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Understanding overeating disorders

The topic of overeating has become endemic in Western society in recent decades. This article will be covering the types of eating disorders that involve overeating, the emotional causes which underlie these disorders along with the physical and emotional consequences resulting from overeating. Finally I will mention the treatments and support available for these debilitating disorders.

Before discussing overeating it is important to make clear that not all overeaters suffer from an eating disorder. Many people who are clinically obese are very comfortable with their eating habits and size, even if it is a result of overeating. However overeating, although not necessarily causing emotional distress, nonetheless can result in physical ill health as a result of obesity. This includes (among other conditions): type 2 diabetes, various cancers, gallbladder and heart disease, adrenal exhaustion fatigue, high cholesterol/blood pressure, osteoarthritis, hypertension, sleep apnoea, asthma, visual impairment, muscle and joint pain, gastrointestinal problems and complications during pregnancy. 

Causes

Psychological distress is an essential underlying component of most eating disorder diagnoses, apart from very rare disorders such as Rumination disorder. As in the vast majority of illnesses within the mental health field, the condition, be it anxiety, depression or an eating disorder, is merely a symptom of psychological distress rather than resulting from organic causes such as brain damage.

Diagnosis

Diagnosis of eating disorders has been recently overhauled as seen in last year's publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). For the first time 'binge eating disorder' (BED) has become a disorder in its own right and is no longer included in the previous category known as 'eating disorders not otherwise specified' (EDNOS). BED is the most common eating disorder of all and its incidence is rapidly increasing within both male and female populations. It is not the only eating disorder in which overeating plays a role as it is also found in bulimia nervosa (BN) and less frequently in one of the subtypes of anorexia nervosa (AN), binge-eating or purging type.

In order to seek the correct treatment it is important that nurses have an understanding of the diagnostic criteria for each individual disorder since it has been shown that entitlement to treatment and the type of treatment offered is contingent upon a patient meeting strict criteria requirements. For this reason it is helpful to give a synopsis of the diagnostic criteria for BED and BN since they are the main disorders which involve overeating. This will enable medical staff to signpost patients towards the most appropriate support for their condition. 

Diagnosis of BED will only be given if all five of the following criteria are met:

1. Repeated episodes of bingeing large quantities of food within a short amount of time, while feeling out of control and incapable of stopping.

2. The binge episode contains at least three of the following: 

a) Eating when not hungry.

b) Feeling uncomfortably full.

c) Eating more rapidly than normal.

d) Experiencing feelings of guilt, or self-disgust and depression.

e) Due to embarrassment, insisting on eating alone.

3. Considerable distress is experienced as a result of bingeing.

4. Occurrence of bingeing is on average at least once a week for the duration of three months.

5. No compensatory behaviours are used such as purging and the patient does not suffer from AN, BN or avoidant/restrictive food intake disorder (ARFID).

Diagnosis of BN requires all of the following five criteria to be met:

1. As above.

2. Repeated inappropriate compensatory behaviour to prevent weight gain by purging (self-induced vomiting) or misuse of enemas, diuretics and laxatives or excessive over-exercising.

3. Binging and compensatory behaviour must occur at least once a week for a minimum of three months.

4. Self-evaluation is inordinately based on weight and body shape.

5. The disturbance does not occur exclusively during episodes 

of AN.

When discussing overeating, the term 'binge' is key in differentiating between those who are just overeaters by choice and those who are suffering from psychological distress. This may seem like splitting hairs, since the end result may be the consumption of similar quantities of food, but there is a subtle difference. Bingeing, when used in the strict clinical sense, refers to someone who consumes an excessive amount of food (on average 3,000-5,000 calories) within a short space of time (usually one hour) while feeling totally out of control. It is this final element that is key and needs to be understood by medical practitioners, since binge eating sufferers are often accused of being greedy gluttons as though this is a lifestyle choice, when this is far from the case. Bingeing is very similar to any form of addiction, however, the solution of abstention is not on offer since eating is essential to survival; this factor makes things considerably more complicated with regard to treatment. Added to this mix is the central role food plays in most social occasions as an intrinsic component of both celebration and commiseration. For those with an addiction it is difficult to escape temptation.

The very act of bingeing and the accompanying inappropriate compensatory behaviours, as is the case in BN, actually causes damage to the body's signaling mechanisms, which enable us to recognise satiety and hunger. It is not dissimilar to how it would feel if you had to operate your car without a fuel gauge to inform you if the tank was full or empty. Should this be the case, many of us would err on the side of caution and keep topping up the tank rather than risk being stranded with no petrol. The brain too will avoid the possibility of starvation at all costs. 

Furthermore, even if these mechanisms have any functionality, the speed of the binge incapacitates this process since there is a considerable time lapse between the act of swallowing to the stomach registering that it is full. In affluent countries the 24-hour availability of food and the convenience and ease by which it can be obtained exacerbates the problem further. Processed food, with its overly generous helpings of preservative additives, fats, salt and sugar, the latter of which accelerate the development of sugar cravings, accelerate the likelihood that the overeater will become more and more addicted to their 'food fix'. 

The main reason why people resort to overeating is often as a means to finding a temporary respite from emotional problems, which are too overwhelming for the individual to face. This is similar to why individuals self-harm - a short-term reprieve from experiencing unbearable feelings which they are incapable of addressing in a healthy manner. The most common causes for the onset of overeating is low self-esteem, being over weight as a child, suffering from other problems such as anxiety, depression, abuse or experiencing some kind of trauma. In addition, there is a powerful link with the development of overeating in those who have engaged in yo-yo dieting. Nurture also plays a significant role in overeating, making individuals much more susceptible to its development if they come from a family in which food was used to reward or punish. It should also be mentioned that for some people overeating has a genetic component and this is currently attracting considerable research. 

The psychological consequences of overeating are many and varied but leading the charge is the further erosion of self-esteem. Self-loathing and guilt become constant companions to the person who feels inadequate because of their lack of self-restraint and control. This is further compounded by shame, which can be experienced by what the individual may perceive as an unattractive physical appearance, which in turn may cause them to shun company leading to loneliness and social isolation. Not unsurprisingly a vicious cycle can arise where the embarrassment about body image, self-disgust and the debilitating incessant preoccupation with food can cause a deepening of anxiety or depression and even lead to suicidal ideation. The physical consequences accompanying obese overeaters, as mentioned earlier, are not inconsequential and apart from hindering mobility due to weight gain may include more minor symptoms such as sweating, tremors, headaches, skin problems and back pain.

In the same way that dyslexia was met with considerable ignorance in the last century, public understanding of eating disorders is patchy to say the least. Overeaters can visibly see the public's censure and this immediately shuts down communication and the flow of empathy, which in turn ramps up the sufferers' isolation and tendency towards secrecy. 

Good communication is an essential component when supporting overeaters and in essence the only way to break a sufferers reliance on their addiction is to facilitate them in learning to communicate their underlying problems in a healthy manner via discussion and communication. This in turn will build self-esteem based upon the sufferer's knowledge that they can cope with running their life by being assertive and valuing themselves. Treatment for overeaters can be very varied ranging from individual counselling using various approaches such as cognitive analytic therapy or cognitive behavioural therapy, self-help groups, intensive inpatient treatment and even surgical interventions involving the insertion of a gastric band. In conjunction with mainstream treatments complementary therapies also have a place in recovery and many overeaters have found acupuncture, hypnotherapy, kinesiology, yoga and massage to be beneficial.

The binge-eater's charter1 maps out 20 practical steps for overeaters to follow. With regard to those who have been entrusted with the care of overeaters I would suggest the advice listed in Box 1.

Overeating and the susceptibility to becoming obese has become a major problem in the UK. The greatest weapon against this problem is education; facilitating understanding that overeating like alcoholism and drug dependency is a cry for help. We need to help people to express their difficult emotions in a healthy way through open communication rather than suppress their hurt by stuffing down food. As primary carers, you are uniquely well positioned to help the sufferer start this long journey towards recovery by acknowledging the whole person in all their complexity rather than just addressing the condition. The old adage 'that you are what you eat', needs to be amended to, 'you are so much more than what you eat'. By sewing the seeds of empathy, respect and dignity in the sufferer you can make a difference.