To the Family Member Who Worries I Am Not Helping Your Loved One’s “Weight Problem”

To the family member who worries I am not helping your loved ones "weight problem"
image by Representation Matters

Dear Family Member,

I understand your fears. I get it. You want the best for your loved one. You want him or her to have the best and healthiest and fullest life possible. I do too.

You believe that helping your loved one to lose weight will help achieve these goals. Here, I disagree—I will explain below.

You believe that weight loss will lead to better health. You have heard the scary information about the dangers of obesity and know there is an all-out war on obesity. Or you have seen or heard your loved one ridiculed or judged negatively by peers because they didn’t conform to a certain size.

 

However, did you know that:

I have been working in the field of eating disorders since my training at a bulimia research lab in 1991. When I first learned to treat binge-eating disorder, a course of cognitive behavioral therapy (CBT) for binge eating was expected to be followed by a course of behavioral weight loss. However, since that time we have learned that behavioral weight loss doesn’t work. And while CBT for binge-eating disorder can be successful, it rarely leads to significant weight loss, even among those considered to be in an “overweight” weight category. However, CBT does lead to cessation of binge eating and prevention of further weight gain, which are lofty goals in their own right.

I firmly believe that bodies are meant to come in a variety of shapes and sizes. We are not all meant to be Size 0 or 2 or 4.

Take shoe size: while the average woman today has an 8 shoe size, most do not—some will have size 5 and others will have size 10. Shoe size has a normal distribution within the population.

Just as with shoe size, so it is with body weight. Every body appears to have a set point, a weight at which it functions optimally. This set point is not destined to be at the 50th percentile for every person—some will be heavier and some will lighter. Repeated attempts at dieting seem to increase a body’s setpoint, which is the opposite of what most dieters are trying to achieve.

I no longer support attempts at deliberate weight loss because I have come to believe it is not only fruitless but in fact harmful. Every day in my practice I witness the destruction left by the war on obesity and failed diet attempts. I see the carnage of past dieting, weight regain, shame and self-loathing in the form of disordered eating and intractable eating disorders. Against this backdrop, I believe that above all else, my duty to your family member is to not harm them.

There is no magic solution. Failing to fit the thin mold can be a burden. I wish I could wave a magic wand and have your loved one’s body transform into one that would not be stigmatized, would be celebrated, and would fit into all spaces. But I can’t change your loved one’s genetic body destiny, just as I can’t change any person’s ethnic background or skin color to conform to the privileged group. And I believe the solution is not to change your loved one’s body to conform—the solution is to fight to end weight stigma and the oppression of larger bodies.

Here’s what I can do:

  • I can help your loved one recover from an eating disorder, using evidence-based treatments backed by scientific research.
  • I can help your loved one work on accepting and appreciating their body and all its capabilities.
  • I can help your loved one unfetter themselves from self-imposed rules and restrictions and live a fuller life.
  • I can help your loved unburden themselves from shame and self-loathing.
  • I can help your loved one to advocate for themselves if he or she needs accommodations from a world that was not built to accommodate his or her body.
  • I can help your loved one learn to stand up to weight stigma and bullying.
  • I can help your loved one request and receive respectful health care.
  • I can help your loved one improve their relationship with food so that eating and social situations are enjoyable.
  • I can help your loved one achieve peace.

If you want these things for your loved one, please let me do what I was hired to do—guide your loved one to healthiest, best, and fullest life possible. Please examine the basis of your own hope that your loved one will conform to the thin standard. While I know this comes from a good place, it’s not pointing to the right destination. There are happier places to land. There is much work to be done. We all have weight stigma.

To learn more, I suggest reading the following articles:

Interested in Weight Loss? I CAN’T Help You. Here’s Why

Are We Setting Recovery Weights Too Low?

Is Weight Suppression Driving Your Binge Eating?

How Health at Every Size Can Help With Eating Disorder Recovery

Look before you leap: Binge Eating Disorder, Vyvanse, and evidence-based psychotherapies

Binge Eating Disorder, Vyvanse, and evidence-based psychotherapiesGuest post by Elisha M. Carcieri, Ph.D. 

Binge eating disorder (BED) has been making headlines with the recent announcement that the FDA has approved lisdexamfetamine dimesylate (Vyvanse) for the treatment of BED.

So, what is BED, how is it treated, and what does this new treatment option mean for sufferers?

What is Binge Eating Disorder

BED is a condition in which a person engages in recurrent episodes of binge eating at least once a week for three months1. Binge eating episodes typically involve eating rapidly until uncomfortably full, and eating when one is not necessarily hungry. Some individuals with BED report feeling unable to stop the episode, and describe themselves as being out of control during a binge. Binge eaters often binge alone and make efforts to hide their behavior from friends, partners, or family members. Episodes of binge eating often end in feelings of guilt, shame, and depressed mood. Unlike other eating disorders, such as bulimia nervosa, people with BED do not vomit or use other methods of compensation (such as excessive exercise or fasting) to shed calories or lose weight after a binge. It should be clear that this is a very different experience than, say, overeating on Thanksgiving, having a second piece of birthday cake, or eating foods that are outside of your normal pattern while on vacation.

Until 2013, BED was not a diagnosable eating disorder. It was instead grouped in with other unspecified eating disorders that didn’t quite meet criteria to be formally diagnosed. After much research, the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), has included BED as a specific eating disorder distinct from other diagnoses.

Despite only recently being formally acknowledged, BED is the most commonly occurring eating disorder. Prevalence estimates vary, ranging from 1.6-3.5% of women, 0.8-2% of men, and 1.6% of adolescents.1, 2, 3 BED occurs as commonly among women from racial or ethnic minority groups as for white women, 1 and is often seen in people with severe obesity.1, 4 Up to 30% of people seeking bariatric surgery or other interventions for weight loss are suffering from BED5. While it is more common for women to meet all of the criteria for BED, men tend to engage in binge eating as frequently as women2. Like all eating disorders, the causes of BED are complex. There is evidence for genetic, biological, and environmental risk factors. BED is associated with significant chronic health problems. It is also common for individuals with BED to struggle with other mental health disorders at the same time, including depression, anxiety, and substance use disorders.

The good news is that there are established treatments that work for BED. Unfortunately, effective psychological interventions for eating disorders don’t get as much press as pharmaceuticals. Nevertheless, those suffering from BED should be aware of what is available.

Treatment for Binge Eating Disorder

Evidence-based psychological treatments are first-line considerations for the treatment of BED. A psychologist or other mental health professional qualified to treat eating disorders usually conducts psychological treatment for BED on an outpatient basis. Cognitive behavioral therapy (CBT) is the most well studied and established treatment for BED with demonstrated effectiveness.6 The treatment involves reducing episodes of binge eating using tools such as establishing regular eating patterns and self-monitoring of food intake and patterns of eating. CBT also addresses concerns about shape and weight, and examines and challenges patterns of thinking that may be keeping a person stuck in a pattern of binge eating. CBT for BED involves discussion and planning of how to maintain progress, and how to recognize and respond to relapse. Studies have demonstrated improvements lasting up to 12 months post-treatment with CBT.7 Interpersonal therapy (IPT) has also been proven effective for BED with strong research support.8 IPT involves more of a focus on interpersonal (relationship) difficulties with an understanding of how these problems may have precipitated BED, or how they might be keeping the BED going. Finally, there is evidence that dialectical behavior therapy (DBT), which focuses on mindfulness, emotion regulation, and distress tolerance, is effective at treating BED.9

Pharmacological Treatments for Binge Eating Disorder

In addition to psychological treatments, some antidepressants and anticonvulsants have proven helpful at reducing the frequency of binge eating in patients with BED.6 The newest and only medication specifically approved by the FDA for BED is Vyvanse, a central nervous system stimulant that has been approved to treat ADHD in children and adults since 2007. The approval for BED came after clinical trials demonstrated that the average number of binge eating days per week among sufferers were decreased in those who took Vyvanse, compared to those who took a placebo.10 Sounds promising…but there are other considerations to keep in mind…side effects, long-term use, and the question of whether a medication can address the complex nature of a serious eating disorder such as BED.

The potential side effects of Vyvanse include decreased appetite, dry mouth, increased heart rate or blood pressure, difficulty sleeping, anxiety, gastrointestinal problems, feeling jittery, and even sudden death among people with heart problems. The drug is also particularly risky for individuals with a history of seizures or mania. Vyvanse may cause psychotic or manic symptoms in people with no history of mental illness, and has a high potential for abuse, dependence, tolerance, and overdose.

Vyvanse appears to decrease symptoms over a short period of time (about three months) while taking the medication. However, it is unlikely that the medication will result in long-term changes in complex binge eating behavior once the drug is stopped, meaning that one might expect to take Vyvanse for the rest of their lives in order to keep BED at bay. This is problematic considering the chronic nature of BED, 2 and the fact that the negative emotion, distress, shame, and weight or shape concerns that are often related to BED would almost certainly remain unaddressed.

While there are no identified side effects to engaging in psychological treatment of BED, these treatments do take time (often around 20 weeks), and not every person will respond to an intervention the same way. It may take some trial and error to find the right therapist or treatment. However, psychological treatments are more equipped than medication alone to address the binge eating behavior itself, and the different ways binge eating relates to other areas of a person’s life and functioning. Rather than simply masking and reducing symptoms in the short term with a medication, completing a course of evidence-based therapy can provide the insight and tools needed for managing the patterns of disordered eating that are characteristic of BED for life. Many people with BED may benefit from trying a psychological approach before initiating treatment with a serious medication like Vyvanse.

Implications for Patients

All of these factors should be carefully considered when making a decision about treatment for BED. With all eating disorders including BED, it is important to get help sooner rather than later. For many people, turning to their primary care doctor is the first step. Patients should keep in mind that these conversations can be sensitive and difficult, and many providers may not be familiar with BED. Other providers may be familiar with the recent approval of a new drug, and will be eager to explore prescription medication options for treatment.

If you aren’t getting anywhere with your doctor, it is always appropriate to ask for a referral to a medical provider who is more familiar with eating disorders. Your doctor may also be able to provide you with a referral to a mental health provider, such as a psychologist, who can provide one of the therapies discussed above, and to a nutritionist or dietician who specializes in eating disorders for even more comprehensive support. Remember that it is important to seek help from professionals qualified to treat eating disorders, and treatment decisions should be tailored to the unique needs of each person.

If you do see a psychiatrist regarding any medication, we have some recommendations.

References

1. American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. bookpointUS.

2. Hudson, J. I., Hiripi, E., Pope Jr, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348-358.

3. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.

4. Marcus, M. D., & Levine, M. D. (2005). Obese patients with binge-eating disorder. In The management of eating disorders and obesity (pp. 143-160). Humana Press.

5. Kalarchian, M. A., Marcus, M. D., Levine, M. D., Courcoulas, A. P., Pilkonis, P. A., Ringham, R. M., … & Rofey, D. L. (2007). Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. The American journal of psychiatry, 164(2), 328-334.

6. Brownley, K. A., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Binge eating disorder treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders, 40(4), 337-348.

7. Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3), 199.

8. Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., … & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of general psychiatry, 59(8), 713-721.

9. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of consulting and clinical psychology, 69(6), 1061.

10. McElroy S. L., Hudson, J. I., Mitchell, J. E., et al. (2014) Efficacy and Safety of Lisdexamfetamine for Treatment of Adults With Moderate to Severe Binge-Eating Disorder: A Randomized Clinical Trial. JAMA Psychiatry.

Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716) practicing in the Los Angeles area. Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity, and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she also incorporates alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size, and welcomes new clients from all backgrounds. She is a member of the American Psychological Association (APA), the Academy for Eating Disorders (AED), and the Los Angeles County Psychological Association (LACPA).