Explanation of normal and binge eating in eating disorder recovery
This explanation is drawn from Chapter 13, Confronting the Eating Challenge, in Anorexia Nervosa: A Recovery Guide for Sufferers, Families and Friends. Janet Treasure and June Alexander. 2nd edition: Routledge (London) 2013.
FOOD COMES FIRST
The journey towards a normal, healthy diet is best taken a step at a time. For the sufferer, reducing their over-controlled behaviour and facing the consequences of weight gain is extremely difficult. Following a carefully calculated, individual plan to produce a predictable, steady gain may be useful. A dietician can help with this. Taking the person through the calculations to estimate their individual energy needs can help build their confidence that their weight can behave predictably.
To increase the sufferer’s variety of food, you will find a series of small changes more useful rather than attempting an immediate move to “normal.” Small snacks will probably be easier for them to eat than normal-sized meals. The feeling of a bloated, distended stomach is less marked, and the food itself seems less daunting in limited quantities. The sufferer will most likely be able to eat larger amounts of “safe” foods, while moving more gently toward increased amounts of “risky” foods. For example, a first step towards oil-based foods may be low fat spread, semi-skimmed milk, or tuna fish. A first move towards more sugary food may be a muesli bar, or fruit yogurt. For someone who has never eaten breakfast, a glass of orange juice can be a start with toast added later, then maybe cereal. At all times, eating enough to prevent weight loss is vital, and weight gain also is likely to be necessary. But normal eating does not have to resume immediately.
A common occurrence is for feelings of hunger to reappear with a vengeance once a pattern of eating re-emerges. This is very frightening for the sufferer – their worst nightmare come true. They fear that they will become bulimic, that they will never be able to stop eating and will blow up like a balloon. This is a normal phase. It does not mean that you will develop bulimia nervosa, although some do. Men who were starved as part of an experiment in the 1950s went through a phase of binge eating when they were allowed access to more food. Victims of famine binge eat when food arrives. Out-of-control overeating develops as a result of weight loss and, of course, in anorexia nervosa, by definition, weight loss is large. If the so-called binges are analysed they are often not that big and the daily intake including the contents of the binge is often well below the recommended calorie level.
We can understand why this pattern develops as it represents one of the body’s feedback control mechanisms. The body acts as if it has a lipostat, that is, a monitor which can detect how much fat tissue there is in the body. Fat tissue secretes a protein which acts on the brain to control appetite and metabolism. If the amount of fat tissue is low, little of this “satiety” protein is produced. This leads to increased appetite. Conversely, once the fat tissue reaches normal levels higher amounts of this “satiety” protein are secreted and appetite falls.
The amount of this “satiety” protein produced therefore depends on the genetic make-up and on the state of nutrition (i.e. the size of fat stores). Many questions remain, including the way in which anorexia nervosa overrides this feedback mechanism.
We are certain of some facts. People at risk of anorexia nervosa do not appear to have the obesity gene, that is, they are able to produce normal levels of the “satiety” protein. Commonly, the families of sufferers with anorexia nervosa tend towards leanness rather than obesity. Body composition returns to normal after recovery from anorexia nervosa. Anorexia nervosa does not lead to obesity.
Therefore, the increased hunger that occurs during weight recovery is a temporary and normal phase. It will gradually pass if small regular meals are eaten throughout the day and there are no metabolic “surprises” caused by vomiting, fasting and feasting. Bulimia need not become a habit.
The appetite centre of the brain can heal with regularly spaced meals ideally with foods with a low glycaemic index so that blood sugar levels do not swing too much. Ideally, it is helpful to not be exposed to highly-processed palatable foods that can stoke up addictive processes. Monitoring binges and eating patterns enables the brain’s control system to switch into action.