Contributor: Lee Kern, MSW, LCSW, Clinical Director at Structure House
Overweight binge eaters represent a collision of two traditional treatment worlds: eating disorders and weight control. 30-40% of those seeking weight loss treatment meet the criteria for BED.
In a residential weight control treatment setting this link between overweight/obesity and binge eating is striking. Our mean BMI is 43.3 and data suggests that 43.7 % of our participants have BED. A host of co-morbidities result from this combination of eating pathology and obesity:
- Cardiovascular disease
- Low self-esteem
- Interpersonal distress
- Mobility challenges
Effective Treatment Methods for BED
An effective treatment paradigm is one that blends the legitimate need for weight loss with strategies that target the underlying eating pathology.
The blended treatment model supports a role for food in which the focus is eating to meet health and nutritional needs, rather than eating to produce psychological or emotional effects. This therapeutic style of eating has varying labels: mindful, structured, prescriptive, conscious.
Meals and snacks areL
- Calorie conscious
When combined with an appropriate program of physical activity (cardio, strength training, flexibility) there is weight loss and often dramatic improvements in health and other co-morbidities mentioned above.
Self-Monitoring Is Necessary
Self-monitoring is a core part of behavioral weight control and the management of emotional eating. Many people eat twice as much as they think, and think they are twice as active as they are. Whether we call this denial, mindlessness, or inattention, it is unlikely to lead to recovery.
Clients need to be encouraged to record what they eat and track their activity, and to be reflective about deviations from eating and activity plans.
Cognitive Behavioral Therapy
An “ABC” cognitive behavioral model is an effective way to help clients understand the vicious cycle of overeating in which they are trapped. (A) is the antecedent, or trigger, that leads to the (B) behavior of emotional eating, eventually producing (C) the consequences of weight gain and associated co-morbidities.
Attention to triggers brings a very important “digging deeper” level to the recovery process. For example, a stress eater is likely to be using the food as a vehicle for seeking comfort or calming. The use of a more functional self -soothing technique, such as deep breathing or visualization, can produce the desired effect without the excess calories.
By respecting the effect or heeding the need, clients probe the binge urge for the underlying effect or need it is seeking. Alternate interventions can then be used that meet the need in more functional ways.
Effective Emotion Management
Effective emotion management is a vital part of BED recovery and weight control. There are indications that a high percent of binges are triggered by negative emotional states, and that they are an attempt to blunt, escape or stuff emotions.
By adding DBT strategies to the CBT treatment regimen clients are empowered with techniques for emotion regulation. Instead of eating to escape feelings, the goal is to live with them at a more functional level. Emotions may be vital signals that direct us to meaningful action, as in anger mobilizing problem solving, or anxiety triggering preparation for handling a difficult situation.
The mindfulness component of DBT helps clients detach from emotions and urges, view them as waves that come and go, “surf” their peaks and allow them to subside, thus producing a sense of self-efficacy. This leads to powerful learning moments: I handled it replaces I was overcome by the emotions and the urge.
Managing Stress to Prevent Binge Eating
Stress management strategies are also vital to recovery. Most clients link stress with excess eating. This “emotion focused coping” targets the negative emotions of stress. As an alternative, clients are encouraged to consider “problem focused coping” – address the stressor more directly, if possible.
A client who uses eating as a way to escape when feeling pressure from others might learn assertion techniques to be able to say: I need some time alone. Teaching clients to reframe stressors as challenges rather than threats can encourage positive coping options. In addition, techniques for creating the relaxation response, such as diaphragmatic breathing and visualization, are also beneficial for stress reduction.
Making Lifestyle Changes to Make Coping Easier
Lifestyle change serves as the foundation upon which a holistic approach to weight loss and eating recovery is built. Imbalances in lifestyle have the potential to create vulnerability to binges. Loneliness can lead to using food for companionship, work-a-holism leads to reward eating, and boredom seeks food for stimulation.
Clients are encouraged to explore potential lifestyle deficits and to reduce emotional vulnerability through lifestyle enrichment:
- Meaningful activity
- Adequate interpersonal support
- Self- care
- Healthy pleasures
Relapse Prevention Strategies
Relapse prevention and management strategies are an important part of clients’ preparation to return home from residential treatment. Clients are encouraged to reduce exposure to high risk eating situations, while at the same time appreciating that not all difficult situations can be avoided.
By thinking ahead and being prepared, clients learn they can protect their recovery in tempting situations such as restaurants and celebrations, and to make life at home safer by keeping tempting food out of the house. Yet, lapses are inevitable in a food toxic culture, and “damage control” strategies are an essential tool in the tool box of continued success.
The “next play” principle is a reminder that when a lapse is followed by something positive (plan a meal, take a walk), a sense of control is restored.
A Combination of All Strategies Has the Greatest Success
The results of an integrated (DBT, CBT), holistic (healthy diet, lifestyle balance, exercise, stress reduction) approach are impressive. Our data show that a 4-week stay produces weight and health improvements:
- 5.6% lost in pounds and BMI
- Reductions in:
- Fasting glucose (3.9%)
- Triglycerides (17.7%)
- Total cholesterol (20.6%)
- LDL (18.4%)
In addition, mood, self-efficacy, and binge eating symptoms improve for all levels of binge severity. While not every overweight binger is a candidate for residential treatment, the evidence supports the potential benefits of an integrated, holistic, intensive treatment model.
Lee Kern, MSW, LCSW, is the Clinical Director at Structure House, psychologically based residential weight control center in Durham, NC. He supervises a team of therapists, provides program development, psychotherapy, and educational workshops. He received a MSW from UNC-CH and has authored numerous publications on weight. management.
Pells, Stout, Musante (2010). Expanding Stepped Care for Obesity: Overview and Evaluation of an Intensive Treatment Program for Adults. Obesity and Weight Management, June, 146-151.
Pells, Rodriguez-Diaz, Stout, Musante. Response to Weight Loss Treatment among Severe Binge Eaters who are Morbidly Obese: Implication for an Integrative, Intensive, Residential Treatment Model. Poster presented at the annual meeting of The Obesity Society, Washington D.C., 2009.