Feel out of control with your eating? Find yourself restricting your food during the daytime and overdoing it at night? Having a hard time resisting the urge to eat “forbidden” foods, especially when you feel tired and stressed? Do you experience a wave of shame after you eat a large amount of these foods—or a large amount of any foods? It sounds like you could be suffering from binge eating patterns, or even binge eating disorder (BED). I think that one of the best outpatient treatment strategies for binge eating and/or BED is to work with a therapist AND a dietitian who specialize in BED. I’ve shared my therapy approaches treating to BED, so I now wanted to convey the opinions of expert San Diego eating disorder dietitians: Theresa Carmichael, RD of Center For Discovery (and private practice), Dr. Megan Holt Hellner, RD of Potentia Therapy, and Dr. Saori Obayashi, RD of UCSD CHEAR. They have some wonderful tips on how to manage binge eating from a nutritional perspective.
***Trigger warning*** This blog post interview does include the term weight loss, as well as discussion of how some people seeking treatment for binge eating also want to lose weight. I cannot stress enough that these San Diego eating disorder dietitians do NOT advocate extreme behaviors that could trigger eating disorder symptoms. In fact, their approaches encompass reducing binge eating symptoms instead of focusing on weight loss.
How did you learn about treating binge eating in San Diego?
Theresa: Most of my knowledge has been through the amazing mentorship (whether he knows it or not!) from Aaron Flores, registered dietitian in Los Angeles who specializes in the treatment of BED. Aaron Flores took time out of his day when I first starting diving into Health at Every Size (HAES) work for client consults and non-judgmental open discussions, which ultimately inspired me to look further into the intricacies of this disease. I began doing A LOT of reading, whether it be books, literature, podcasts, etc. I began challenging many of my own assumptions about weight and health and realized that I was meant to be a HAES provider—someone who is using evidence-based treatment to treat clients in a compassionate and inclusive way. I also give credit of my learned knowledge to the Binge Eating Disorder Program at Center for Discovery, at which I have had the pleasure to work for the last several years. Nothing has been more helpful to my education in this area than simply listening to my clients with BED and hearing their lived experiences.
Megan: I first learned about binge eating behaviors in 2002 while completing my dietetic internship with Sharp Mesa Vista’s Eating Disorder Program. I began to see more of this in the following years while working with UCSD’s Eating Disorder Program. Now, with the addition of BED to the DSM-5, the proportion of clients on my caseload with BED has been steadily increasing. The addition of BED as an official diagnosis was an important distinction, as prior to that, it was largely underappreciated and unrecognized, and it was difficult for persons struggling to find support (and competent clinicians).
Saori: I first learned about how to treat binge eating by reading Overcoming Binge Eating by Dr. Christopher Fairburn of Oxford University in the UK. I continue to gain additional knowledge and skills through reading research articles and attending seminars. I learn additional treatment components through my work at the Center for Healthy Eating and Activity Research (CHEAR) at University of California San Diego (UCSD). CHEAR conducts research and provides clinic services to patients who struggle with eating disorders and want to lose weight.
What can clients struggling with binge eating expect in a session with you?
Theresa: My clients can expect a safe place to heal their relationship with food. This means that, no matter what shape or size, all clients will receive respectful care. I do NOT focus on weight change as an outcome in my sessions. This is because weight is not a behavior. In order to do true behavior change, my clients and I are focusing on health-promoting behaviors to find health at every size. Clients can expect to be met halfway with interventions and recommendations that take into account their reality. Clients can also expect me to be an advocate for them among their providers, while they continue to find their own voice within their healthcare teams as well.
Megan: The initial session always includes a detailed assessment, when I begin to understand a bit about their history, relationship with food, and treatment goals/objectives. Weight is never the focal point of our work, and clients will not receive a restrictive/low calorie meal plan. We embrace the ‘non-diet’ and HAES approach, and will evaluate the many other vital markers of health as a means of measuring progress (energy levels, endurance, blood work results, presence or absence of preventable disease, quality of life, etc.) as we work toward meeting the client’s needs. Sessions tend to entail a review and discussion around current intake and maladaptive eating behaviors, nutrition education on any number of topics (including intuitive eating) and experiential practices, such as mindful eating exercises or guided grocery store outings, based upon a client’s wishes and comfort level.
We may work on sample menus or grocery lists together, and will likely spend some time processing relevant comments, events or behaviors noted within their food journal, if they are open to keeping one. I have incorporated walking into sessions from time to time for clients who may be struggling to enjoy movement. I’ve found that simply being in motion and having a walk together can also help the client feel more comfortable and at ease throughout our discussions, as many present with intense shame around their eating behaviors.
Saori: They will learn evidence-based nutritional strategies to reduce binge-eating episodes. Many patients categorize food into “bad food” and “good food.” I will help patients understand that there are no “good food” or “bad food.” I also help them establish eating habits that support their enjoyment of foods they used to think of as “bad” while balancing with foods that support their health. I will also help patients develop critical thinking skills so that they can identify valid and reliable information from a large volume of often confusing or conflicting nutrition information, so that they can make their own decisions with confidence.
What are some of the challenges people face with binge eating?
Theresa: One of the biggest challenges include standing up to weight stigma in a society that sees "thinness" as an ideal for "health." This can be very frustrating for a lot of clients as they are experiencing this from all angles in their lives. Another challenge is being okay with the idea that binges will still occur through out treatment, especially in the beginning. Our work, however, focuses on accepting that these experiences will actually act as road maps to explore further interventions and recommendations to reduce binge eating behaviors. It is also important to recognize how physical restriction of foods may play a role in binging behavior. This is because many of my clients diagnosed with binge eating disorder are praised by their external environment for both restricting themselves from food and under-portioning food. Part of the challenge is recognizing that, for some, this very restrictive behavior can act as a driving force for binge eating.
Megan: For those with BED who inhabit a large body, they often battle daily with weight discrimination/fat-phobia, and this extends to their interaction with clinicians, especially in medical settings. Consequently, many dread doctor visits and may even avoid seeking care due to negative past experiences. Finding a medical provider who is HAES informed, and will not focus solely on size is challenging. Also, binge eating episodes are often accompanied by intense feelings of shame, distrust of and disconnection from the body/bodily cues, as well as by a long history of dieting and weight cycling.
I find that clients have been so inundated with conflicting messages around what to eat and how to eat, that they are rather disoriented when we start our work together. They will often report that they “just don’t know how to eat or know what is ‘normal’ anymore.” Many clients want to be given a structured diet or meal plan and a weight loss protocol, as these are the only tools they’ve encountered in the past to deal with food/body issues and/or subsequent health related concerns. Binge eating also brings about a great deal of physical discomfort, and makes it challenging for the person struggling to maintain consistent energy levels. In a nutshell, BED can wreak havoc on emotional and physical health, and requires the support of a competent multidisciplinary team to treat it effectively.
Saori: Many patients with binge eating have psychiatric comorbidity, sleep problems, and difficulties in planning and organizing. They also have a long history of eating disorders or have repeated the cycles of weight loss and regain to the point that they no longer can sense their hunger/fullness and are not sure how to and what to eat.
How do you handle these challenges?
Theresa: By first listening! The best thing a provider can do is truly listen to their clients and what they have to say. Each challenge deserves it's own space to process in order to trouble shoot what interventions and recommendations may be most helpful. I also believe that all of these challenges must be handled with a trauma-informed lens, being careful not to re-traumatize clients who may have had negative past experiences with a dietitian. Finding alternative ways to cope without the use of food can be hard, but there are many tools on this tool belt of mine that can help tease out what is going to be most effective for each client in individualized care.
Megan: We are fortunate in San Diego to have access to a number of excellent physicians and nurse practitioners who are HAES-informed, so connecting clients with these medical providers is a first step. This multidisciplinary approach ensures that the client gets the best support and will enjoy better outcomes, as this data (blood work and vitals, for example) allows us to use measures other than weight to inform our treatment course and gauge progress. Also, given the information overload that clients are often burdened with, we may lean away from nutrition education that centers on ‘what to eat’ and focus more on ‘how to eat’- that is, how to reconnect with intuition and hunger/fullness cues, and how to respond organically to the body’s feedback.
Although I’m not at all opposed to offering some structure in terms of meal planning, I find that we have more success and movement toward a sustainable recovery when we go beyond these strategies and begin to integrate the intuitive eating work. Finally, just simply naming weight stigma can be very empowering for the client, and acknowledging that we can normalize eating behavior and enjoy significant improvements in health regardless of weight loss (in many cases).
Saori: I am grateful to be part of a team that consists of very compassionate, skilled therapists and a psychiatrist who help patients learn how to manage psychiatric comorbidity. As a nutrition expert, I try to help patients re-establish regular eating habits, clarify misunderstanding about nutrition information, and develop critical-thinking skills so that they can evaluate nutrition information with confidence.
I know that some clients who struggle with binge eating also want to lose weight. How do you address that in your work?
Theresa: GREAT QUESTION! Almost every single one of my clients who struggle with binge eating come to my office wanting to lose weight. I do not "blame" them for this and I certainly do not judge them. For so long we have been convinced that weight loss is the end all be all to finding health. So the way I address it is "slowly but surely," and at the clients own pace. I will start with asking clients what it would be like to simply stabilize their weight first while focusing on health-promoting behaviors. My clients and I usually agree that weight is not a behavior, so we discuss what their treatment outcomes could look like if we measure success outside of weight. Lastly, once rapport has been built, we work to really debunk some of the philosophies set forth by diet culture that are inaccurate. Each client will slowly build their own tool belt full of skills and one of those skills will be reality checking the fact that diets "work." Research has shown otherwise time and time again. So let's focus on modifiable behaviors and let our body do the rest!
Megan: This is a rather controversial topic in our field, and I’d say that my approach is somewhat unique, as I do help clients who wish to lose weight, though again, weight loss is not the focal point. It may be one of a number of treatment outcomes. Clients are often uncomfortable in their skin and are desperate to lose weight, and excess weight may indeed have resulted from the maladaptive eating behaviors. Although I do not pursue weight loss with clients as a treatment goal, it is common for clients to lose weight while eating normalizes. This, in turn, can lower risk of preventable illness (such as diabetes/insulin resistance, heart disease), and can make it easier for clients to enjoy movement without pain, for example. Most of the positive changes are because of improvements in dietary quality and other lifestyle modifications, but weight loss in itself (when indicated) also predicts better health outcomes in some clients. However, the goal here is not the achieve a certain weight for height or BMI….I am aiming to help the client meet needs and normalize eating and exercise-related behaviors. Weight loss, if appropriate, will follow.
Often the weight loss is more subtle than what clients may have encountered on diets/low calorie meals plans in the past (or more subtle than what they’ve been promised by other providers offering dietary advice), and that can be disappointing for some. Risk of many preventable diseases decrease significantly with a weight loss of just 5-10%, with the dietary and lifestyle changes being the most vital part of this equation. We are not aiming for a quick fix here, and my hope is that clients go on to enjoy better health and quality of life for decades to come.
Saori: The majority of patients I see want to lose weight and attempted weight loss in the past. However, when patients struggle with binge eating disorder, the priority should be reducing binges. Therefore, I let my patients know at the first encounter that we will not focus on weight loss until the frequency of binges reduces and stabilizes. We make the decision as a team whether patients are ready to work on weight loss while continuously strengthen their skills to manage their binges. Rather than setting a “goal weight,” I focus on making behavioral changes that support weight loss. When they are about to make changes, they need to recognize that weight loss or maintenance is a lifelong journey and they need to think about long-term sustainability. They need to make small, gradual changes. This can be very challenging for some patients who have black and white thinking. I will also try to help them build problem-solving skills so that they can modify their plans on their own in the future. It is very easy to overeat and become sedentary in our society. Patients should recognize every effort they make no matter how small it appears and be kind to themselves as they try to change their behaviors.
Thank you so much for such valuable information on treating binge eating from a nutritional perspective!
If you want to find out more information and contact these gifted eating disorder dietitians, you can look for Theresa Carmichael, RD at Center For Discovery (or at her private practice), Dr. Megan Holt Hellner, RD at Potentia Therapy, and Dr. Saori Obayashi, RD at UCSD CHEAR.
Hey everyone, I really appreciate you reading my blog! Have a wonderful day. :)
If you are struggling to find eating disorder treatment in San Diego, give me a call for your free 15-minute phone consultation at (858) 699-3754, and I will help you get where you need to be!