Binge eating disorder is the most common eating disorder in the United States, affecting an estimated 2.3 million people. (1) Binge eating disorder is a serious, life-threatening condition characterized by recurrent episodes of eating large quantities of food, often in a short period of time. Individuals with binge eating disorder feel a loss of control during the binge, and they will often experience overwhelming feelings of guilt, shame, and self-hatred afterwards.
As a registered dietitian, I often saw patients with obesity, diabetes, and various gastrointestinal disorders confess to episodes of uncontrollable binging. These patients expressed a genuine desire to follow a prescribed meal plan, but they would inevitably “lose control” and binge when they felt hungry, lonely, frustrated, or bored. Several of these patients candidly expressed feelings of extreme shame, frustration, and worthlessness.
Were these patients simply lacking willpower when it came to making food choices?
Was it simply a self-control problem?
Or is something other than the patient to blame?
Do Patients with Binge Eating Disorder Recover?
Every single individual I’ve met who was dealing with binge eating disorder is, without exception, capable and determined, and feels incredible frustration at what appears to be a personal inability to overcome their disorder. Many of these individuals have tried multiple diet strategies and behavioral therapies in an attempt to control their binge eating. While some of these efforts provided temporary relief, almost all are ineffective in the long term.
This perspective is consistent with the medical dogma that eating disorders are incurable diseases. Someone with an eating disorder, if hospitalized, is likely to require hospital readmission at some point in the future. But, even if they aren’t hospitalized, they are “definitely” going to fall back into previous behavior patterns or dysfunctional modes of thinking at some point. And, based on my years of experience, it seemed to me that the dogma proved true. No matter how motivated patients were to abstain from binging, they fell back into behaviors.
However, the only way we can stand by the “incurability hypothesis” is if we accept that patients are broken. I promise you; they are not. So, I asked myself:
“Could the quality of their prescribed diet contribute to the near universal failure of patients to maintain remission?”
In other words, maybe it’s not my patients who are failing themselves, but the nutritional advice that is failing them?
Carbohydrate Addiction Cycle
Standard practice is to provide nutrition advice based on the Dietary Guidelines for Americans (DGA), an eating pattern represented by the Food Pyramid or, more recently, MyPlate models. Whatever graphic the DGA chooses to represent their perspective, the advice always prioritizes carbohydrates and grains as dietary fuel. Fueling with carbohydrates may be unlikely to support recovery in people with binge eating disorder from a biophysiological standpoint.
To begin to understand why, take a look at the six-step cycle below, which depicts what can happen in the brain and body when someone is eating a diet rich in carbohydrates, especially refined carbohydrates and sugar.
(i) Every time we eat carbohydrates, which includes anything from fruit or oatmeal to highly processed carbohydrates like pasta or cookies, these carbohydrates are broken down into sugar. (ii) The sugar goes into the blood, and our blood sugar increases. (iii) In response, the pancreas will release insulin (except in persons with type I diabetes). (iv) Insulin promotes fat storage and (v) drives down blood sugar levels. For some people, this drop in blood sugar can cause symptoms such as dizziness, shakiness, intense hunger, or irritability, but almost everyone experiences a form of carbohydrate late post-prandial craving. To prevent or alleviate these symptoms, (vi) the individual naturally seeks out more sugar and carbohydrates. And the cycle continues indefinitely.
Fueling the Cycle 1: Our Modern Food Environment
Sugar and processed carbohydrates are ubiquitous in our modern food environment. From hospital foodservice and cafeterias to our schools, hardware stores, jails, and even to veterinary clinics, it seems that everywhere you go, you are offered food options consisting of high amounts of sugar, flours, and processed oils.
It’s estimated that up to 80% of items in the grocery store contain added sugar or corn syrup. But that’s just the tip of the iceberg. Sugar is hidden everywhere, from sauces and dressings to broths and deli meats.
The social environment compounds upon the physical environment. Friends, relatives, and co-workers are always “food-pushing.” They are certainly well-intentioned, but living in a nation with an artificially carbohydrate centric physical and social space can make avoiding the carbohydrate cycle difficult.
Fueling the Cycle 2: Sugar is Addictive
In my experience as a clinical dietitian, the idea that someone could literally be addicted to sugar or carbohydrates was generally dismissed. However, the rise in obesity, coupled with the emergence of scientific findings of parallels between drugs of abuse and palatable foods has given credibility to the idea that some people may develop an unhealthy dependence on sugar and processed foods. (2,3)
Individuals who develop food addictions are proposed to display symptoms similar to those of drug addiction, including craving for “problem foods,” tolerance (needing more food to satisfy cravings), limited control of food intake, unsuccessful attempts to reduce intake as well as withdrawal symptoms. It’s worth noting that commonly suspected problem foods share nutritive properties (they tend to be high in sugar or high in fat and sugar). I’ve met many individuals who state that if they have a single bite of a processed food item, such as a cookie or even a taste of something sweet, they are unable to control their intake. This suggests a chemical or metabolic link versus simply a behavioral link.
In fact, the brain systems that support the abuse of addictive drugs, like nicotine, amphetamine, or cocaine, are the same systems that support sugar addiction. (4) These include the dopamine system and opioid system and other components of the limbic system, which controls emotion. Just like drugs of abuse, the more sugar you have, the more sugar you want. This is called sensitization. Interestingly, in studies performed on rats, sugar cross-sensitizes with amphetamine or cocaine. In other words, giving rats sugar sensitizes them to these drugs of abuse. Why? Because they work on the exact same brain systems.
In fact, the neurobiological and neurochemical imprints of drugs of abuse and sugar are highly similar. They decrease the expression of certain dopamine receptors, like the D2 receptor, as well as decrease the expression of brain opioids, like enkephalin. Also similar to drugs of abuse, sugar restriction can cause temporary withdrawal symptoms. And these symptoms can be mimicked in the presence of sugar by injected opioid blockers, further confirming that sugar and drugs of abuse work on the same systems.
Fueling the Cycle 3: Eating “in Moderation”
Having reviewed the carbohydrate addiction cycle and previewed the concept that sugar is a substance of abuse at a neurobiochemical level, let’s ask ourselves whether it makes sense to suggest that individuals with binge eating disorder should be prompted to consume anything “in moderation.” The conventional logic goes that placing any restrictions on foods for someone with an eating disorder, including binge eating disorder, can worsen their already dysfunctional relationship with food.
But this logic fails to consider the fact that, in binge eating disorder and related conditions, refined carbohydrates (sugar) can effectively become a substance of abuse, as reviewed above. If this is the case, then “everything in moderation” is effectively a strategy in which we bait individuals suffering from a form of addiction with the addictive substance, suggesting that it’s okay – even healthy – to have just a little bit of the substance of abuse.
Is it any wonder that individuals with binge eating disorder experience loss of control and a sense of failure? They cannot will their way out of a dysfunctional eating pattern being driven by their biology.
Individuals with binge eating disorder desire to find food freedom and regain a sense of control. Following the standard American dietary guidelines will set them up for the exact opposite of what they are hoping to achieve. Food will control them, rather than the other way around.
Is there an alternative?
Ketogenic Diet for Binge Eating Disorder, Case Series
In a recent case series, published by Carmen and colleagues in the Journal of Eating Disorders, three individuals with obesity and binge eating disorder achieved complete remission following a ketogenic diet. (5)
In this case, the patients were prescribed a ketogenic diet containing 10% calories from carbohydrates, 30% calories from protein, and 60% calories from fat. All three patients tolerated the diet well, with no major adverse side effects, and all were able to adhere to the diet for the prescribed period and at follow-ups.
The patients universally reported reductions in binge eating episodes and food addiction symptoms, including cravings and lack of control as determined by validated binge eating or food addiction measuring tools. Additionally, patients lost 10-24% of their body weight. Finally, all patients reported substantial improvements in mood symptoms.
Could a ketogenic diet be the key to full recovery for individuals with binge eating disorder?
Could a primal diet of meat, eggs, fish, nuts, oils, butters, select, non-starchy vegetables be the key to long-term recovery?
While it almost seems too good to be true, this report suggests that “therapeutic carbohydrate restriction” (TCR) for binge eating disorder may be more effective than the alternative everything “in moderation” diet. Certainly, controlled trials will be required before ketogenic diets can become standard of care for any eating disorders, but the mere possibility that they could provide a cure (or permanent remission) for a mental illness that almost never remains in remission given the current standard advice should give academics and medical professionals pause to think.
It is my sincerest hope that more professionals become open to exploring the possibility that a ketogenic diet could help patients with binge eating disorder achieve lasting recovery. What “we,” as a medical and dietetics community normally do doesn’t work for these patients. So, now, we need to try something different.
“Eating Disorder Statistics • National Association of Anorexia Nervosa and Associated Disorders.” National Association of Anorexia Nervosa and Associated Disorders, 17 June 2019, anad.org/education-and-awareness/about-eating-disorders/eating-disorders-statistics/.
Kim J Shimy, Henry A Feldman, Gloria L Klein, Lisa Bielak, Cara B Ebbeling, David S Ludwig, Effects of Dietary Carbohydrate Content on Circulating Metabolic Fuel Availability in the Postprandial State, Journal of the Endocrine Society, Volume 4, Issue 7, July 2020, bvaa062, https://doi.org/10.1210/jendso/bvaa062
Avena NM, Rada P, Hoebel BG. Evidence for sugar addiction: behavioral and neurochemical effects of intermittent, excessive sugar intake. Neurosci Biobehav Rev. 2008;32(1):20-39. doi:10.1016/j.neubiorev.2007.04.019
Carmen, M., Safer, D.L., Saslow, L.R. et al. Treating binge eating and food addiction symptoms with low-carbohydrate Ketogenic diets: a case series. J Eat Disord8, 2 (2020). https://doi.org/10.1186/s40337-020-0278-7