). Additionally, teach kids to learn to cope with their emotions in other ways.
  6. Promote body acceptance. Some kids are naturally smaller, some kids are naturally bigger. And that is ok! Weight-related comments are really not necessary at all, and often harmful. Additionally, avoid holding different standards for children of different sizes. Encourage a balanced, “everything in moderation” approach to eating for all children.
  7. Practice what we preach! Be a good role model for body acceptance and positive attitudes towards food. Those little ears are listening! Sure, go out for ice cream sometimes. And avoid criticizing your body or telling yourself you have to work out to get rid of the calories from eating that ice cream. Prioritize sitting down to eat and having regular, balanced meals and snacks.
  8. Encourage healthy activity without tying this to food or weight. Help kids find activities that they truly enjoy, and focus on the value of exercise to help our bodies become stronger, improve our mood, and nourish.
  9. Teach kids to savor food. Help them be selective in choosing which dessert sounds the best, and demonstrate taking slow bites to truly relish them.
  10. If they, or you, mess up, treat this with compassion. No one is perfect, and we don’t need to beat ourselves, or others, up about our mistakes.

Farrow, C. V., Haycraft, E., & Blissett, J. M. (2015). Teaching our children when to eat: How parental feeding practices inform the development of emotional eating—a longitudinal experiential design.  American Journal of Clinical Nutrition, 101, 908-13.

Jacobsen, M. (2016). How to Raise a Mindful Eater. Middletown, DE: First Printing.

Maimaran, M., & Fishbach, A. (2014).  If it’s useful and you know it, do you eat? Preschoolers refrain from instrumental food.  Journal of Consumer Research, 41, doi:10.1086/677224

Scaglioni, S., Arrizza, C., Vecchni, F., & Tedeschmi, S. (2011). Determinants of children’s eating behaviors. American Journal of Clinical Nutrition, 94, 6. doi: 10.3945/ajcn.110.001685

Tribole, E. & Resch, E. (2012). Intuitive eating: A revolutionary program that works. New York: St. Martin’s Griffin.

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Byline:  Anna I. Guerdjikova, PhD, LISW

Binge eating disorder (BED) is the most common eating disorder in adults. The lifetime prevalence of BED has been estimated to be 2.0% for men and 3.5% for women, higher than that of the commonly recognized eating disorders anorexia nervosa and bulimia nervosa. Of note, BED is found in all cultures and ethnicities and spans from childhood to old age.

What is a Binge Eating Disorder

Binge eating disorder is an eating disorder characterized by binge eating without subsequent purging episodes. Individuals with BED consume large amounts of food in a short period of time while feeling out of control and powerless to stop the overeating. BED patients often struggle with feelings of guilt, disgust, and depression related to their abnormal eating behavior.

Since May 2014, the updated version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) formally recognized binge eating disorder as a distinct eating disorder, separate from the general Eating Disorder, Not Otherwise Specified category where BED was categorized. In order to receive the diagnosis of BED, an individual must meet the DSM-5diagnostic criteria listed below: experiencing recurring episodes of binge eating (consuming an abnormally large amount of food in a short period of time) and experiencing a lack of control over eating during the episode. Binge eating episodes must also exhibit at least 3 of the following characteristics: consuming food faster than normal; consuming food until uncomfortably full; consuming large amounts of food when not hungry; consuming food alone due to embarrassment; and feeling disgusted, depressed, or guilty after binging. A binging episode needs to occur at least once weekly for 3 months for formal diagnosis.

Examples of Binge Eating Episodes

An example of a binge episode might be: an individual would eat a bowl of cereal with milk, 2 scoops of ice cream, ½ bag of chips and a sleeve of cookies in a two hour period, shortly after a full size dinner; or a person driving through a fast food restaurant after work, consuming a whole meal there, and then going home to eat a regular dinner with family. Of note, the binge eating episode must be accompanied by sense of lack of control and distress in order to meet DSM-5 diagnostic criteria for BED.

While etiology of binge eating disorder is not fully understood, it is believed that dysregulation in dopamine, serotonin and glutamate neurotransmitter systems might contribute to BED development. Furthermore, there may be a genetic inheritance factor involved in BED. Risk factors for BED development may also include repetitive yo-yo dieting, childhood obesity, critical comments about weight, low self-esteem, depression, and physical or sexual abuse in childhood.

Individuals with binge eating disorder commonly have other psychiatric comorbidities such as mood disorders (major depressive disorder or bipolar disorder) and anxiety disorders. Binge eating is also a core symptom of bulimia nervosa. Unlike in bulimia, however, individuals with BED do not exhibit compensatory behaviors such as purging, fasting or engaging in compensatory excessive exercise after binge eating episodes.

Individuals suffering from binge eating disorder often have a lower overall quality of life and commonly experience social difficulties. BED is often associated with increased medical morbidity. Up to 80% of individuals with BED are overweight or obese and are at risk of suffering from obesity related complications like metabolic syndrome, increased risk for cardiovascular diseases, gastrointestinal problems and cancer.

Treatment of Binge Eating Disorder

Successful treatment of binge eating disorder begins with proper and thorough diagnosis. Binge eating is a shameful behavior and most of the time patients do not disclose it readily. Focusing their attention on specific examples like excessive, repetitive snacking or sneaking food or eating way beyond the point of comfort regularly might help with self-disclosure.

If binge eating disorder is diagnosed, a plethora of psychological and pharmacological options for its treatment are available. BED care is best implemented by a professional team consisting of a psychiatrist, a psychologist and a dietician. Cognitive behavior therapy (CBT) is currently considered the gold standard in the treatment for BED. Dialectical Behavior therapy techniques as well as guided self-help might also be helpful. While no medication is currently approved in the treatment of BED, certain antidepressants, antiepileptic and Attention Deficit Hyperactivity Disorder (ADHD) drugs hold promise in controlling BED. For example, Vyvanse (lisdexamfetamine dimesylatelate; approved for ADHD in the US) was recently announced to be effective in significantly decreasing binge days per week as compared to placebo in two pivotal Phase 3, multi-center, randomized studies.

Binge eating disorder is a biological illness and an important public health problem that is under-recognized. Timely diagnosis and comprehensive treatment are important in BED management, possibly decreasing long term consequences of dysregulated eating behavior and associated weight gain.

Learn more about Lindner Center of HOPE’s treatment for binge eating disorder.

Learn more about skills building options for binge eating disorder.