Anxiety Program
Remuda Life
Special Holiday Issue 2006, Volume 5, Issue 4
Emotional Eating
Emotional Eating: A Case Study
We take a break from our series on eating disorder comorbidity with this special holiday issue focusing on emotional eating.
We are offering information on emotional eating at this time because emotional eating becomes even more common and distressing during the holidays. People who eat emotionally through-out the year are confronted with heightened accessibility to foods that they have come to view as “forbidden” and “bad”. Those who experience holiday-related sadness due to past life events are also more apt than usual to engage in emotional eating behaviors to soothe difficult feelings. Even people who are functioning emotionally and psychologically without much distress may eat for emotional reasons at this time of year, because hurriedness and stress increase and naturally lead people to eat without thinking, merely because food is present.
Emotional eating is an emerging concept in the field of eating disorders. Its definition is evolving as clinicians learn to treat people with emotional eating problems and researchers begin to examine this domain. In this issue of The Remuda Review, we offer a preliminary definition of emotional eating. We lean primarily on the literature about binge-eating disorder—the most extreme form of emotional eating—to understand the antecedents and treatments most appropriate for those who eat emotionally.
We hope you will find this issue timely during the holiday season and throughout the year as you work with clients who may struggle with emotional eating.
In our next issue, we will resume our ongoing exploration of eating disorders’ most significant co-occurring concerns.
Emotional Eating
Edward J. Cumella, PhD, Department of Research and Education
Darcy Tucker, MA, LAMFT
Remuda Ranch Programs for Eating Disorders
“Eat your food with gladness, and drink … with a joyful heart...” Ecclesiastes 9:7
Emotional eating refers to a range of behaviors in which people eat for reasons other than physiological hunger or participation in cultural events. When people eat for emotional reasons, rarely do they eat their food with gladness or drink with a joyful heart. Instead, they eat to manage uncomfortable emotions, such as sadness, loneliness, grief, worthlessness, hopelessness, anger, anxiety, guilt, and shame. Beyond these disquieting emotions which they are attempting to manage, the very act of emotional eating leads those who are doing so to anguish about weight gain, social taboos, possible illnesses, and their loss of control over food. So emotional eating itself can create or intensify emotional distress, including feelings of embarrassment, self-disgust, depression, guilt, and shame. Hence, emotional eating becomes a vicious cycle: eating to escape negative feelings ultimately intensifies negative feelings and precipitates additional emotional eating. “He eats in darkness, with great frustration, affliction, and anger” (Ecclesiastes 5:17).
With the obvious negative affect associated with emotional eating, a logical question arises: Why does anyone eat for emotional reasons? Simply, emotional eating is effective at short-term emotion regulation. Its short-term effects arise from various factors:
Eating produces physiological satiety, which reduces and may even supplant the physiological agitation associated with anger, distress, and anxiety.
Eating large amounts of food may raise blood sugar levels, producing an experience of numbness in which all emotions, including depression and loneliness, are minimized.
Eating to the point of physical discomfort distracts individuals from their emotional pain.
Continuous eating over several hours or throughout the day distracts people from disturbing thoughts.
Consuming foods that are associated with past positive experiences may bring immediate pleasure, temporarily supplanting depression.
Certain foods raise endorphin levels, mimicking drug use and temporarily elevating mood.
Combinations of these effects, and others, may drive emotional eating in particular individuals. These multiple effects on mood readily reinforce emotional eating behavior. The immediate and short-term results are often stronger than the longer-term consequences which, at the moment the emotional eating occurs, are merely a cognitive awareness relegated to the future. The promise of immediate release from emotional distress, in spite of longer-term consequences, is precisely why those with substance abuse problems rely on dangerous drugs. Short-term reinforcement often overwhelms our awareness of longer-term risks.
Some people eat emotionally but are not overweight or only slightly overweight. They experience a range of biological, psychological, social, and spiritual consequences from their emotional eating. Obese emotional eaters contend with the additional problems that obesity may cause. Medical authorities inform us that obesity is an epidemic in the United States, affecting all age, ethnic, faith, gender, and socioeconomic groups. Somewhere between 1/3 and 1/2 of obese individuals may engage in emotional eating (Spitzer et al, 1993).
With all groups of emotional eaters combined—those of normal weight, the overweight, and the obese—emotional eating affects far more Americans than the more extensively researched eating disorders, anorexia and bulimia. Emotional eating problems affect men, women, children, adults, and people from diverse cultural backgrounds. Emotional eating problems have become so common, however, that we often forget that they are seriously distressing to people even when weight issues are not present. In addition, many people are ashamed of their emotional eating, so they keep their behaviors secret, or they have relied on emotional eating for so long that it almost seems normal to them and they would not think to mention it to a healthcare professional.
For these reasons, the 25%-30% of Americans with emotional eating issues (Cumella, 2005) are not being routinely identified by healthcare professionals or seeking help for their emotional eating problems. It’s time to remove the veil of secrecy, to ask our patients direct questions about their eating behaviors, and to offer sound assistance.
Etiology
Since women who frequently diet binge more often, some believe that dieting triggers a physiological starvation response leading to bingeing. However, because half those with binge-eating disorder begin to binge without dieting (Abbott et al, 1998), bingeing must serve functions besides a physiological response to dieting. The affect regulation model sees emotional eating as maladaptive coping intended to reduce unpleasant emotion and reinforced by the experience, albeit temporary, of reduced negative emotion (Polivy & Herman, 1993). Simply stated, the existing research indicates that moods, thoughts, and relationship issues may be more influential in precipitating binges than physiological functions. We explore these psychosocial issues below.
A primary risk factor for emotional eating is living in a culture that values thinness. As such, all Americans are at risk. Cultures that value thinness create categories of “forbidden” foods, leading to chronic experiences of food deprivation. The situation for Americans is exacerbated by the abundant availability of rich foods, large restaurant portion sizes served in environments designed to promote rapid and distracted eating, the perception that eating while working or engaging in other activities is normal, and a sedentary lifestyle promoted by cities built around automotive travel rather than walking. These conditions place Americans in a contradiction: we’re told to fight our biological drive to eat and minimize food intake in order to achieve a highly valued thin appearance, but we are simultaneously saturated with a plethora of available and appealing foods and food choices. In this environment, eating becomes a highly emotionally charged event and becomes intertwined with a variety of feelings and needs.
These cultural influences are not consistent with a Biblical worldview. In a healthy environment, we would recognize: that each person is created unique by a loving God—unique in body, soul, and spirit; that beauty comes in many forms, shapes, and sizes, and is both internal and external; that all foods are good, gifts of a loving God; that, barring genetic abnormality, natural hunger urges are built into us by God’s design and should not be negated, overruled, or manipulated. In the Bible, eating and feasting are repeatedly associated with family, fellowship, joy, and celebration—social experiences set aside from the workday and other distractions. In a healthy environment, then, people would eat with others, taking time to relate and enjoy their food, not rushed by a clock or distracted by noise and images, with a sense of gratitude for the nourishment, flavors, and relationships, relaxing and noticing their hunger and satiety cues to complete their eating with a sense of physical, emotional, relational, and spiritual satisfaction.
Those most vulnerable to emotional eating are the same individuals most vulnerable to the other eating disorders. Such individuals are more likely to have been abused physically, sexually, or emotionally. They are often depressed, anxious, have low self-esteem, and may misuse substances. They may have a history of repeated dieting and regaining of weight or continued weight increases over a long period of time. Difficulties in any relationship also tend to drive emotional eating behaviors. As such, people who eat for emotional reasons may come from overweight families or families with other psychiatric disorders. Their families may be rigid and unsupportive, indirect or mute with feelings, isolated and sedentary, lacking in structure, consistency, and predictability. Independence is not stressed. All of these factors may contribute to a sense of having no control over one’s life and provide an inclination to use food as a source of comfort and short-term emotional control.
Diagnosis and Assessment
The best researched emotional eating problem is binge eating. When this occurs with regularity and without efforts to purge the calories consumed, the individual might have binge-eating disorder; see the DSM-IV for diagnostic details. But other forms of emotional eating also exist; they are often less extreme than binge-eating disorder in terms of the quantity of food consumed or the frequency of binges, but they can be quite distressing to those involved and can lead to serious physiological problems. The range of emotional eating issues includes: eating when not hungry, eating when stressed, eating in secret, eating foods perceived as “forbidden”, grazing or snacking throughout the day, eating to soothe or forget feelings, and other emotional uses of food. If severe enough, the DSM-IV permits diagnosis of all these emotional eating problems as eating disorder not otherwise specified.
What separates a diagnosable eating disorder from less severe emotional eating is often the frequency and severity of the behaviors, the degree of distress the behaviors cause, and the degree of body hatred that ensues. Of note, among emotional eaters, people who are overweight, normative, or underweight can all be significantly uncomfortable in their body.
When the level of physical or emotional distress escalates, assistance should be sought from a qualified medical professional, counselor, or registered dietician. Sadly, however, while these emotional eating behaviors often start in a person’s teens or early twenties, many individuals fail to seek or receive appropriate intervention until their thirties or forties. That is a long time to suffer. And some never ask for help, but remain in the darkness of shame and secrecy, never even telling their closest friends, family, or spouse.
People who are overweight are often viewed in our society as being unattractive, awkward, weak-willed, lazy, unintelligent, and lacking in self-control. Overweight individuals may suffer discrimination in employment, salary, promotion, and education. Considering the amount of ridicule many overweight individuals endure, it is no wonder that many internalize the toxic beliefs of our society. Research sadly suggests that even healthcare professionals who are trained to understand risk factors and intervene appropriately often evidence bias against the overweight. As such, overweight individuals may be less likely to visit healthcare professionals for preventive healthcare to avoid lectures about weight or embarrassment at inappropriately-sized medical equipment. It is therefore critical for healthcare providers to examine their own biases and understand the nature of emotional eating so that they can accept and validate their overweight emotional eating patients and offer effective therapeutic solutions.
Initial screening for emotional eating can be accomplished with five questions asked of clients:
Do you eat a lot of food in a short period of time?
Do you sometimes feel out of control when you eat?
Do you eat when you are not hungry?
Do you eat to soothe your feelings or distract yourself from uncomfortable thoughts?
Do you eat in secret?
If clients answer “yes” to one or more of these questions, a more detailed assessment is indicated. It is necessary at this juncture to differentiate emotional eating from bulimia nervosa and to determine whether the emotional eating symptoms rise to the extreme level of binge-eating disorder, are distressing enough to be diagnosed as eating disorder not otherwise specified, or, if not directly diagnosable, nevertheless merit therapeutic attention.
Several self-report questionnaires may bring objective data into this assessment:
Eating Disorder Inventory-3, measuring clinical features of eating disorders and associated issues (Garner, 2004).
Three Factor Eating Questionnaire, measuring behaviors of dietary/cognitive restraint, disinhibition, hunger (Stunkard & Messick, 1985).
Questionnaire on Eating and Weight Patterns-Revised, producing information on weight cycling, weight/dieting history, and body image (Spitzer, Yanovski, & Marcus, 1993).
Questionnaires that measure depression, anxiety, substance use.
Paper-and-pencil questionnaires such as these can be quite helpful in assessing patients with emotional eating issues, since many feel more comfortable disclosing information in this format, rather than face to face, when it comes to behaviors about which they are ashamed.
Detailed psychosocial, nutritional, medical, and body image assessments are often needed when an emotional eating problem exists. Patient self-monitoring of behaviors can also reveal important data about experiences that trigger and maintain individuals’ emotional eating.
Intervention
Intervention with emotional eating clients has three main objectives:
Possible weight loss, or prevention of further weight gain, as medically indicated, combined with solid nutrition education and counsel.
Reduction or cessation of binge eating or over-eating.
Improved attitudes about one’s weight, shape, eating behaviors, and physical activity.
Several approaches described below have research support as effective in achieving these goals. In Remuda’s Emotional Eating Program, each of these approaches may be used, depending on the individualized assessment of each patient’s needs.
Weight Loss/Nutrition Education. If someone who eats emotionally is extremely overweight with imminent resulting medical compromise, counselors—along with medical consultation—need to consider the wisdom on weight loss interventions. However, in most cases of overweight and obesity, weight loss may not be the goal. Controversy exists regarding Behavioral Weight-Loss Treatments (BWL) because their long-term effectiveness is extremely poor. Furthermore, authorities are now questioning the oft-heard idea that overweight inevitably leads to health problems and are suggesting instead that people can be healthy at any size. In addition, BWL often intensifies emotional eating and leads to severe relapses with additional weight gain. Unless the emotional, cognitive, relational, and spiritual aspects of emotional eating are addressed, disordered eating and weight itself may be difficult to reduce. In lieu of BWL, we recommend that counselors consider the Health at Any Size approach, which emphasizes self-acceptance, a renewed relationship with food, and engaging in enjoyable physical activity rather than exercise per se. This approach is gaining prominence among eating disorder specialists. For more details, see www.healthyweight.net.
American’s waistlines are growing in spite of the many diet aids, weight loss products, and medical weight-loss procedures available. According to the American Academy of Family Physicians, there are more than 50 individual dietary weight-loss supplements and more than 125 commercial combination products available for weight loss. The pictorials and testimonials that accompany the advertising for these products and services often seem convincing. Yet none of these products meet the criteria for recommended use for their efficacy, safety, or quality. In extreme cases, surgical interventions can be life saving, but often do not address the underlying issues that created the obesity in the first place.
Most anyone could readily think of many “magic bullet” weight-loss methods that have been proffered over the years–such as diet pills, green tea, smoking, fasting, restricting intake only to “good” or “healthy” foods, commercial meal replacement programs, low-fat/no-fat diets, low carbohydrate diets, and dehydration techniques. There are also fitness centers, gyms, and personal trainers claiming that they can remake someones physically.
Dieting is very ineffective. In almost all cases, the lost weight is regained. Dieting by its nature avoids recognizing important internal cues related to hunger and satiety, although more weight loss programs today are including such awareness in their curricula. Dieting can create food and weight preoccupations, a physiological and psychological experience of deprivation, and decreased metabolism. It often depletes the pocketbook through costly regimes, and reinforces the notion that there are good and bad foods while increasing shame for giving into temptation and eating foods deemed unacceptable. Dieting can lead to depression, anxiety, anger, and irritability while impairing body image and decreasing self-esteem. Dieting can be outright harmful medically, and it can lead to anorexia and bulimia, the most extreme forms of eating disorder.
Therefore, dieting is not the focus of treating emotional eating, except perhaps in cases of extreme obesity with imminent medical consequences. Instead, a healthy relationship with food and one’s body are the main goals. Such changes may ultimately lead to appropriate, gradual, and sustainable weight loss—which is often quite modest in quantity—with positive physiological effects. For example, the American Dietetic Association has seen that a decrease of a mere 6-7% of body weight paired with a 30-minute per day increase in physical activity can decrease the conversion of impaired glucose tolerance to diabetes by more than half. Weight reduction of just 5-10% decreases the risk and status of cardiovascular diseases, arteriosclerosis, and Type II diabetes. Total cholesterol decreases, low-density lipoproteins (LDLs or “unhealthy cholesterol”) decrease, and the high-density lipoproteins (HDLs or “healthy cholesterol”) increase. Sleep apnea improves. Yet even if weight does not decrease, the healthier emotional and physical lifestyle has major benefits, such as improved self-esteem, relationships, life quality and satisfaction, and immune response.
It is important to remember that emotional eaters are often very aware of their past weight loss “failures”. Guilt, shame, and feelings of failure typically increase emotional eating. When engaging in treatment that does not offer immediate weight loss, emotional eaters will need to recognize the power of the slow process of change and identify new and alternative responses. Eventually emotional eaters will redefine success from weight loss to healthy lifestyle and improved life quality. Through this education process, emotional eaters can define what success truly means for them.
This positive focus on a healthy relationship with food and one’s body is a breath of fresh air for Americans who are burdened by the incessant blare of dieting messages and thin images. Such a change of focus opens the door for individuals to function in greater harmony with their bodies, listening to internal cues regarding hunger and satiety. This changed focus therefore allows people to appreciate their bodies and the life-giving mechanisms that God built into them. To be at war with the body God gave us inherently disconnects us from our spirituality. To appreciate and understand our body deepens our experience of God’s love for us as unique creations and his presence in our everyday life.
Psychopharmacology. Antidepressants, anticon-vulsants, and centrally acting appetite sup-pressants have shown some efficacy in treating binge eating and promoting weight loss. But it is essential to recognize that medications for binge eating and weight loss offer only marginal results. As such, pharmacological treatment may frankly be of minimal value in treating emotional eating itself. However, since many who eat emotionally also have depression and anxiety, standard psychopharmacologic treatments for these co-occurring and sustaining issues may prove quite useful, particularly if medications are selected that do not intensify appetite or lead to weight gain.
Exercise Instruction. Remuda’s emotional eating patients are recommended to exercise three times per week for 60 minutes with staff, once per week with a group for 90 minutes, and on their own at least one other time per week for 60 minutes. The first group focuses on techniques, cardiovascular training, overall flexibility, and strength building, which allow for an improved quality of life. The second group focuses on experiencing a variety of activities, trying something new, attempting activities patients had not previously given themselves permission to try or enjoy, and learning to exercise with others. Finally, when exercising on their own, patients have the opportunity to do the activity they enjoy the most.
Cognitive Behavioral Therapy (CBT). CBT identifies and helps patients to change irrational, distorted, and harmful thoughts/beliefs that are leading to painful feelings and problematic behaviors. Those with emotional eating problems often evidence self-defeating beliefs, including low self-worth and self-efficacy, doubts about their ability to tackle problems, a lack of effective problem-solving skills, entitlement, unrelenting perfectionistic standards, codependency, and black-and-white thinking. Emotional eaters often have extreme and specific rules about what, when, and how much to eat. They become distressed when they fail to follow their self-imposed rules, often precipitating further emotional eating. CBT is capable of assisting in each of these areas and is therefore often a core treatment modality for those who eat emotionally.
Interpersonal Therapy (IPT). Relationship diffi-culties have been shown to drive bingeing and emotional eating. Because IPT focuses on clients’ personal relationships, it can be a useful approach to treatment for emotional eating. It has been shown to reduce emotional eating in 50% of clients. IPT concentrates on four interpersonal themes: loss, disputes, life transitions, and isolation/loneliness. Other relationship-oriented approaches may also be effective in addressing these issues.
Dialectical Behavioral Therapy (DBT). Because clients rely on emotional eating to regulate negative emotions, emotional eating can be addressed directly by teaching healthy emotion regulation skills. DBT (Linehan, 1993) is the most well-researched method for teaching such skills and would often be central in treating those who eat emotionally.
Marital/Family Therapy. Because marital and family distress/conflict may contribute to emotional eating, pending appropriate assessment spousal and family treatment may be needed. Family systems and structures that resist change and promote unhealthy emotion regulation can be challenged. This often includes a focus on improved intimacy in relationships, assertion, and communication skills to overcome patterns of codependency, shame, and mistrust.
Support Groups. Self-help and professionally-led support groups can be quite effective, since people with emotional eating problems often attempt to soothe their distress through isolated eating rather than by reaching out to a support network. Groups can help patients reduce shame and isolation, to learn to identify and express emotions directly, receive affirmation and counsel, choose supportive relationships, and trust that others may be willing and able to help when distress arises. Groups are particularly important from a spiritual perspective, because they reconnect us to the human community, allow us to experience God’s love, forgiveness, and acceptance in palpable ways, and help us to feel less alone with our emotional burdens and worries.
Spiritual Care. Helping patients to explore their relationship with God and food can offer new insights in the journey of recovery from emotional eating. Important questions may include the following. Is God sometimes left out of the process of dealing with emotional pain? Are there ways to bring God into this process, into the pain itself, and thereby to honor God more fully with one’s body? How would this affect one’s food choices? What is the meaning and role of suffering within one’s faith background, and can some unavoidable emotional pain be tolerated—even embraced—through spiritual transcendence? For Christians, what does the Bible say about the role of food in our lives, and also the role of emotions—both the joyful and difficult ones? Additional guidance on the individualized spiritual assessment and care of eating disorder patients can be found in a series of articles published in two prior issues of The Remuda Review (2005, Vol. 4, Issues 1 and 2).
Conclusion
Emotional eating is a common problem in the United States, but one that has received insufficient attention in the mental health field.
Many people are experiencing significant distress from emotional eating—distress that can be relieved. Public and professional awareness is paramount, so that professionals identify and sufferers seek assistance for emotional eating problems.
There is hope for those who are the silent sufferers among us. To reach a state of enjoying food and life in contentment with self, without guilt and shame, is to experience God’s providence: “for without him, who can eat or find enjoyment?” (Ecclesiastes 2:25)
Useful Resources
Cash, T. F. (1997). The Body Image Workbook. Oakland, CA: New Harbinger.
Fairburn, C. (1995). Overcoming Binge Eating. New York: Guilford.
Health at Any Size Journal
King, N., Kratina, K., & Hayes, D. (1999). Moving Away From Diets: New Ways to Heal Eating Problems and Exercise Resistance. Lake Dallas, TX: Helm Publishing.
May, M., Galper, L. & Carr, J. (2005) Am I Hungry?: What to do When Diets Don’t Work. Phoenix, AZ: Nourish Publishing.
Roth, G. (1984). Breaking Free from Emotional Eating. New York: Plume.
Tribole, E., & Resch, E. (1995). Intuitive Eating: A Revolutionary Program That Works. New York: St. Martin’s.
References
Abbott, D.W., de Zwaan, M., Mussell, M., Raymond, N.C., Seim, H.C., Crow, S., Crosby, R.D. & Mitchell, J.E. (1998). Onset of binge eating and dieting in overweight women: Implications for etiology, associated features, and treatment. Journal of Psychosomatic Research, 44, 367-374.
Cumella, E.J. (2005). Address the treatable emotional eating. Behavioral Healthcare Tomorrow, 14, 12-13.
Garner, D. M. (2004). Eating Disorder Inventory-3 Professional Manual. Lutz, FL: Psychological Assessment Resources.
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Polivy, J., & Herman, C.P. (1993). Etiology of binge eating: Psychological mechanisms. In C.G. Fairburn & G.T. Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 173-205). New York: Guilford.
Spitzer, R.L., Yanovski, S.Z., & Marcus, M.D. (1993). Questionnaire on Eating and Weight Patterns-Revised (QEWP-R, 1993). New York: The New York State Psychiatric Institute.
Spitzer, R.L., Yanovski, S., Wadden, T., Wing, R., Marcus, M.D., Stunkard, A., Devlin, M., Mitchell, J., Hasin, D., & Horne, R.L. (1993). Binge eating disorder: It’s further validation in a multi-site study. International Journal of Eating Disorders, 13, 137-153.
Stunkard, A. J., & Messick, S. (1985). The Three-Factor Eating Questionnaire to Measure Dietary Restraint, Disinhibition and Hunger. Journal of Psychosomatic Research, 29(1), 71-83.
Emotional Eating: A Case Study
Darcy Tucker, MA, LAMFT
Remuda Ranch Programs for Eating Disorders
Emotional eating is part of the eating disorder spectrum. It requires specific, scientifically-valid treatments that address its biological, psychological, social/cultural, and spiritual aspects. Remuda’s Emotional Eating Program offers this package for those who eat emotionally, whether overweight or not. Patients participate in a Biblically-based program that promotes healthy eating and a balanced lifestyle. The program integrates portions of Dialectical Behavior Therapy (Linehan, 1993), cognitive-behavioral therapy, family therapy, body image therapy, nutrition counseling, and experiential modalities as appropriate, to address the skills needed to support ongoing recovery. Treatment is provided by a team of professionals, including Master’s level therapists, primary and psychiatric care providers, registered dieticians, and 24-hour support staff.
Susan was a recent patient in Remuda’s Emotional Eating Program. Susan experienced body dissatisfaction from a young age. She knew that she had an honest mix of her mother’s larger bone structure and her father’s tendency to hold weight around the middle. Struggling with her weight most of her life, she realized in her late 30s that she had tried practically every weight-loss method, owned seemingly every weight-loss book published, and yet ended up gaining more weight after each dieting attempt. She was angry at herself for being unable to control what she ate and her ongoing weight gain.
Susan was experiencing acid reflux, difficulty sleeping, constipation, and arthritis in her knees. Her physician diagnosed her with hypertension and elevated cholesterol, putting her at increased risk for stroke. She was also at high risk for developing Type II diabetes. Her physician had long encouraged her to lose weight. She entered Remuda’s Emotional Eating Program because everything else she had tried had failed. Susan was anxious because she was used to weight loss programs, but the Remuda program was focused less on weight loss and more on the underlying issues that lead to a patient’s current condition. Susan knew intellectually that she needed something new, something that could reach her emotionally and spiritually and help her heal the inner wounds that were continually driving her unhealthy eating behaviors. But emotionally, she was still quite focused on weight loss as her ultimate goal and the one thing that could bring her happiness.
At admission, Susan presented as sad and somewhat anxious. She was diagnosed with moderate depression and mild anxiety. She also related in an interpersonally guarded fashion. Her psychosocial assessment revealed an extensive history of increasing guilt and shame, evidenced by growing disgust for her body. With this combination of symptoms, Susan’s psychiatric provider recommended that Susan begin taking Fluoxetine for depression.
Remuda’s Emotional Eating patients have been anywhere from 10 to 185 pounds overweight. Susan was in the higher range. Her nutritional assessment revealed she weighed 237 lbs., 159% of her ideal body weight. Her Body Mass Index (BMI) was 39.4, at the top end of the obesity range. She reported her highest weight to be 243 lbs., which occurred just prior to treatment at Remuda. Susan often ate alone and in secret, feeling ashamed because she could not control her eating behaviors and because of the stigma that her family and society place on obesity. She used moderate amounts of caffeine, diet and reduced calorie products, and had attempted smoking cigarettes to control her weight. She occasionally used drastic weight control measures, but was unable to maintain the weight loss or the behaviors; she would soon lose control and binge eat once again.
Prior to coming to Remuda, she had not recognized the multitude of times each day and night that she ate without regard to sensations of hunger or fullness. Susan ate between meals, mostly sweet, salty, and high-carbohydrate foods. During group meals at Remuda she often denied her feelings of hunger, but would then hide food to be available for later when she was alone. During a binge, or “uncontrollable eating” as she called it, she reported feeling “detached, zoned out, and out of control”. Afterward, she reported feeling guilty, ashamed, and even more uncomfortable in her body.
With the help of her dietician and therapist, Susan began to recognize her pattern of regulating emotions, particularly her negative emotions, by zoning out through uncontrollable eating. As such, her therapist determined that it was critical to begin by teaching Susan distress tolerance skills on which to rely instead of her binge eating behaviors. In this process, Susan was helped to identify and consciously experience her emotions so that she could choose appropriate distress tolerance skills to manage them. She was delighted at the emotional depth this allowed her to feel, and the relief of having tools to lean on during emotionally difficult moments rather than food.
In therapy sessions, Susan and her therapist identified key issues that made it hard for her to deal openly and directly with her difficulties and thus apt to rely on emotional eating to do so. These issues included a history of superficial relationships, people-pleasing, feeling empty inside, and care-taking her family. Her actual eating disorder began when she was a teenager, with the social and academic pressures of high school, increasing body image awareness, and an instance of sexual abuse. She had no one to talk to about these concerns, and turned to food to numb her feelings and dissociate. The behavior continued since that time.
Susan was then assisted in identifying the typical, immediate triggers to her emotional eating behavior. She identified stress, aloneness, tiredness, and feeling overwhelmed, sad, or angry. In years past, she used alcohol to soothe these feelings, but now—not wishing to become an alcoholic—she used only food. To help her respond to her immediate emotional eating triggers more effectively, Susan’s therapist met with her to establish basic distress tolerance and practicing presence skills. Through this process, Susan acknowledged that although her initial treatment goal was weight loss, these internal emotion regulation changes were necessary for her.
Susan’s dietician instructed her to read the book, Intuitive Eating (Tribole & Resch, 1995), to learn to select foods based on her enjoyment of them rather than by their caloric content. The very notion frightened her. To assist, Susan kept food logs, chronicling the food groups she had eaten across three meals and three snacks each day, noting periods of exercise and movement, including her thoughts, feelings, and emotions. Her initial nutrition plan was aimed at normalizing and regulating her eating patterns throughout the day and utilizing appropriate serving sizes. Susan learned how to leave bites behind when full, to wait 20 minutes to register fullness, and to use intuitive eating principles. She began to recognize lapses—i.e., eating out of emotion rather than hunger—and redirected herself to use skills during these times rather than to catastrophize by seeing the lapse as a sign that she was a total failure and then shaming herself for being so. She learned to rely here on her faith, forgiving herself because God forgives her, recognizing that God has given her a lifetime to grow in a spiritual process, that God does not expect perfection of her today, and that God loves her very much as she is today.
Susan also met with her dietician to assess her level of physical fitness and activity. Together, they explored the physical activities she enjoyed in the past or might enjoy if she gave herself permission to try. Based upon the results of this assessment, and with some coaching, Susan began to exercise three times per week for 60 minutes with staff, learning about proper techniques, cardiovascular training, strength building, and most significantly for her, stretching exercises to develop greater flexi-bility. She quickly gained enough flexibility to put her shoes on comfortably—something she had been unable to do for several years. This improvement was very reinforcing for her. Once a week she also exercised with a group for 90 minutes to learn how to exercise with other people and to give herself permission to try new activities. Through this experience, she confronted her discomfort at exercising in public and appeared to overcome the associated anxiety. Finally, she began to exercise on her own once a week for 60 minutes, doing the activity she enjoyed the most—bicycling. Susan’s regular independent exercise only became possible when she was not only helped to discover activities she enjoys but also to build those activities into a flexible, realistic exercise plan that she could engage in anywhere without the need to visit a gym.
Susan learned emotion regulation skills to help her “talk things out,” rather than suppress her feelings or use sarcasm merely to suggest her emotions indirectly. She took opportunities to participate more in fun activities to decrease stress and shame about her appearance. She was taught how to recognize small accomplishments, rather than just big ones. She learned to reframe her thoughts more positively, with less self-condemnation. She deep-ened her connection with God, learning to practice spiritual disciplines like meditation on God’s word and time alone in prayer. She recognized how her negative emotions had been controlling her choices and relationships. Over the weeks, Susan realized that consistent eating, exercising, sleeping, and connection with others and God were critical for her continued recovery and daily happiness.
As treatment progressed, Susan began to focus on upcoming intensive family therapy sessions. The family therapy sessions appeared to go well. They increased her family’s awareness and insight into Susan’s struggles, enhancing their ability to understand and support Susan, and appeared to improve their communication skills. As such, Susan challenged herself by going home for a leave of absence, to practice her new skills in her real-life home environment with her family. She returned from this visit with a fresh awareness of the skills’ usefulness and clarity about what she needed to continue working on prior to discharge.
Preparation for the transition to aftercare began early in treatment, focusing on developing the support system Susan would need to continue her recovery. In addition to an outpatient treatment team, Susan identified support groups and a church community in her local area, knowing from her experience at Remuda that connections with others helped her greatly to maintain her focus on recovery and honesty about her feelings and needs. Susan and her therapist identified together that during aftercare the initial issues she should consider addressing would be boundaries, self-care, honesty, and people-pleasing behaviors.
Susan admitted at 237 lbs. and discharged 42 days later at 230 lbs., averaging a loss of 1.1 pounds per week. She was discharged with a flexible 1800 calorie per day meal plan designed for very gradual weight loss, but with the understanding that weight loss was not the measure of success. She had taken a pivotal step: she was no longer measuring the rate or amount of weight loss, but drawing empowerment from understanding the dynamics that had kept her bound in a cycle of emotional eating most of her life and from the new ways of approaching her emotions that she believed would keep her free of this cycle in the years to come. This is a difficult step for anyone in our weight-obsessed society to take, but an essential one to protect oneself from the toxic influences of the thin-obsessed, yo-yo dieting culture that we live in. Even with the minimal weight loss that occurred during Susan’s treatment, her blood pressure and cholesterol had decreased, sleep difficulties had improved, and knees were hurting less often. These positive physiological effects from relatively minimal weight loss further reinforced Susan’s understanding that recovery was not measured in pounds but in health. Susan also recognized an improved quality of life, and no longer wanted her happiness to be dictated by a number on a scale that means little in terms of actual well-being. She understood that she could accept her body as it is and celebrate as it might change in relation to her more balanced lifestyle and enjoyment of food.
Susan thus left Remuda with a new sense of self, improved self-esteem, skills to manage relationships, improved emotional awareness, and hope for the future. She called these changes in knowledge and perception “a spiritual renewal and revelation of truth”. She stated that she now knew that God’s grace was not something that would come one day when she achieved a specific weight or degree of health, but that she was living in his grace today. She committed as she left for home to live in this awareness of God’s unconditional love for her and the continued, gentle healing that would likely result from life approached in this holistic manner.
Susan had made much progress in six weeks of intensive residential treatment. For her, the treatment truly was intensive and life-changing. Her continued progress would require effort and ongoing outpatient treatment to sustain. Yet she left Remuda equipped with the essential tools to tackle her everyday world in a new, healthier, and more satisfying fashion. She had arrived not seeing a way out of her emotional eating cycles. She left aware of new options, skills, and opportunities for a better life. She had exited the endless cycle that often traps people in emotional eating for decades and lifetimes, and she went home with hope and optimism.
References
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Tribole, E., & Resch, E. (1995). Intuitive Eating: A Revolutionary Program That Works. New York: St. Martin’s.
Next Issue: Substance Use and Eating Disorders
Emotional Eating
Emotional Eating: A Case Study
We take a break from our series on eating disorder comorbidity with this special holiday issue focusing on emotional eating.
We are offering information on emotional eating at this time because emotional eating becomes even more common and distressing during the holidays. People who eat emotionally through-out the year are confronted with heightened accessibility to foods that they have come to view as “forbidden” and “bad”. Those who experience holiday-related sadness due to past life events are also more apt than usual to engage in emotional eating behaviors to soothe difficult feelings. Even people who are functioning emotionally and psychologically without much distress may eat for emotional reasons at this time of year, because hurriedness and stress increase and naturally lead people to eat without thinking, merely because food is present.
Emotional eating is an emerging concept in the field of eating disorders. Its definition is evolving as clinicians learn to treat people with emotional eating problems and researchers begin to examine this domain. In this issue of The Remuda Review, we offer a preliminary definition of emotional eating. We lean primarily on the literature about binge-eating disorder—the most extreme form of emotional eating—to understand the antecedents and treatments most appropriate for those who eat emotionally.
We hope you will find this issue timely during the holiday season and throughout the year as you work with clients who may struggle with emotional eating.
In our next issue, we will resume our ongoing exploration of eating disorders’ most significant co-occurring concerns.
Emotional Eating
Edward J. Cumella, PhD, Department of Research and Education
Darcy Tucker, MA, LAMFT
Remuda Ranch Programs for Eating Disorders
“Eat your food with gladness, and drink … with a joyful heart...” Ecclesiastes 9:7
Emotional eating refers to a range of behaviors in which people eat for reasons other than physiological hunger or participation in cultural events. When people eat for emotional reasons, rarely do they eat their food with gladness or drink with a joyful heart. Instead, they eat to manage uncomfortable emotions, such as sadness, loneliness, grief, worthlessness, hopelessness, anger, anxiety, guilt, and shame. Beyond these disquieting emotions which they are attempting to manage, the very act of emotional eating leads those who are doing so to anguish about weight gain, social taboos, possible illnesses, and their loss of control over food. So emotional eating itself can create or intensify emotional distress, including feelings of embarrassment, self-disgust, depression, guilt, and shame. Hence, emotional eating becomes a vicious cycle: eating to escape negative feelings ultimately intensifies negative feelings and precipitates additional emotional eating. “He eats in darkness, with great frustration, affliction, and anger” (Ecclesiastes 5:17).
With the obvious negative affect associated with emotional eating, a logical question arises: Why does anyone eat for emotional reasons? Simply, emotional eating is effective at short-term emotion regulation. Its short-term effects arise from various factors:
Eating produces physiological satiety, which reduces and may even supplant the physiological agitation associated with anger, distress, and anxiety.
Eating large amounts of food may raise blood sugar levels, producing an experience of numbness in which all emotions, including depression and loneliness, are minimized.
Eating to the point of physical discomfort distracts individuals from their emotional pain.
Continuous eating over several hours or throughout the day distracts people from disturbing thoughts.
Consuming foods that are associated with past positive experiences may bring immediate pleasure, temporarily supplanting depression.
Certain foods raise endorphin levels, mimicking drug use and temporarily elevating mood.
Combinations of these effects, and others, may drive emotional eating in particular individuals. These multiple effects on mood readily reinforce emotional eating behavior. The immediate and short-term results are often stronger than the longer-term consequences which, at the moment the emotional eating occurs, are merely a cognitive awareness relegated to the future. The promise of immediate release from emotional distress, in spite of longer-term consequences, is precisely why those with substance abuse problems rely on dangerous drugs. Short-term reinforcement often overwhelms our awareness of longer-term risks.
Some people eat emotionally but are not overweight or only slightly overweight. They experience a range of biological, psychological, social, and spiritual consequences from their emotional eating. Obese emotional eaters contend with the additional problems that obesity may cause. Medical authorities inform us that obesity is an epidemic in the United States, affecting all age, ethnic, faith, gender, and socioeconomic groups. Somewhere between 1/3 and 1/2 of obese individuals may engage in emotional eating (Spitzer et al, 1993).
With all groups of emotional eaters combined—those of normal weight, the overweight, and the obese—emotional eating affects far more Americans than the more extensively researched eating disorders, anorexia and bulimia. Emotional eating problems affect men, women, children, adults, and people from diverse cultural backgrounds. Emotional eating problems have become so common, however, that we often forget that they are seriously distressing to people even when weight issues are not present. In addition, many people are ashamed of their emotional eating, so they keep their behaviors secret, or they have relied on emotional eating for so long that it almost seems normal to them and they would not think to mention it to a healthcare professional.
For these reasons, the 25%-30% of Americans with emotional eating issues (Cumella, 2005) are not being routinely identified by healthcare professionals or seeking help for their emotional eating problems. It’s time to remove the veil of secrecy, to ask our patients direct questions about their eating behaviors, and to offer sound assistance.
Etiology
Since women who frequently diet binge more often, some believe that dieting triggers a physiological starvation response leading to bingeing. However, because half those with binge-eating disorder begin to binge without dieting (Abbott et al, 1998), bingeing must serve functions besides a physiological response to dieting. The affect regulation model sees emotional eating as maladaptive coping intended to reduce unpleasant emotion and reinforced by the experience, albeit temporary, of reduced negative emotion (Polivy & Herman, 1993). Simply stated, the existing research indicates that moods, thoughts, and relationship issues may be more influential in precipitating binges than physiological functions. We explore these psychosocial issues below.
A primary risk factor for emotional eating is living in a culture that values thinness. As such, all Americans are at risk. Cultures that value thinness create categories of “forbidden” foods, leading to chronic experiences of food deprivation. The situation for Americans is exacerbated by the abundant availability of rich foods, large restaurant portion sizes served in environments designed to promote rapid and distracted eating, the perception that eating while working or engaging in other activities is normal, and a sedentary lifestyle promoted by cities built around automotive travel rather than walking. These conditions place Americans in a contradiction: we’re told to fight our biological drive to eat and minimize food intake in order to achieve a highly valued thin appearance, but we are simultaneously saturated with a plethora of available and appealing foods and food choices. In this environment, eating becomes a highly emotionally charged event and becomes intertwined with a variety of feelings and needs.
These cultural influences are not consistent with a Biblical worldview. In a healthy environment, we would recognize: that each person is created unique by a loving God—unique in body, soul, and spirit; that beauty comes in many forms, shapes, and sizes, and is both internal and external; that all foods are good, gifts of a loving God; that, barring genetic abnormality, natural hunger urges are built into us by God’s design and should not be negated, overruled, or manipulated. In the Bible, eating and feasting are repeatedly associated with family, fellowship, joy, and celebration—social experiences set aside from the workday and other distractions. In a healthy environment, then, people would eat with others, taking time to relate and enjoy their food, not rushed by a clock or distracted by noise and images, with a sense of gratitude for the nourishment, flavors, and relationships, relaxing and noticing their hunger and satiety cues to complete their eating with a sense of physical, emotional, relational, and spiritual satisfaction.
Those most vulnerable to emotional eating are the same individuals most vulnerable to the other eating disorders. Such individuals are more likely to have been abused physically, sexually, or emotionally. They are often depressed, anxious, have low self-esteem, and may misuse substances. They may have a history of repeated dieting and regaining of weight or continued weight increases over a long period of time. Difficulties in any relationship also tend to drive emotional eating behaviors. As such, people who eat for emotional reasons may come from overweight families or families with other psychiatric disorders. Their families may be rigid and unsupportive, indirect or mute with feelings, isolated and sedentary, lacking in structure, consistency, and predictability. Independence is not stressed. All of these factors may contribute to a sense of having no control over one’s life and provide an inclination to use food as a source of comfort and short-term emotional control.
Diagnosis and Assessment
The best researched emotional eating problem is binge eating. When this occurs with regularity and without efforts to purge the calories consumed, the individual might have binge-eating disorder; see the DSM-IV for diagnostic details. But other forms of emotional eating also exist; they are often less extreme than binge-eating disorder in terms of the quantity of food consumed or the frequency of binges, but they can be quite distressing to those involved and can lead to serious physiological problems. The range of emotional eating issues includes: eating when not hungry, eating when stressed, eating in secret, eating foods perceived as “forbidden”, grazing or snacking throughout the day, eating to soothe or forget feelings, and other emotional uses of food. If severe enough, the DSM-IV permits diagnosis of all these emotional eating problems as eating disorder not otherwise specified.
What separates a diagnosable eating disorder from less severe emotional eating is often the frequency and severity of the behaviors, the degree of distress the behaviors cause, and the degree of body hatred that ensues. Of note, among emotional eaters, people who are overweight, normative, or underweight can all be significantly uncomfortable in their body.
When the level of physical or emotional distress escalates, assistance should be sought from a qualified medical professional, counselor, or registered dietician. Sadly, however, while these emotional eating behaviors often start in a person’s teens or early twenties, many individuals fail to seek or receive appropriate intervention until their thirties or forties. That is a long time to suffer. And some never ask for help, but remain in the darkness of shame and secrecy, never even telling their closest friends, family, or spouse.
People who are overweight are often viewed in our society as being unattractive, awkward, weak-willed, lazy, unintelligent, and lacking in self-control. Overweight individuals may suffer discrimination in employment, salary, promotion, and education. Considering the amount of ridicule many overweight individuals endure, it is no wonder that many internalize the toxic beliefs of our society. Research sadly suggests that even healthcare professionals who are trained to understand risk factors and intervene appropriately often evidence bias against the overweight. As such, overweight individuals may be less likely to visit healthcare professionals for preventive healthcare to avoid lectures about weight or embarrassment at inappropriately-sized medical equipment. It is therefore critical for healthcare providers to examine their own biases and understand the nature of emotional eating so that they can accept and validate their overweight emotional eating patients and offer effective therapeutic solutions.
Initial screening for emotional eating can be accomplished with five questions asked of clients:
Do you eat a lot of food in a short period of time?
Do you sometimes feel out of control when you eat?
Do you eat when you are not hungry?
Do you eat to soothe your feelings or distract yourself from uncomfortable thoughts?
Do you eat in secret?
If clients answer “yes” to one or more of these questions, a more detailed assessment is indicated. It is necessary at this juncture to differentiate emotional eating from bulimia nervosa and to determine whether the emotional eating symptoms rise to the extreme level of binge-eating disorder, are distressing enough to be diagnosed as eating disorder not otherwise specified, or, if not directly diagnosable, nevertheless merit therapeutic attention.
Several self-report questionnaires may bring objective data into this assessment:
Eating Disorder Inventory-3, measuring clinical features of eating disorders and associated issues (Garner, 2004).
Three Factor Eating Questionnaire, measuring behaviors of dietary/cognitive restraint, disinhibition, hunger (Stunkard & Messick, 1985).
Questionnaire on Eating and Weight Patterns-Revised, producing information on weight cycling, weight/dieting history, and body image (Spitzer, Yanovski, & Marcus, 1993).
Questionnaires that measure depression, anxiety, substance use.
Paper-and-pencil questionnaires such as these can be quite helpful in assessing patients with emotional eating issues, since many feel more comfortable disclosing information in this format, rather than face to face, when it comes to behaviors about which they are ashamed.
Detailed psychosocial, nutritional, medical, and body image assessments are often needed when an emotional eating problem exists. Patient self-monitoring of behaviors can also reveal important data about experiences that trigger and maintain individuals’ emotional eating.
Intervention
Intervention with emotional eating clients has three main objectives:
Possible weight loss, or prevention of further weight gain, as medically indicated, combined with solid nutrition education and counsel.
Reduction or cessation of binge eating or over-eating.
Improved attitudes about one’s weight, shape, eating behaviors, and physical activity.
Several approaches described below have research support as effective in achieving these goals. In Remuda’s Emotional Eating Program, each of these approaches may be used, depending on the individualized assessment of each patient’s needs.
Weight Loss/Nutrition Education. If someone who eats emotionally is extremely overweight with imminent resulting medical compromise, counselors—along with medical consultation—need to consider the wisdom on weight loss interventions. However, in most cases of overweight and obesity, weight loss may not be the goal. Controversy exists regarding Behavioral Weight-Loss Treatments (BWL) because their long-term effectiveness is extremely poor. Furthermore, authorities are now questioning the oft-heard idea that overweight inevitably leads to health problems and are suggesting instead that people can be healthy at any size. In addition, BWL often intensifies emotional eating and leads to severe relapses with additional weight gain. Unless the emotional, cognitive, relational, and spiritual aspects of emotional eating are addressed, disordered eating and weight itself may be difficult to reduce. In lieu of BWL, we recommend that counselors consider the Health at Any Size approach, which emphasizes self-acceptance, a renewed relationship with food, and engaging in enjoyable physical activity rather than exercise per se. This approach is gaining prominence among eating disorder specialists. For more details, see www.healthyweight.net.
American’s waistlines are growing in spite of the many diet aids, weight loss products, and medical weight-loss procedures available. According to the American Academy of Family Physicians, there are more than 50 individual dietary weight-loss supplements and more than 125 commercial combination products available for weight loss. The pictorials and testimonials that accompany the advertising for these products and services often seem convincing. Yet none of these products meet the criteria for recommended use for their efficacy, safety, or quality. In extreme cases, surgical interventions can be life saving, but often do not address the underlying issues that created the obesity in the first place.
Most anyone could readily think of many “magic bullet” weight-loss methods that have been proffered over the years–such as diet pills, green tea, smoking, fasting, restricting intake only to “good” or “healthy” foods, commercial meal replacement programs, low-fat/no-fat diets, low carbohydrate diets, and dehydration techniques. There are also fitness centers, gyms, and personal trainers claiming that they can remake someones physically.
Dieting is very ineffective. In almost all cases, the lost weight is regained. Dieting by its nature avoids recognizing important internal cues related to hunger and satiety, although more weight loss programs today are including such awareness in their curricula. Dieting can create food and weight preoccupations, a physiological and psychological experience of deprivation, and decreased metabolism. It often depletes the pocketbook through costly regimes, and reinforces the notion that there are good and bad foods while increasing shame for giving into temptation and eating foods deemed unacceptable. Dieting can lead to depression, anxiety, anger, and irritability while impairing body image and decreasing self-esteem. Dieting can be outright harmful medically, and it can lead to anorexia and bulimia, the most extreme forms of eating disorder.
Therefore, dieting is not the focus of treating emotional eating, except perhaps in cases of extreme obesity with imminent medical consequences. Instead, a healthy relationship with food and one’s body are the main goals. Such changes may ultimately lead to appropriate, gradual, and sustainable weight loss—which is often quite modest in quantity—with positive physiological effects. For example, the American Dietetic Association has seen that a decrease of a mere 6-7% of body weight paired with a 30-minute per day increase in physical activity can decrease the conversion of impaired glucose tolerance to diabetes by more than half. Weight reduction of just 5-10% decreases the risk and status of cardiovascular diseases, arteriosclerosis, and Type II diabetes. Total cholesterol decreases, low-density lipoproteins (LDLs or “unhealthy cholesterol”) decrease, and the high-density lipoproteins (HDLs or “healthy cholesterol”) increase. Sleep apnea improves. Yet even if weight does not decrease, the healthier emotional and physical lifestyle has major benefits, such as improved self-esteem, relationships, life quality and satisfaction, and immune response.
It is important to remember that emotional eaters are often very aware of their past weight loss “failures”. Guilt, shame, and feelings of failure typically increase emotional eating. When engaging in treatment that does not offer immediate weight loss, emotional eaters will need to recognize the power of the slow process of change and identify new and alternative responses. Eventually emotional eaters will redefine success from weight loss to healthy lifestyle and improved life quality. Through this education process, emotional eaters can define what success truly means for them.
This positive focus on a healthy relationship with food and one’s body is a breath of fresh air for Americans who are burdened by the incessant blare of dieting messages and thin images. Such a change of focus opens the door for individuals to function in greater harmony with their bodies, listening to internal cues regarding hunger and satiety. This changed focus therefore allows people to appreciate their bodies and the life-giving mechanisms that God built into them. To be at war with the body God gave us inherently disconnects us from our spirituality. To appreciate and understand our body deepens our experience of God’s love for us as unique creations and his presence in our everyday life.
Psychopharmacology. Antidepressants, anticon-vulsants, and centrally acting appetite sup-pressants have shown some efficacy in treating binge eating and promoting weight loss. But it is essential to recognize that medications for binge eating and weight loss offer only marginal results. As such, pharmacological treatment may frankly be of minimal value in treating emotional eating itself. However, since many who eat emotionally also have depression and anxiety, standard psychopharmacologic treatments for these co-occurring and sustaining issues may prove quite useful, particularly if medications are selected that do not intensify appetite or lead to weight gain.
Exercise Instruction. Remuda’s emotional eating patients are recommended to exercise three times per week for 60 minutes with staff, once per week with a group for 90 minutes, and on their own at least one other time per week for 60 minutes. The first group focuses on techniques, cardiovascular training, overall flexibility, and strength building, which allow for an improved quality of life. The second group focuses on experiencing a variety of activities, trying something new, attempting activities patients had not previously given themselves permission to try or enjoy, and learning to exercise with others. Finally, when exercising on their own, patients have the opportunity to do the activity they enjoy the most.
Cognitive Behavioral Therapy (CBT). CBT identifies and helps patients to change irrational, distorted, and harmful thoughts/beliefs that are leading to painful feelings and problematic behaviors. Those with emotional eating problems often evidence self-defeating beliefs, including low self-worth and self-efficacy, doubts about their ability to tackle problems, a lack of effective problem-solving skills, entitlement, unrelenting perfectionistic standards, codependency, and black-and-white thinking. Emotional eaters often have extreme and specific rules about what, when, and how much to eat. They become distressed when they fail to follow their self-imposed rules, often precipitating further emotional eating. CBT is capable of assisting in each of these areas and is therefore often a core treatment modality for those who eat emotionally.
Interpersonal Therapy (IPT). Relationship diffi-culties have been shown to drive bingeing and emotional eating. Because IPT focuses on clients’ personal relationships, it can be a useful approach to treatment for emotional eating. It has been shown to reduce emotional eating in 50% of clients. IPT concentrates on four interpersonal themes: loss, disputes, life transitions, and isolation/loneliness. Other relationship-oriented approaches may also be effective in addressing these issues.
Dialectical Behavioral Therapy (DBT). Because clients rely on emotional eating to regulate negative emotions, emotional eating can be addressed directly by teaching healthy emotion regulation skills. DBT (Linehan, 1993) is the most well-researched method for teaching such skills and would often be central in treating those who eat emotionally.
Marital/Family Therapy. Because marital and family distress/conflict may contribute to emotional eating, pending appropriate assessment spousal and family treatment may be needed. Family systems and structures that resist change and promote unhealthy emotion regulation can be challenged. This often includes a focus on improved intimacy in relationships, assertion, and communication skills to overcome patterns of codependency, shame, and mistrust.
Support Groups. Self-help and professionally-led support groups can be quite effective, since people with emotional eating problems often attempt to soothe their distress through isolated eating rather than by reaching out to a support network. Groups can help patients reduce shame and isolation, to learn to identify and express emotions directly, receive affirmation and counsel, choose supportive relationships, and trust that others may be willing and able to help when distress arises. Groups are particularly important from a spiritual perspective, because they reconnect us to the human community, allow us to experience God’s love, forgiveness, and acceptance in palpable ways, and help us to feel less alone with our emotional burdens and worries.
Spiritual Care. Helping patients to explore their relationship with God and food can offer new insights in the journey of recovery from emotional eating. Important questions may include the following. Is God sometimes left out of the process of dealing with emotional pain? Are there ways to bring God into this process, into the pain itself, and thereby to honor God more fully with one’s body? How would this affect one’s food choices? What is the meaning and role of suffering within one’s faith background, and can some unavoidable emotional pain be tolerated—even embraced—through spiritual transcendence? For Christians, what does the Bible say about the role of food in our lives, and also the role of emotions—both the joyful and difficult ones? Additional guidance on the individualized spiritual assessment and care of eating disorder patients can be found in a series of articles published in two prior issues of The Remuda Review (2005, Vol. 4, Issues 1 and 2).
Conclusion
Emotional eating is a common problem in the United States, but one that has received insufficient attention in the mental health field.
Many people are experiencing significant distress from emotional eating—distress that can be relieved. Public and professional awareness is paramount, so that professionals identify and sufferers seek assistance for emotional eating problems.
There is hope for those who are the silent sufferers among us. To reach a state of enjoying food and life in contentment with self, without guilt and shame, is to experience God’s providence: “for without him, who can eat or find enjoyment?” (Ecclesiastes 2:25)
Useful Resources
Cash, T. F. (1997). The Body Image Workbook. Oakland, CA: New Harbinger.
Fairburn, C. (1995). Overcoming Binge Eating. New York: Guilford.
Health at Any Size Journal
King, N., Kratina, K., & Hayes, D. (1999). Moving Away From Diets: New Ways to Heal Eating Problems and Exercise Resistance. Lake Dallas, TX: Helm Publishing.
May, M., Galper, L. & Carr, J. (2005) Am I Hungry?: What to do When Diets Don’t Work. Phoenix, AZ: Nourish Publishing.
Roth, G. (1984). Breaking Free from Emotional Eating. New York: Plume.
Tribole, E., & Resch, E. (1995). Intuitive Eating: A Revolutionary Program That Works. New York: St. Martin’s.
References
Abbott, D.W., de Zwaan, M., Mussell, M., Raymond, N.C., Seim, H.C., Crow, S., Crosby, R.D. & Mitchell, J.E. (1998). Onset of binge eating and dieting in overweight women: Implications for etiology, associated features, and treatment. Journal of Psychosomatic Research, 44, 367-374.
Cumella, E.J. (2005). Address the treatable emotional eating. Behavioral Healthcare Tomorrow, 14, 12-13.
Garner, D. M. (2004). Eating Disorder Inventory-3 Professional Manual. Lutz, FL: Psychological Assessment Resources.
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Polivy, J., & Herman, C.P. (1993). Etiology of binge eating: Psychological mechanisms. In C.G. Fairburn & G.T. Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 173-205). New York: Guilford.
Spitzer, R.L., Yanovski, S.Z., & Marcus, M.D. (1993). Questionnaire on Eating and Weight Patterns-Revised (QEWP-R, 1993). New York: The New York State Psychiatric Institute.
Spitzer, R.L., Yanovski, S., Wadden, T., Wing, R., Marcus, M.D., Stunkard, A., Devlin, M., Mitchell, J., Hasin, D., & Horne, R.L. (1993). Binge eating disorder: It’s further validation in a multi-site study. International Journal of Eating Disorders, 13, 137-153.
Stunkard, A. J., & Messick, S. (1985). The Three-Factor Eating Questionnaire to Measure Dietary Restraint, Disinhibition and Hunger. Journal of Psychosomatic Research, 29(1), 71-83.
Emotional Eating: A Case Study
Darcy Tucker, MA, LAMFT
Remuda Ranch Programs for Eating Disorders
Emotional eating is part of the eating disorder spectrum. It requires specific, scientifically-valid treatments that address its biological, psychological, social/cultural, and spiritual aspects. Remuda’s Emotional Eating Program offers this package for those who eat emotionally, whether overweight or not. Patients participate in a Biblically-based program that promotes healthy eating and a balanced lifestyle. The program integrates portions of Dialectical Behavior Therapy (Linehan, 1993), cognitive-behavioral therapy, family therapy, body image therapy, nutrition counseling, and experiential modalities as appropriate, to address the skills needed to support ongoing recovery. Treatment is provided by a team of professionals, including Master’s level therapists, primary and psychiatric care providers, registered dieticians, and 24-hour support staff.
Susan was a recent patient in Remuda’s Emotional Eating Program. Susan experienced body dissatisfaction from a young age. She knew that she had an honest mix of her mother’s larger bone structure and her father’s tendency to hold weight around the middle. Struggling with her weight most of her life, she realized in her late 30s that she had tried practically every weight-loss method, owned seemingly every weight-loss book published, and yet ended up gaining more weight after each dieting attempt. She was angry at herself for being unable to control what she ate and her ongoing weight gain.
Susan was experiencing acid reflux, difficulty sleeping, constipation, and arthritis in her knees. Her physician diagnosed her with hypertension and elevated cholesterol, putting her at increased risk for stroke. She was also at high risk for developing Type II diabetes. Her physician had long encouraged her to lose weight. She entered Remuda’s Emotional Eating Program because everything else she had tried had failed. Susan was anxious because she was used to weight loss programs, but the Remuda program was focused less on weight loss and more on the underlying issues that lead to a patient’s current condition. Susan knew intellectually that she needed something new, something that could reach her emotionally and spiritually and help her heal the inner wounds that were continually driving her unhealthy eating behaviors. But emotionally, she was still quite focused on weight loss as her ultimate goal and the one thing that could bring her happiness.
At admission, Susan presented as sad and somewhat anxious. She was diagnosed with moderate depression and mild anxiety. She also related in an interpersonally guarded fashion. Her psychosocial assessment revealed an extensive history of increasing guilt and shame, evidenced by growing disgust for her body. With this combination of symptoms, Susan’s psychiatric provider recommended that Susan begin taking Fluoxetine for depression.
Remuda’s Emotional Eating patients have been anywhere from 10 to 185 pounds overweight. Susan was in the higher range. Her nutritional assessment revealed she weighed 237 lbs., 159% of her ideal body weight. Her Body Mass Index (BMI) was 39.4, at the top end of the obesity range. She reported her highest weight to be 243 lbs., which occurred just prior to treatment at Remuda. Susan often ate alone and in secret, feeling ashamed because she could not control her eating behaviors and because of the stigma that her family and society place on obesity. She used moderate amounts of caffeine, diet and reduced calorie products, and had attempted smoking cigarettes to control her weight. She occasionally used drastic weight control measures, but was unable to maintain the weight loss or the behaviors; she would soon lose control and binge eat once again.
Prior to coming to Remuda, she had not recognized the multitude of times each day and night that she ate without regard to sensations of hunger or fullness. Susan ate between meals, mostly sweet, salty, and high-carbohydrate foods. During group meals at Remuda she often denied her feelings of hunger, but would then hide food to be available for later when she was alone. During a binge, or “uncontrollable eating” as she called it, she reported feeling “detached, zoned out, and out of control”. Afterward, she reported feeling guilty, ashamed, and even more uncomfortable in her body.
With the help of her dietician and therapist, Susan began to recognize her pattern of regulating emotions, particularly her negative emotions, by zoning out through uncontrollable eating. As such, her therapist determined that it was critical to begin by teaching Susan distress tolerance skills on which to rely instead of her binge eating behaviors. In this process, Susan was helped to identify and consciously experience her emotions so that she could choose appropriate distress tolerance skills to manage them. She was delighted at the emotional depth this allowed her to feel, and the relief of having tools to lean on during emotionally difficult moments rather than food.
In therapy sessions, Susan and her therapist identified key issues that made it hard for her to deal openly and directly with her difficulties and thus apt to rely on emotional eating to do so. These issues included a history of superficial relationships, people-pleasing, feeling empty inside, and care-taking her family. Her actual eating disorder began when she was a teenager, with the social and academic pressures of high school, increasing body image awareness, and an instance of sexual abuse. She had no one to talk to about these concerns, and turned to food to numb her feelings and dissociate. The behavior continued since that time.
Susan was then assisted in identifying the typical, immediate triggers to her emotional eating behavior. She identified stress, aloneness, tiredness, and feeling overwhelmed, sad, or angry. In years past, she used alcohol to soothe these feelings, but now—not wishing to become an alcoholic—she used only food. To help her respond to her immediate emotional eating triggers more effectively, Susan’s therapist met with her to establish basic distress tolerance and practicing presence skills. Through this process, Susan acknowledged that although her initial treatment goal was weight loss, these internal emotion regulation changes were necessary for her.
Susan’s dietician instructed her to read the book, Intuitive Eating (Tribole & Resch, 1995), to learn to select foods based on her enjoyment of them rather than by their caloric content. The very notion frightened her. To assist, Susan kept food logs, chronicling the food groups she had eaten across three meals and three snacks each day, noting periods of exercise and movement, including her thoughts, feelings, and emotions. Her initial nutrition plan was aimed at normalizing and regulating her eating patterns throughout the day and utilizing appropriate serving sizes. Susan learned how to leave bites behind when full, to wait 20 minutes to register fullness, and to use intuitive eating principles. She began to recognize lapses—i.e., eating out of emotion rather than hunger—and redirected herself to use skills during these times rather than to catastrophize by seeing the lapse as a sign that she was a total failure and then shaming herself for being so. She learned to rely here on her faith, forgiving herself because God forgives her, recognizing that God has given her a lifetime to grow in a spiritual process, that God does not expect perfection of her today, and that God loves her very much as she is today.
Susan also met with her dietician to assess her level of physical fitness and activity. Together, they explored the physical activities she enjoyed in the past or might enjoy if she gave herself permission to try. Based upon the results of this assessment, and with some coaching, Susan began to exercise three times per week for 60 minutes with staff, learning about proper techniques, cardiovascular training, strength building, and most significantly for her, stretching exercises to develop greater flexi-bility. She quickly gained enough flexibility to put her shoes on comfortably—something she had been unable to do for several years. This improvement was very reinforcing for her. Once a week she also exercised with a group for 90 minutes to learn how to exercise with other people and to give herself permission to try new activities. Through this experience, she confronted her discomfort at exercising in public and appeared to overcome the associated anxiety. Finally, she began to exercise on her own once a week for 60 minutes, doing the activity she enjoyed the most—bicycling. Susan’s regular independent exercise only became possible when she was not only helped to discover activities she enjoys but also to build those activities into a flexible, realistic exercise plan that she could engage in anywhere without the need to visit a gym.
Susan learned emotion regulation skills to help her “talk things out,” rather than suppress her feelings or use sarcasm merely to suggest her emotions indirectly. She took opportunities to participate more in fun activities to decrease stress and shame about her appearance. She was taught how to recognize small accomplishments, rather than just big ones. She learned to reframe her thoughts more positively, with less self-condemnation. She deep-ened her connection with God, learning to practice spiritual disciplines like meditation on God’s word and time alone in prayer. She recognized how her negative emotions had been controlling her choices and relationships. Over the weeks, Susan realized that consistent eating, exercising, sleeping, and connection with others and God were critical for her continued recovery and daily happiness.
As treatment progressed, Susan began to focus on upcoming intensive family therapy sessions. The family therapy sessions appeared to go well. They increased her family’s awareness and insight into Susan’s struggles, enhancing their ability to understand and support Susan, and appeared to improve their communication skills. As such, Susan challenged herself by going home for a leave of absence, to practice her new skills in her real-life home environment with her family. She returned from this visit with a fresh awareness of the skills’ usefulness and clarity about what she needed to continue working on prior to discharge.
Preparation for the transition to aftercare began early in treatment, focusing on developing the support system Susan would need to continue her recovery. In addition to an outpatient treatment team, Susan identified support groups and a church community in her local area, knowing from her experience at Remuda that connections with others helped her greatly to maintain her focus on recovery and honesty about her feelings and needs. Susan and her therapist identified together that during aftercare the initial issues she should consider addressing would be boundaries, self-care, honesty, and people-pleasing behaviors.
Susan admitted at 237 lbs. and discharged 42 days later at 230 lbs., averaging a loss of 1.1 pounds per week. She was discharged with a flexible 1800 calorie per day meal plan designed for very gradual weight loss, but with the understanding that weight loss was not the measure of success. She had taken a pivotal step: she was no longer measuring the rate or amount of weight loss, but drawing empowerment from understanding the dynamics that had kept her bound in a cycle of emotional eating most of her life and from the new ways of approaching her emotions that she believed would keep her free of this cycle in the years to come. This is a difficult step for anyone in our weight-obsessed society to take, but an essential one to protect oneself from the toxic influences of the thin-obsessed, yo-yo dieting culture that we live in. Even with the minimal weight loss that occurred during Susan’s treatment, her blood pressure and cholesterol had decreased, sleep difficulties had improved, and knees were hurting less often. These positive physiological effects from relatively minimal weight loss further reinforced Susan’s understanding that recovery was not measured in pounds but in health. Susan also recognized an improved quality of life, and no longer wanted her happiness to be dictated by a number on a scale that means little in terms of actual well-being. She understood that she could accept her body as it is and celebrate as it might change in relation to her more balanced lifestyle and enjoyment of food.
Susan thus left Remuda with a new sense of self, improved self-esteem, skills to manage relationships, improved emotional awareness, and hope for the future. She called these changes in knowledge and perception “a spiritual renewal and revelation of truth”. She stated that she now knew that God’s grace was not something that would come one day when she achieved a specific weight or degree of health, but that she was living in his grace today. She committed as she left for home to live in this awareness of God’s unconditional love for her and the continued, gentle healing that would likely result from life approached in this holistic manner.
Susan had made much progress in six weeks of intensive residential treatment. For her, the treatment truly was intensive and life-changing. Her continued progress would require effort and ongoing outpatient treatment to sustain. Yet she left Remuda equipped with the essential tools to tackle her everyday world in a new, healthier, and more satisfying fashion. She had arrived not seeing a way out of her emotional eating cycles. She left aware of new options, skills, and opportunities for a better life. She had exited the endless cycle that often traps people in emotional eating for decades and lifetimes, and she went home with hope and optimism.
References
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Tribole, E., & Resch, E. (1995). Intuitive Eating: A Revolutionary Program That Works. New York: St. Martin’s.
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