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Is Binge Eating Disorder A Restrictive Eating Disorder?
On weight stigma in the treatment system, reactive hunger, and the 'from one eating disorder to another' trope.
I recently did a podcast episode with Sarah Frances Young on whether or not binge eating disorder (BED) would count as a restrictive eating disorder (RED), and and what that distinction would practically mean and signify in terms of how to approach BED. In this post, I want to further elaborate on this topic, and some of the conclusions we reached. Thank you to Sarah for participating in this conversation, both in the podcast and privately.
TLDR; whether or not BED is a RED depends on what criteria you follow, and how you interpret this criteria. If going by the (very imperfect) diagnostic criteria, BED should not count as a RED per se, but this depends on how you interpret the slightly elusive diagnostic criteria in itself. If going by restrictive behaviours present and/or previously present (which I’d argue is most important), then BED would in most cases count as a RED, as BED rarely comes without any current or past restrictive behaviours. The diagnostic criteria for eating disorders overall kind of suck and is still quite seeped in weight stigma, which leads to misdiagnosis of both people with BED, and fat people with other eating disorders.
When I first started my work in recovery spaces, I strictly viewed BED as a non-restrictive eating disorder. Why? Because the diagnostic criteria specifies that “the binge eating is not associated with the regular use of inappropriate compensatory behaviour (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa” (source). Well, that settles it then, doesn’t it?
…Except time and time again, I see people formally diagnosed with BED who are very much engaging in restrictive, compensator behaviours. What’s that about?!
(Dipping crisps in ice cream? I mean, why not, I’d give it a try personally.)
A restrictive eating disorder (often shortened ‘RED’) is an eating disorder involving restrictive and/or compensatory behaviours. This can mean restricting food (amounts or certain types of food), excessive, compulsive or compensatory exercise and purging (eg. laxative abuse or self-induced vomiting). On the other hand, binge eating disorder (often shortened ‘BED’) is an eating disorder involving reoccurring episodes of binge eating, per DSM without any restrictive, compensatory behaviours in response.
First off al, it is important to clarify that binge eating (if defined as eating a large amount of food in a short period of time, often followed by negative feelings) occurs in the majority of restrictive eating disorders. People w/ RED’s who never, ever binge do exist, but they are in the minority. (Yes, this also includes in restrictive-type Anorexia, although the behaviour may not pop up until recovery and re-feeding). Why? Because that is literally how humans (and even animals) respond to starvation. It even has a fancy scientific name: ‘post-starvation hyperphagia’, or as I like to call it, ‘reactive hunger’, often called ‘extreme hunger’ in recovery spaces. (I’ve done several podcast episodes on the phenomena, and I’m even doing post-graduate studies on it currently. Meanwhile, here and here is a recommended read on the topic).
(Note: I’ve observed that the concept of ‘eating too little = more hungry later’ makes perfect sense to the lay person, whilst it is often people with eating disorders (and ironically, their treatment professionals) who will tends to mystify and pathologise it: “using food to cope with feelings”, “one ED to another”, and on it goes. I remember explaining the concept to my very-not-in-the-ED/therapy-community-partner, who was like, “yeah, duh?!”).
Although traditional treatment tends to be weird about reactive hunger in general, post-restriction binge eating is far more likely to be pathologised in fat people with eating disorders. This is part why I believe BED seems to be more likely to be diagnosed in fat people, despite bingeing being present across the size spectrum. The underweight anorexic might be applauded for ‘finally eating’ (as if people with anorexia always ‘stop eating’ in the first place…), whilst a fat person who may have restricted just as heavily or lost just as much weight (just from a bigger starting frame) is suddenly being asked if they’re ‘eating their feelings’.
Heck, the fat person might not even be bingeing much in the first place, or no more than a thin person with an ED, yet as they are a fat person with an ED, they’re automatically assumed to have BED. I’ve heard too many stories of fat people with restrictive eating disorders such as ‘atypical’ (ugh) anorexia seeking out treatment and being treated very differently from their thin peers; restrictive meal plans, being presumed to be ‘emotionally eating’, or weight loss being presented as a goal or seen as a ‘perk’ of treatment. In an interview with Stat News, Shira Rosenbluth, a former patient and now-therapist, describes that she was applauded for weight loss in treatment for eating disorder:
“A doctor noticed that she wasn’t eating much, and congratulated her on the weight she’d lost during her time in treatment. She remembers he framed it as: Look what happens when you don’t binge and purge! But the message that Rosenbluth received was: Your body is different from other patients here. You are supposed to feel a little hungry.”
Yeah, that is really not great. Unfortunately, Shira’s story is not unique. Many eating disorder treatment providers even proudly proclaim they treat ‘eating disorders and obesity’.
(Slightly generic stock imagery roughly encapsulating the topic of my text, chosen because I like the baby pink colour theme)
Now back to the diagnosis of BED, and where the RED-part comes in.
Here’s what I believe to be the problem: due to our society being rather infiltrated with diet culture, certain more subtle restrictive, compensatory behaviours go under the radar (and in the case of fat people with eating disorders, the behaviours may even be applauded). For example, a person with a BED diagnosis might not immediately bow to the toilet bowl after a binge, but instead they tell themselves ‘diet starts tomorrow’. The days between a binge are focused on ‘healthy eating’, which becomes a euphemism for restriction. They ban themselves from certain foods- and food groups, over-exercise daily, or just overall eat far less than they need, and unsurprisingly the binges hit eventually. Unfortunately, some treatment providers may fail to see these behaviours as a restriction; restriction that drives or worsens the bingeing. Maybe they are invested in diet culture themselves, and see this behaviour as ‘normal’. Or maybe - especially if the client is fat - they see this yoyo-dieting pattern as an act of ‘self-improvement’, and even encourage it.
(Another generic stock image to split up the text more to avoid a processing nightmare. I’m really liking this pink theme!)
One thing me and Sarah discussed is how we’ve never come across a person with binge eating disorder who does not engage in at least some form of restriction. We both agreed that this person surely exists out there, but that it does not seem to be the common presentation of BED. For most people, binges tend to start during or after a period of restriction (intentional or unintentional), which implies it is reactive hunger we’re dealing with. In cases where the binges did not start during or after a period of restriction, restriction surely does not help, because guess what? It drives more bingeing!
There is a tendency to blame what is caused by the absence of food by the presence of food, not to mention we often look for answers where we want to find them. For the eating disordered individual, it would be very much preferred if the solution to bingeing was self-control and food deprivation but basic biology and psychology (un)fortunately debunks this.
”There is a tendency to blame what is caused by the absence of food by the presence of food.”
Can you go from one eating disorder to another when experiencing post-starvation bingeing? Sure, if you’re repeatedly engaging in compensatory and/or restrictive behaviours that maintain that bingeing. Unfortunately, this is not uncommon. Reactive hunger can be terrifying, and turning to behaviours to ‘make up for it’ is a typical knee-jerk reaction. It also makes everything worse. What would normally have been a temporary phase that would run its course (if giving in to it, no restriction involved) turns into a never-ending binge/compensate cycle, and a body that is in constant ‘starvation mode’. Yes, this can create a weight overshot (which may further reinforce the behaviour), but that’s not why it is bad. A never-ending binge/compensate cycle is bad because it is a miserable existence, with serious mental and physical complications.
I believe this is how and why some people go ‘from one eating disorder to another’, and unfortunately I think treatment professionals sometimes pathologising (or lacking awareness of) reactive hunger plays a part.
So what about if you don’t engage in restrictive, compensatory behaviours when going through reactive hunger? Can’t you risk getting ‘addicted’ to bingeing? Well, that’s not really how it works. Per definition, post-starvation hyperhagia is caused and driven by the state of undernourishment, thus correcting this means it eventually dissipates (albeit this might take a bit longer than you feel comfortable with). A good example illustrating this phenomena is the Minnesota Starvation Study, where the starved participants binged on thousands upon thousands of calories during re-feeding - I’ve done a podcast episode on this study here.
For those poor Minnesotans almost 80 years ago, the binges did not last forever, and as someone who works with people with eating disorders, I still have not seen a case of reactive hunger lasting forever (as long as there’s no restrictive, compensatory behaviours in response, incl. those sneaky, subtle ones). What I have seen is people with reactive hunger ending up in all sorts of restriction-driven cycles, and convincing themselves their bingeing is unrelated, and instead related to anything from ‘sugar addiction’ to emotional eating. The best therapeutic outcomes I’ve had with clients have been with clients determined to go ‘all in’ and fully give in to their hunger, despite their fear, doubt and unicorn-syndrome way of thinking, and including all foods (incl. those foods they fear becoming ‘addicted’ to). Like one of my former clients explains (shared with consent):
”One thing I wish I had been able to believe at the start of my journey is that every stage you go through in recovery is just temporary. Whenever I moved into experiencing something different I worried it would be that way forever. One of my stages was being completely and utterly obsessed with garlic bread - it was all I wanted to eat and there wasn’t enough garlic bread in the world to satisfy my cravings. I can confirm that garlic bread is still delicious, yes, but it is no longer my life’s purpose to eat garlic bread. It’s nice, I still eat it occasionally, but that’s about as far as my interest goes on the topic now. I spent quite a while only wanting to sit on the sofa and eat processed, beige oven foods and cheese, and I did fear that I would be stuck like that forever, but it really is just temporary. Now that I’m quite far into recovery and am in my set point weight range, I still eat whatever I fancy with no restriction, but rather than that only being garlic bread it is all kinds of foods and very varied.”
I wonder how many people are currently diagnosed with BED, when it is actually reactive hunger, or a result of their chronic yoyo-dieting. I wonder how many people who have their hunger treated as a problem to be solved, when it is actually part of the solution. I wonder how much diet culture and fat-phobia - fear of ‘eating too much’, or ‘gaining too much’ - plays into this, also within the treatment system and treatment professionals fearing what the ED fears. Unfortunately, I believe the answer to all of these is ‘a lot’.
(Last generic pink stock image for this post, I promise!)
Another thing that is presented in the BED diagnostic criteria is feeling negative emotions after a binge, such as guilt, shame and depression. Furthermore, another common factor that is being used to ‘differentiate’ types of bingeing is the emotional components involved, such as the tendency to turn to binges when ‘going through it’ in one’s emotional and/or personal life.
Here’s the thing: most people experiencing reactive hunger will experience feeling rather down and ashamed (not exactly helped by a treatment professional implying they ‘did something wrong’ for eating), especially if they don’t know what is going on. Additionally, being nutritionally deprived makes bingeing a more rewarding and emotionally heightened behaviour, so the tendency to turn to it for a dopamine kick when feeling down is no surprise. For someone who’s not undernourished or deprived, physically or psychologically, stuffing your face with fifteen thousand calories worth of cookies does not really ‘hit the same’, and is therefore not a go-to ‘coping mechanism’. More on this (and what we get wrong about ‘emotional eating’) in a future post.
So, to conclude: I believe BED often is a RED in disguise, and this is why treatment so often fails. We could of course argue that if BED is a RED, it is not ‘truly BED’, and that there should be a separate condition for non-restrictive BED. Nevertheless, in a society where even eating disorder treatment professionals fail to spot and target restrictive behaviours and often fear what the ED fears (food and weight gain), this might not be realistic.
I would love to hear your thoughts and experiences!
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