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"Sarah" (not her real name) remembers one particularly argumentative telephone call from her ex-husband a few years ago, a call that really set her off. "I felt so uncomfortable and inadequate," the 57-year-old Vermont-based social worker remembers, "the thought of candy just popped into my mind, and I couldn't get rid of it. It was almost as if I was having two conversations. One was with him, fighting, and the other was with myself, saying, 'When can I go out and get that candy?" Long after she'd hung up, the visions of sweet treats remained, tempting and specific: "It was Pepsi, and three different types of candy," she recalls distinctly. "Pull-apart Twizzlers, Skor bars and Butterfinger bars." Though it was the middle of a workday, Sarah couldn't concentrate on her work or think of anything else until she went out and bought the candy and soda. "I ate them all in my car, really fast," she remembers. "And then, like always, I felt terrible about myself for being so weak."
The shame and remorse led Sarah to keep going, onto a second binge. "Once I started, I figured I'd blown it anyway, so I might as well have everything I like." She stopped at a McDonald's drive-through and ordered the works burger, fries, soda; on another day, she might have ordered a pizza or subs to be delivered to her house. Either way, it ended as it always did: with her stuffing herself with food, alone and ashamed. "I took in thousands of calories without even feeling it," she recalls.
A binger most of her adult life, Sarah's weight fluctuated as she alternated binging with extreme dieting. "I've been as much as 250 pounds, and at my thinnest, around 125," says Sarah, who now carries 215 pounds on her 5-foot-6-inch frame. After nearly two years of counseling and weight-control group sessions at the Vermont Center for Cognitive Behavior Therapy (VCCBT) along with daily, conscious effort she has finally gained the upper hand over what she eats, but not always. "I'm in control of my eating 90 percent of the time now," she says. "I have to struggle with it every day."
Sarah is typical of most of the patients seen by Elena Ramirez, Ph.D. (co-founder of VCCBT) in that her eating patterns frequently spiraled out of control, but not nearly enough to qualify as having a classic eating disorder like bulimia or anorexia. Nor does she fit the profile of a more recently recognized problem, binge eating disorder, or BED which features regular bulimia-like binges but without its "purging" behaviors (like vomiting and laxative abuse). "I see a lot of people with subclinical eating problems who fall between the cracks," Ramirez explains. Many, like Sarah, "use food to distract themselves from negative emotions like anxiety, fear or anger." Some, she adds, are serial dieters who have been so restrictive about what they can or can't eat that when they finally do give in to that forbidden bite of pizza or chocolate, "they think they don't have any control at all, and just eat everything in sight."
This kind of eating behavior can evolve into a full-fledged eating disorder, but more often the overeater waxes and wanes on the edges of an "almost eating disorder," says Ramirez. "Over time, their eating tends to get more and more out of control, and they start to gain weight. That's when they seek help."
Whether binge-eating problems are diagnosed or fly under the diagnostic radar, researchers are just beginning to understand their impact on the population. Last year, researchers at Harvard's McLean Hospital in Belmont, Massachusetts, polled 2,980 Americans in the first national survey of eating disorders. They found that BED is the most common eating disorder, affecting some 3.5 percent of women and 2 percent of men making it more than twice as common as bulimia and more than four times as prevalent as anorexia. While BED and other binging behaviors aren't as well recognized as anorexia and bulimia, "some of the driving forces behind them are the same," notes Cynthia Bulik, Ph.D., director of the eating disorders program at the University of North Carolina at Chapel Hill and co-author of Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions (Rodale, 2005). All involve "the consistent use of food or food-related behaviors (such as purging or exercising excessively) to deal with unpleasant feelings," she notes, coupled with "the feeling that these behaviors are out of control."
Most experts believe binge eating is much more prevalent than any survey can measure. "Our findings only document people whose eating problems are clinically significant and causing marked distress and that's probably just the tip of the iceberg," says James Hudson, M.D., Sc.D., director of the psychiatric epidemiology research program at McLean Hospital and lead author of the national eating disorders survey. "Because there's so much shame associated with eating disorders, a lot of people aren't willing to admit they have a problem.
"We suspect there's a much larger group of people who aren't binging as often or as intensely, but nevertheless have tendencies toward out-of-control eating," Hudson continues. "That's hard to quantify in a survey, but it's out there."
Most of us have done our share of out-of-control eating, whether it's polishing off a family-size bag of potato chips without noticing or eating all the chocolates in the Valentine's sampler and we've probably felt at least a little guilty for overindulging. But if you find yourself having those "slip-ups" fairly regularly or if your eating causes you so much shame that you have to do it in secret your eating issues might be cause for concern.
To some extent we've been programmed to overeat since the days our ancestors hunted and gathered on the African savanna. Having the capacity to binge on huge quantities of food whenever it became available was probably an evolutionary advantage in an environment where food supplies were erratic and scarce. So anytime we see or smell food, several systems kick in simultaneously in various parts of the brain to make sure we don't miss the opportunity to chow down. The brain's reward and motivation system gets fired up ("I must have that pizza now!"), while centers of the brain that link to emotion and memory switch into higher gear ("The last time I had pizza, it made me happy!"). At the same time, the brain's pleasure centers are activated ("Pizza is yummy!"), with the most high-calorie foods causing the most stimulation ("Pizza with double cheese and pepperoni is even yummier!"). The result? Too often we dig in, hungry or not.
These overlapping systems made sense on the savanna, ensuring we'd always seek out the calorie-packed foods that offered the most insurance against famine. But for most of us living in America today, every day is a feast, not a famine. Ads for doughnuts and soda confront us every time we pump gas, and cinnamon buns and pretzel aromas fill every shopping mall. That means our brains' appetite systems are in a frequent sometimes constant state of arousal, experts say. "If you're the type who lights up at the sight or smell of food, just shopping at the mall is a barrage," says Bulik. "You can't even go to a bookstore anymore without being bombarded by the smell of baked goods and coffee. You have to be vigilant almost all the time."
What makes us decide to eat, or not eat, begins in the hypothalamus, a key control center at the base of the brain, explains Mary Boggiano, Ph.D., a psychologist at the University of Alabama at Birmingham who has extensively researched neurochemical changes associated with dieting and binging. "The hypothalamus is what induces satiety or hunger, depending on our caloric needs," she says. ""But when it comes to binge eating, which really isn't about true hunger or satiety, normal hypothalamic function may get overpowered." The parts of the brain that govern rational responses, like the neocortex ("I need sleep, not that pint of Ben & Jerry's") get overridden, too, she explains. What seem to win out are other, connected brain structures that form the "feeling parts of the brain," she says regions like the amygdala (which plays a role in attaching emotional meanings to various stimuli) and the nucleus accumbens (involved in emotions, addictions and pleasure-seeking behavior). For some of us, this inner war with our rational sides and our primal urges to stock up on calories happens dozens of times daily or more. Consider that we're confronted with an average of 200 food-related decisions to make every day, according to Brian Wansink, Ph.D., of Cornell University's Food and Brand Laboratory and an EatingWell advisory board member.
The overstressed lives most of us lead today make the picture even more complicated. "We're also hard-wired to store up calories to deal with stress," says Boggiano, recalling that primordial savanna. "In those days, stress involved events where we needed energy. It was important for the body to have plenty of calories if it was being attacked by a saber-toothed tiger." Food fuels muscles to launch a life-saving response (something along the lines of "Run for your life!") so "it makes sense for survival that stress and food are coupled," she adds.
But in modern life, most of the stresses we face are the sedentary, nonfuel-requiring type like that overdue presentation that must be finished tonight or the simmering feud with a nasty in-law. Nonetheless, the vestigial connections between food and stress remain and we turn to food to soothe, or distract us from, our stressful emotions, especially if we have a tendency to binge. There's a reason why we often turn to chocolate, cake and other treats. Anything high in sugar and fat causes opioids" feel-good" chemicals like endorphins to be released in the brain, which replace stressed-out feelings with pleasurable ones. Researchers from Boggiano's l ab and from the University of California, San Francisco, also found that sugary, fatty foods seem to help suppress levels of a key stress hormone, adrenocorticotropic hormone (ACTH).
"Of course, for bingers and other disordered eaters, overeating in response to stress becomes a stressor in itself," notes Boggiano. "It becomes a vicious cycle of feeling bad about overeating, then eating more to distract from the guilt."
Whether you're stressed or sad, food can also provide a quick fix by stimulating the brain's pleasure/reward system, in which the neurotransmitter dopamine is released in response to pleasurable experiences involving, say, food, music or sex. Those rewards make us want to repeat a behavior again and again, says Nora Volkow, M.D., director of the National Institute on Drug Abuse at the National Institutes of Health in Bethesda, Maryland. "Dopamine is in charge of motivation. Drugs like cocaine use these same reward systems only much more powerfully," she explains. "In some people the compulsive pattern of food intake is so out of control that it mimics what you see in people who are addicted to drugs."
Overeating to soothe emotions is also what behavioral scientists call a "conditioned" or "learned" response. When we repeatedly engage in a certain behavior every time we're in a certain situation say, grabbing a bag of chips at the vending machine every time we have a stressful meeting at work we learn to associate one activity with the other. In the brain, the pleasure-inducing opioids that surge when you eat the chips work together with the dopamine system to make the experience more reinforcing, says Boggiano, "meaning that we are likely to want to do it again." The more the behavior is repeated, the more ingrained it becomes; eventually just seeing the conference room door might trigger a powerful craving for Pringles.
"If you've always had something you do in response to stress, like eating, you keep on turning to it because that's what you've practiced," says Ramirez. "You've become 'conditioned' to that behavior. That kind of behavior might feel 'addictive,' but it's not a true addiction."
Of course, there are those lucky few people who don't soothe themselves with food or find it hard to resist foods' siren songs unless their stomach is empty. "You can put five people in a room with a cake," says eating-disorders researcher Gayle Timmerman, Ph.D., R.N., of the University of Texas at Austin; "there will be one or two people who couldn't care less about the cake, unless they're really hungry. But at least a few of them will have a hard time thinking about anything but the cake."
Genetic programming may determine why at least some of us are the cake-obsessing types. Last year, Hudson and his colleagues reported that binge eating (along with a tendency toward obesity) often runs in families. "If you have a relative who's a binge eater, you're twice as likely to have problems with binging yourself," he says. "And you're also about two and a half times as likely to become obese."
Research by Volkow and Gene-Jack Wang, M.D., at Brookhaven National Laboratory in Upton, New York, suggests a neurochemical basis for why some people might be more likely to become "addicted" to food than others. Using positron emission tomography (PET) scans computerized images that show activity levels in various parts of the brain Volkow and Wang looked at the brains of the most likely candidates for the "food addict" label: a group of 10 extremely obese women and men. They found the group had fewer receptors for dopamine in their brains than did a similar group of normal-weight controls suggesting, perhaps, that an impaired dopamine system might make obese people more sensitive to the rewarding properties of food.
Last October, researchers at the University at Buffalo, State University of New York, uncovered a possible genetic link to dopamine's influence on overeating. When they looked at the DNA of 29 obese people and that of 45 slightly overweight or normal-weight people, the researchers found that about half of them had a form of a gene linked to having fewer dopamine receptors in the brain. The scientists then gave the study subjects computer tasks to perform with their favorite foods (like chocolate and potato chips) as a reward more work, more f ood. They found that the obese people with he fewer-dopamine-receptors gene worked twice as hard for their food rewards than the other obese group who didn't have the variation and much harder than those in the normal-weight groups of either genetic background. The investigators speculated that without as many dopamine receptors, the obese group might have had to seek out excess reward from their food. (What about those people who had the gene, but remained a normal weight? The researchers speculated that they might have found other, nonfood ways to satisfy their need for rewarding experiences for example, smoking or exercising.)
Do obese people eat more, perhaps, to stimulate the dopamine pleasure circuits in their brains, as addicts might do by taking drugs? "I think so, but that's just one piece of what's involved," says Wang. "Humans are complicated, and many factors affect the dopamine system, including social behavior and sleep patterns." But the model provides tantalizing clues as to why so many disordered eaters eventually become overweight.
"You name a diet, I've been on it," says Sarah, the social worker from Vermont who has struggled with binging most of her life. She's not alone. In fact, says Ramirez, most of the people she treats for eating disorders started out as dieters. "It's not uncommon for someone who's been very restrictive to have some form of binge eating eventually for physical as well as psychological reasons, their bodies won't let them be that restrictive for very long."
For her part, Bulik believes chronic dieting is a "catalyst" for eating disorders. "It encourages rigid, hypercontrolled behavior, encouraging you to ignore your body's own signals of hunger and satiety." This negative relationship with food, she believes, "can trigger binging."
Chronic dieting can also induce changes in levels of key neurotransmitters, according to research from Boggiano's laboratory. When she put rats on a "weight cycling" diet that simulated the on-again, off-again pattern many human dieters follow, she found the rats' levels of serotonin (a "feel-good" neurotransmitter) dropped significantly, similar to what's seen in the brain of an anorexic at the height of illness. Dopamine levels also plummeted, and the food-deprived animals had symptoms that suggested depression.
At the same time, in follow-up experiments, Boggiano found that the dieting rats seemed to be extremely sensitive to the effects of opioid drugs like morphine, which tend to stimulate appetite if given in high enough doses. The dieting rats went on a rat-chow binge when given an opioid drug dose that had no effect on nondieting rats. Later, when the rats were subjected to the equivalent of a stressful lifestyle (occasional harmless but annoying shocks) and allowed just a bite of sugary, fatty cookies, the dieting rats reacted the same way that they had to the opioid drugs. "It triggered them to overeat everything even boring rat chow if that was all that was available even when they were completely full," says Boggiano. In contrast, rats who'd never been put on a restricted diet ate normally.
This sounds a lot like what happens with chronic human dieters like Sarah, for whom, when they're stressed, just a taste of a forbidden, calorie-packed food (like a Butterfinger bar) can trigger an uncontrolled eating binge. It also helps explain why so many dieters meet their downfall in calorie-laden fare like peanut butter and pizza. "Nobody breaks a diet with broccoli and cottage cheese," quips Boggiano. "A very powerful food like chocolate that's loaded with fat and sugar is going to create a big release of endorphins in the brain, which can trigger overeating. And for someone who has been dieting, that reaction might be exaggerated."
The finding suggests that a tendency toward overeating isn't all in our heads, she adds. "Psychologists have always explained this problem as a cognitive process the 'I've blown it' syndrome," she explains. "But dieting rats aren't capable of those higher thought processes they don't worry about their weight or feel guilty about food and they can't stop eating after they've had just a bite of yummy food either."
What does all this mean for humans? "When someone severely restricts their calories or has an eating disorder, having these yummy foods around can be like a drink to an alcoholic," Boggiano says. "Until they've quit dieting and have learned to eat a normal amount of food, it's probably not safe to reintroduce those triggering foods or the floodgates will open."
Overeating may be in our genetic makeup; a tendency toward stressed-out binging might be part of our evolutionary baggage. Our brains' reward systems seem obsessively focused on obtaining calories, and our 24/7 eating environment gives them plenty to dwell on. But the good news is that we can overcome these hurdles to become "normal" eaters again, and perhaps even shift our neurochemistry to favor more stable eating patterns even if we're genetically predisposed to binge-eat. "Your genes don't dictate that you're going to develop an eating disorder, only that you're more vulnerable to it," explains Hudson. "A lot depends on environmental factors bringing that predisposition out." And, while you can't completely control your environment, "you can work on how you react to it."
Emotional eating can be managed too. "Because many associations between negative emotions and eating are learned," says Ramirez, "they can also be unlearned," with cognitive behavioral therapy (CBT) skills, such as the ones she teaches to clients like Sarah. By focusing on replacing old behavior patterns with new ones, she explains, "you can learn how to manage your eating to the point that it doesn't feel like an addiction, but like something you have control over." In some cases, drug therapy including fluoxetine (Prozac) and other medications that target the serotonin system can be a useful addition. (Other drugs that target the dopamine receptors are in the works.) "Behavioral therapy can work without drugs, but drugs can't work without behavioral therapy," says Ramirez. "A combination of the two can be helpful for many people."
"The brain is very plastic," adds Boggiano. The same circuitry that gets activated by learning an association (say, gorging on peanut butter cookies every time you're late with a deadline) gets deactivated when you break that connection with new thinking and behavior (like calling a friend for a "stress break" instead). Expose the brain to new stimuli, she explains, "and it can start forming new, healthier habits and activation pathways."
Practicing new ways of thinking and eating has helped put Sarah back in control, steadily and slowly, over the months she has worked with Ramirez. While she has gradually begun to lose weight, she has, more importantly, shed emotional baggage and retrained her brain to think differently. "I've learned to take a step back when I'm feeling anxious or upset and talk myself through it, rather than going immediately to food," she says. "I'll talk to myself in a positive way, instead of beating up on myself."
Being accountable for her actions has also been key. Sarah logs everything she eats in a food diary even on those (now rarer) occasions when she overeats. She keeps "trigger" foods like chips or French fries out of the house, but lets herself enjoy them in manageable amounts at restaurants. She avoids tempting situations like the gas station checkout counter, where candy bars lurk by the cash register; "I pay at the pump with my credit card instead," she says. She has also "normalized" her favorite binge foods by making them part of her daily eating, and enjoying them out in the open rather than in secret: on most afternoons, she'll have an 8-ounce can of Pepsi and a small chocolate bar. "That comes to between 230 and 300 calories," she says. "I just write it down in my diary."
Recently, Sarah realized how far she had come when she made a "huge" mistake at work that in the old days would have sent her straight to the candy counter. She accidentally hit the "send" button too soon, and an unedited document "went to the wrong person," she remembers. "It created all kinds of bad feelings between the parties involved."
But instead of escaping her feelings temporarily by gorging on candy, Sarah faced up to the problem instead and got on the phone. "I admitted to everyone involved that I had blown it and that I was very sorry," she remembers, "but I also said that I had to move on from there." By taking responsibility for the problem, she was able to get through the bad feelings without eating over them, and now they're history.
"I know I've got to work at this every day, but now I have the skills to do it," she says proudly.
Reprinted with permission from EatingWell Magazine.