Medical Challenges in the Binge-Eating-Disordered Population
By Vicki Berkus, MD, PhD, CEDS
The days of seeing a patient with a single diagnosis of an eating disorder are becoming a rarity. The comorbidities that accompany binge eating disorder (BED) include substance abuse, depression, anxiety, post-traumatic stress disorder, personality disorders, and thought disorders. Patients usually present with more common complaints of fatigue, sleeplessness, lack of energy during the day, lack of motivation, and feeling helpless to address their weight issues. Today, most patients can lose weight and have used various programs over the years to do so. The one common complaint is that they can’t keep the weight off. The frustration of yo-yo dieting and feeling like a failure keeps our patients from pursuing our help.
Today, the therapist, dietitian, psychiatrist, and internist have to deal with not only patients’ body image and their belief system around their weight, but also now the fact that the influx of information on the internet and television, in email and texts, in advertisements for “weight-loss products,” and about various workout options raises patients’ hopes and expectations. They can fall into the “what if” and “if only” position of being a victim of their BED. It is not unusual to see a patient who has been on several medications for hypertension, hypercholesterolemia, diabetes, depression, and numerous other medical issues.1 These patients may also present with a list of “natural supplements” they feel are necessary to “be healthy.” Their previous psychiatric history may show that they are addicted to alcohol or amphetamines. A medical condition might have progressed to the point that they need a risky surgery that is prohibited because of their weight. The patient may be in chronic pain and have limited mobility. The answer to how medications interact with substances and natural remedies is not available to providers. The picture becomes more complex and puzzling.
The unifying feature of BED for patients is the feeling of loss of control over their eating. The ease of ordering food online with their phone, charging food, and having it delivered opens a pattern that allows a person to binge in private and is a challenge for providers. Many patients will binge and then their guilt and self-loathing become overwhelming. The idea that they may stop once they have started to binge is ludicrous to most patients.
The physiological changes that accompany taking in large amounts of food include such challenges as the loss of a feeling of satiety, the inability to regulate high blood sugar levels, and a loss of the ability to make good choices (sometimes referred to as a brain fog) after bingeing.2 Their blood sugar levels may peak, then drop suddenly, leading to fatigue or dizziness.3 The additional weight may lead to joint damage and poor mobility, making movement and exercise difficult. Those with BED often struggle with chronic problems such as diabetes, congestive heart failure, respiratory problems, body rashes, and many more physiological consequences of having excess body weight.4 The patient can start to feel trapped in a behavioral and psychological web.
The idea that people are just “weak” if they can’t control their weight is a message that society has perpetuated. There is a social stigma not only among the general population, but also among health care providers toward obese individuals.
How do people who have been on the receiving end of this discrimination feel good about their social interactions? Professionals know that binge eating numbs some of the feelings of isolation, sadness, and anger that trigger the behaviors. It has been a struggle for patients to get access to quality treatment to learn the appropriate tools for self-acceptance and change. Insurance companies still do not see BED as a disease that requires inpatient care. Why must patients get to the suicidal point with their depression and hopelessness in order to finally get treatment? It is a question that plagues providers—the idea that crisis intervention is the only means to treatment and that preventive or ongoing supportive treatment is “too expensive.”
The treatment options are limited. Prozac, Vyvanse, Topamax, and sibutramine have been used for weight loss because they decrease appetite.5 The side effects of these medications can put the patients at an increased risk for blood pressure complications and can be hard to tolerate. Patients complain that taking a medication to decrease appetite is like taking one to lower blood pressure. Once you stop, the effect of the medication (appetite suppression) is gone and people can gain the weight back easily. The constant variation in a person’s weight can lead to additional problems with fluid and electrolyte regulations. Many patients keep their “fat” wardrobes in their closets just in case they are needed.
So what works? Patients who have successfully lost and kept off weight tell me that they need accountability. Everyday life stressors provide daily challenges to eating healthy. The idea that group therapy can be planned around binge eating was quickly changed to a group therapy where the patients bring to the session their issues for the day. A preset agenda does not meet their needs. They are well-read and know they can get any “diet” information on the Web. These patients want a way to stay in the moment and address their current stressors and temptations. Patients who have had bypass surgery or who just have settled on a way of eating that doesn’t serve them all struggle with their perception of being “good” or “bad” around food. There are groups requesting practical tips such as how to drive home without stopping and eating something that sounds good. They pass numerous fast-food restaurants every day in their cars. They are exquisitely aware of what they would stop and order if they let themselves. It is putting themselves and their relationships ahead of their cravings that finally begins to break the cycle.
Patients can identify with the “screw it principle.” They have the best of intentions until they let themselves become too hungry, angry, lonely, or tired (an old recovery acronym: HALT). Can you imagine hearing from a medical professional that you need to lose 100 pounds? The thought of losing 10 pounds can be overwhelming. Many patients need an immediate source of support for when they become triggered; they need immediate options to get help. They need to understand that their struggle doesn’t have to happen alone. The time it takes to change old habits can vary from person to person. The “stinking thinking” that keeps them from achieving their goals is part of the reason the group process works so well. Group members can point out what thoughts the individual is holding on to rather than letting go. Many patients are willing to stay with a group for years, stating that it was the “only way to keep the weight off.” We can learn from our patients what helps and what doesn’t—we just have to listen.
Telemedicine brings a different chance at a relationship between the BED obese patient and the provider. The patients are on an eye-level basis for their interaction instead of having to navigate a waiting-room chair and seeing a receptionist and others in a waiting room. Providers need to understand how difficult it is for some of their patients to have their bodies scrutinized, worry about hygiene, have to get up on and down off examining tables, or sit in uncomfortable furniture. Patients find relief in knowing that the provider is seeing them only from the neck up and for the moment can focus on what they are feeling and saying instead of how they look. The lack of mobility for these patients also makes telemedicine an attractive alternative. They don’t have to ask for help to ambulate or get in and out of a car. The provider also has a chance to see the patient’s own environment and interact with some level of comfort.
BED is not going to disappear. The stress of just being human has brought BED to a form of comfort that is within the individual’s ability and can be done in private. The tools to deal with feelings need to start when patients are young. Many patients remember binge eating as a child to self-soothe—often feeling the loss of control when eating. This is a symptom, as well as a disease, that takes a toll on the individuals, their families and loved ones, and society, and yet it can be treated. It takes the willingness of the provider to understand the specific challenges for each patient.
About the author:
Vicki Berkus M.D., Ph.D. ,CEDS is a board certified psychiatrist currently living in Newport Beach, California. She is the medical director for EDCC PHP program in Albuquerque and for Monte Nido PHP in Newport Beach, California. Dr. Berkus is the medical director for the substance abuse program at La Ventana. She is the past president of iaedp and currently on the Senior Advisory Board. She is the author of a recent book chapter on physiological effects of eating disorders published in Eating Disorders in Special Populations and is the author of the acclaimed 10 Commitments to Mental Fitness. She has been the medical director for several programs around the country that treat eating disorders and has medically worked with patients at all levels of eating disorders treatment. She has brought telemedicine to several facilities and is dedicated to providing treatment to patients who do not have substance abuse or eating disorder professionals in their area.
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