When binge eating disorder gained legitimacy as a full-fledged mental condition in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders in May, many people in the eating disorders and obesity communities wondered: Will this inspire us to finally get along?
It was a good question, since historically, the two groups have been at odds.
Unlike people with anorexia or bulimia, who tend to be excessively thin, many binge eaters are overweight or obese. And much of the focus of anti-obesity efforts — listing calories at restaurants, banning cupcakes in schools, sending students home with body mass index “report cards” — are decried by eating disorder activists, who say such measures can encourage anorexia or bulimia.
Anti-obesity activists, in turn, worry that the eating disorder community minimizes the medical risks of obesity, which the American Medical Association classified as a disease in June, and plays down the discrimination many obese people face.
“They come out of different traditions,” said Kelly Brownell, dean of the Sanford School of Public Policy at Duke University. “Obesity was mainly dealt with in medical professions, and eating disorders were dealt with more in psychology professions.”
But binge eating disorder, symptoms of which include consuming enormous amounts of food in a two-hour window without purging at least once a week for three months, could bridge the gap between the two worlds, while also reducing the stereotype that only thin people suffer from eating disorders.
“We cannot address obesity and not eating disorders,” said Chevese Turner, 45, founder of the Binge Eating Disorder Association, which lobbied heavily for binge eating disorder’s inclusion in the D.S.M.-5. In September, clinicians, researchers and advocates who work in the eating disorders and obesity communities, or have struggled with the food and weight issues themselves, held a Congressional briefing in Washington to focus attention on the intersection of obesity and eating disorders.
“Part of what drives me crazy is that the obesity community and policymakers dismiss eating disorders as a small group of people, when in fact it is 30 million and growing – with more and more evidence that the focus on obesity and restriction, and growing weight stigma in the culture, is contributing to this rise,” said Ms. Turner, who spoke at the event.
Susan Rappaport knows all about this. At 26 and a petite 5-foot-4, she weighed nearly 200 pounds — the result, she maintains, of years of dieting. She would starve herself during the day and then get out of bed in the middle of the night to binge.
When she told her doctor that she thought she had an eating disorder, he brushed it off, said Ms. Rappaport, 50, who now weighs about 120 pounds and runs the NuYu Revolution Fitness Studio on the Upper West Side of Manhattan. “It was like, ‘You’re not skinny enough to have an eating disorder.’ But I was a fat eating disordered person.”
Indeed, an September study in Pediatrics found that nearly half of adolescents with eating disorders had a history of obesity, but because of their higher weight their symptoms often went unrecognized and untreated. Other studies have found that among individuals with a current or past history of binge eating disorder, approximately 20 percent are of normal weight, 40 percent are overweight and 40 percent are obese.
“I don’t want to say that the eating disorder is causing their obesity; some people with B.E.D. are normal weight,” said Jennifer J. Thomas, co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital and the co-author of “Almost Anorexic,” a book about sub-threshold eating disorders. “But there’s definitely a huge overlap, and if the two communities aren’t working together there is a huge missed opportunity.”
Statistics from the 2001-2003 National Co-Morbidity Survey Replicationreported a 3.1 percent prevalence of binge eating disorder among women and 1.9 percent among men. Nearly 39.8 percent of respondents with binge eating disorder were obese.
Still, despite differences in physical characteristics and symptoms, those suffering from an eating disorder like anorexia or bulimia and those with obesity have “shared psychological components, commonalities and underpinnings,” said Dr. Scott Kahan, director of the Strategies to Overcome and Prevent (STOP) Obesity Alliance at the George Washington University School of Public Health and Health Services, a nonprofit obesity policy organization.
“Low self esteem is extremely common in both, as is body dissatisfaction. They are both very much environmentally driven. Both place excessive emphasis on appearance and body size. In the same way, many of the same psychological underpinnings play into both.”
Another area where the two fields converge is weight stigma, said Rebecca Puhl, deputy director of the Rudd Center for Food Policy and Obesity at Yale. A July study in PLoS One found that the more people feel stigmatized or bullied about their weight, the greater their risk for obesity. Other studies have shown that experiencing weight bias contributes to risk of eating disorders.
Jenni Schaefer, 37, Dr. Thomas’s co-author, is adamant that the two groups work together to ease confusion among recovering patients. “Recently, a teenager in recovery from bulimia said to me, ‘My therapist tells me not to talk about my weight and that my body is fine. But my doctor keeps weighing me and says that I need to lose weight,’” Ms. Schaefer said.
She had a similar experience with her own recovery from a 10-year struggle with anorexia. “My body had changed far more quickly than my mind. While that was confusing in and of itself, it was even more difficult to understand why my doctors were giving me different perspectives regarding my new weight. In many ways, I hit a standstill at that point. I didn’t know what to do.”
With all this in mind, a growing number of eating disorder treatment facilities are treating obese patients with and without binge eating disorder in groups with anorexics and bulimics.
“It makes no sense to separate people based on their size,” said Dr. Susan McClanahan, founder of Insight Behavioral Health, which has four locations in Chicago.
She is aware of the inherent conflict. “You’re telling one group ‘You have to eat’ and the other ‘It’s O.K. not to eat everything on your plate,” she continued. “But I think it’s been a real relief for the anorexics to see someone who is overweight and have them realize, ‘They’re just a person, it’s nothing to be afraid of.’ And the overweight folks can say, ‘Just because you’re skinny doesn’t mean you’re going to be happy.’ You can be absolutely miserable when you’re thin.”
Many treatment methodologies are also similar within the two groups, like eating regular meals, not skipping meals and learning to listen to one’s body for cues of hunger or fullness.
Some patients say that being in a mixed group is helpful. Ann Schaffer, 46, an administrative assistant and musician in Chicago, has struggled with binge eating disorder off and on for 12 years. At her heaviest Ms. Schaffer, who is 5-foot-7, weighed 207 pounds and found it challenging to be in the same room with 80-pound anorexics.
“Sometimes it was almost like envy — ‘I wish I had your problem,” Ms. Schaffer recalled. “After a while it was like camaraderie. The problem is not the food; the problems are the issues in your life, and you turn to food because you can’t handle them.”
This model of treating the two groups together is not without controversy. At Walden Behavioral Care in Waltham, Mass., individuals with binge eating and anorexia used to attend the same groups, but that stopped about five years ago.
“Patients were uncomfortable,” said Stu Koman, a clinical psychologist and the clinic’s founder and chief executive. “A lot of what they were dealing with in therapy was their discomfort at being in the group with someone who was anorexic, rather than focusing on what they needed to focus on: these binge episodes. The anorexic patients were terrified that they would end up looking like the heavier patients suffering from B.E.D.”
One thing nearly everyone agrees on is that the cultural conversation around food and body size must shift, along with media messages promoting images of waiflike models and an estimated $61 billion a year weight loss industry, in which the vast majority of dieters regain their weight within five years.
“The focus should be on behaviors, not weight,” said Dianne Neumark-Sztainer, a professor in the School of Public Health at the University of Minnesota, who has written extensively on obesity prevention and eating disorders.
“We know from our research that talking about weight and diets is not effective, and for many leads to weight gain over time,” said Dr. Sztainer, the author of “I’m, Like, So Fat!” “We really want to focus on providing a community that makes it easy to engage in healthy eating and physical activity.”
Dr. Brownell believes that the two communities could work together as a powerful political force, sharing a goal of better food- and health-related messages and policies. “Better access to healthy, locally grown foods might be such an example,” he said. “The extreme presence in our society of unhealthy, highly processed foods are a problem for both of these camps. Some people respond by eating too much, and others respond by extreme control so it becomes an eating disorder. A healthy food environment would be a benefit in both worlds.”