chapter5

As we discussed in Chapter 4, binge eating problems are associated with a diverse array of difficulties. Over time they can transform an ordinary, happy existence into a miserable one, harming not only the person with the problem but also his or her relationships with family and friends.

Binge eating problems can also affect physical health, either as a direct result of the overeating or as a consequence of any associated weight control behavior. Many of the physical effects are reversible, but some are not. Most become worse with time, so they should not be ignored. But first, some facts about body weight need to be stressed because misconceptions abound.

As we discussed in Chapter 4, most people with binge eating problems are very concerned about their weight and shape. Despite this, many harbor misunderstandings about body weight. Below are some key facts about weight and weight fluctuations.

We are mainly water. About 60% of our weight (as adults) is water. So, if you weigh 160 pounds (72 kilograms), almost 100 pounds (43 kilograms) of your weight is accounted for by water.

Our weight fluctuates within the day and from day to day. These short-term changes in weight (ranging from 1 to 3 pounds [0.5 to 1.5 kilograms]) are largely the result of changes in our level of hydration. As we are mainly water, even small changes in our hydration have a measureable effect on our weight. This phenomenon is exploited by those who participate in sports in which “making weight” is required (see Box 6). In people who vomit, or misuse laxatives or diuretics, hydration levels fluctuate considerably and as a result so does their body weight.

BOX 6. Jockeys and “making weight.”

In some sports participants are required to be below a particular weight at a set time in order to be allowed to compete. This is referred to as “making weight.”

For jockeys, this threshold is most often 120 pounds (54 kilograms; which includes the weight of their clothes, shoes, helmet, and tack). For some jockeys, the pressure to be below a specific weight drives them to use unhealthy weight control practices on the day of races. These practices include self-induced vomiting, “sweat rooms,” and other means of dehydrating themselves.

Cotugna and colleagues interviewed 20 jockeys and found that their race season BMI (see Box 3) ranged between 17.0 and 21.4, placing some in the markedly underweight BMI range. Their average weight loss on race days (days when they had to make weight) was 2.5 pounds, but some jockeys lost as much as 5 pounds. This weight loss is entirely the result of loss of water, highlighting the huge influence hydration has on body weight.

Source: Cotugna, N., Snider, O. S., & Windish, J. (2011). Nutrition assessment of horse-racing athletes. Journal of Community Health, 36, 261–264.

Short-term changes in weight do not reflect changes in body fat. As we noted above, these short-term changes are largely the result of changes in hydration. It is important to keep this is in mind when weighing yourself. In the self-help program in Part II (“What Is Happening to My Weight?”), there are detailed guidelines for how to interpret changes in the number on the scale.

Many people with binge eating problems are also concerned about their diet. Some are assiduous readers of articles on food and nutrition, and many think that they are well informed. My clinical experience, however, suggests that this is often not the case. While some of my patients are knowledgeable, many others hold erroneous views acquired through years of absorbing unreliable and inconsistent sources of information. Below are some important facts about dieting and weight loss.

There is no single “healthy diet.” A healthy diet is one that matches our nutritional needs and optimizes our physical health. As our nutritional needs change according to our age and other life circumstances, so does what constitutes a “healthy diet.” For the majority of adults, and especially those who are middle-aged or elderly, the optimal diet is one that minimizes the risk of weight gain, heart disease, and cancer. However, a different diet is recommended for women who are pregnant and those who are breast feeding. There are also specific diets for people with health problems such as diabetes. There is no single healthy diet.

Weight-loss diets are not healthy diets. Weight-loss diets are designed to help people lose weight. They are not in and of themselves healthy, although they may help you reach a healthier weight if you are overweight (see Appendix II).

Weight-loss diets are designed to create an energy imbalance such that your energy (calorie) intake in the form of food and drink is less than the energy needed to fuel your physical activity and to keep your body working. If this energy imbalance is sustained over time, you will lose weight.

Weight-loss diets are for people who are overweight or who have obesity. If you are not overweight, there is no reason health-wise to follow a weight-loss diet. If you have the goal of achieving an unduly low weight (a BMI below 18.5; see “If You Are Underweight.”), then think twice. As we shall shortly discuss, being underweight adversely affects physical health and it also has major psychological and social effects.

Weight-loss diets are subject to fashion. What is “in” one year may well be “out” the next. For example, in the 1960s and 1970s carbohydrates were “bad” and were to be avoided. Then in the 1980s and 1990s dietary fat was the villain and carbohydrates were ok. In the 2000s carbohydrates were once again the enemy. And so it goes on. If there were a consistently successful way of losing weight, it would sweep aside these fashions and fads. Have a look at the U.S. National Institutes of Health website at www.win.niddk.nih.gov/publications/myths.htm for a list of common myths and misunderstandings about weight loss and nutrition.

Distinguishing weight loss and weight maintenance. Weight-loss diets are not designed to be used for the long term, as they do not match our nutritional needs. Indeed, certain weight-loss diets would do you harm if you followed them for a sustained period of time.

In practice few people can follow a weight-loss diet for more than 4 or 5 months. What they then do is critical. There is a tendency to “give up” and return to their old way of eating. This results in weight regain. Instead, if they want to maintain their new lower weight, they need to move over from their weight-loss regimen to a weight maintenance one. Many weight-loss programs omit to mention this. Perhaps this is why weight regain is so common.

A healthy diet involves eating a wide variety of foods. We should also drink plenty of water. The only things we should go easy on, but not exclude, are salt, sugar, and two types of fat: saturated fat and trans fat. This is because these forms of fat increase the risk of cardiovascular disease. Saturated fats are mostly found in red meat and dairy foods whereas trans fats are found in hard margarine, fried food, and many commercially baked foods. But not all fat is of this type. What can get forgotten is that “unsaturated fat” (found in fish, seafood, nuts, and olive oil) reduces the risk of heart disease.

You may be thinking that you have heard all this before but “How do I translate the healthy eating guidelines into real food? What should I eat?” Until recently health educators used a “food pyramid” to explain what proportions of the various types of food make up a healthy diet. More recently the pyramid has been replaced by a plate (see www.choosemyplate.gov) but the overall message remains much the same.

As for how much you should eat, misunderstandings are rife. I regularly meet people who think that they ought to eat no more than 1,500 calories per day and others who think that 2,500 calories per day is about right. While I certainly would not advocate calorie counting, which can become a problem in its own right, it is important to be in the right ballpark. Table 5 lists the approximate calorie needs of adults with various lifestyles.

For up-to-date information on nutrition and healthy eating go on the web and search the various nutrition-related websites of the U.S. government and the National Institutes of Health. If you are from outside the United States, have a look at your own country’s dietary recommendations as well.

Vitamins and minerals are best obtained from food. Consuming additional quantities of vitamins and the like in the form of pills or liquids is not a good idea unless you have been advised to do so by a health professional. Indeed, doing so can cause you harm (see www.ods.od.nih.gov).

You don’t have to eat perfectly to be perfectly healthy. This message (adapted from one by Marcia Herrin of the Dartmouth College Eating Disorders Program) is for people who are concerned about precisely what they eat. This is not necessary. Healthy eating guidelines are exactly that: they are guidelines. They are intended to be followed in a flexible way. They should not rule your life.

I stop eating when it is impossible for me to continue—when I am literally full. After a binge I feel so full that my stomach hurts and I can hardly move. I feel sick, and sometimes, when I have had a particularly bad binge, even breathing is difficult and painful.

Binge eating has few immediate physical effects, but most binges leave the person feeling full, and in some cases the feeling is intense and painful. As Table 6 shows, people with bulimia nervosa are more likely to feel extremely full after a binge than people with binge eating disorder. This difference probably reflects their relative speed of eating.

TABLE 6. How full people get after binge eating.

Bulimia nervosa

7%—do not feel full

7%—feel slightly uncomfortable (bloated, definite physical sense of having overeaten)

60%—feel moderately uncomfortable (distended but no pain)

26%—physically impossible to continue eating due to painful severe distension

Binge eating disorder

17%—do not feel full

32%—feel slightly uncomfortable (bloated, definite physical sense of having overeaten)

47%—feel moderately uncomfortable (distended but no pain)

4%—physically impossible to continue eating due to painful severe distension

People who eat until they are very full sometimes describe becoming breathless. This is caused by their distended stomach pressing up on the diaphragm. Very rarely, the stomach wall becomes so stretched that it is damaged or even tears. This is a serious medical emergency. If you develop abdominal pain when bingeing it is essential that you stop eating immediately. And if the pain is extreme, get help.

The relationship between binge eating and body weight is not a simple one. In both bulimia nervosa and binge eating disorder binge eating is frequent yet body weight is usually normal in the former condition but raised in the latter (see Chapter 2). Why is this? It is likely to be the result of the way these people eat outside their binges. Remember the eating habits of people with bulimia nervosa consist of extreme dieting punctuated by episodes of binge eating. In contrast, in binge eating disorder the binge eating occurs against the background of a general tendency to overeat. It is therefore not surprising that the majority of the former group are not overweight whereas most of the latter are.

What happens to body weight with successful treatment? In people with binge eating disorder stopping binge eating has little effect on body weight. This is because it is their overeating in general that is contributing most to their high weight. The same is true in bulimia nervosa but for a different reason. In this case it is because the better treatments for bulimia nervosa target both these people’s binge eating and the accompanying dieting, with the resulting effects on weight cancelling each other out. To illustrate this finding, data from a treatment study conducted by my group in Oxford indicate that those who made a full recovery from bulimia nervosa had on average virtually no change in weight: their average weight was 137 pounds (62 kilograms) before treatment and 134 pounds (61 kilograms) 16 months later. However, it is important to note that these figures do reflect the average—some patients lost more weight than this, whereas others gained.

What about anorexia nervosa? In people with anorexia nervosa binge eating has little impact on body weight so long as the binges are relatively infrequent and “subjective” (i.e., small in size; see “The Size of Binges”). However, if the binges become frequent or large, they cause body weight to rise with the result that the person’s eating disorder diagnosis may change from anorexia nervosa to bulimia nervosa (again, see Chapter 2).

Besides having the psychological effects described in Chapter 4, dieting can have adverse physical effects. For example, it has been suggested that repeated cycles of weight loss and regain (weight cycling)—sometimes called “yo-yo dieting”—alter body composition and metabolism in ways that make subsequent attempts to lose weight more difficult.

Dieting may also affect menstruation as regular menstruation requires a certain minimum amount of body fat. It is for this reason almost all women with anorexia nervosa do not menstruate (see Box 7). Even when the amount of body fat is adequate, dieting, irregular eating, and intense exercising all have an influence on menstruation, although the mechanisms responsible are unclear. Menstrual disturbance is seen in up to half of those with bulimia nervosa and in about one in four women with binge eating disorder.

BOX 7. Could mannequins menstruate?

Investigators from Helsinki, Finland, measured the height and other dimensions of mannequins from the 1920s on. They calculated their percentage of body fat as if they had been real women. Before the 1950s the amount of body fat was mostly in the normal range. Thereafter, it was considerably less. They concluded that a woman with the shape of a modern mannequin would be unlikely to menstruate.

Source: Rintala, M., & Mustajoki, P. (1992). Could mannequins menstruate? British Medical Journal, 305, 1575–1576.

As we discussed in Chapter 4, self-induced vomiting is common in bulimia nervosa. It also occurs in anorexia nervosa, particularly among those who binge, and it is also common among those with atypical eating disorders.

Not surprisingly, repeated self-induced vomiting has a number of adverse physical effects. These are seen most often among those who vomit frequently and have done so for some time. As explained here, some of these effects are potentially serious.

Damage to the Teeth. Repeated vomiting over a long period of time damages the teeth; it gradually erodes the dental enamel mainly on the inner surface of the front teeth. Dental fillings are not affected so they become prominent relative to the surface of the enamel. Dentists can readily identify this pattern of erosion and may therefore deduce its cause. The erosion is irreversible but not progressive—in other words, it stops once the vomiting stops. The practice of rinsing the mouth with water after vomiting is thought to accelerate the dental erosion rather than retard it.

Swelling of the Salivary Glands. Surrounding the mouth are glands that produce saliva. In some people who induce vomiting these glands gradually swell. The swelling is painless, but it may increase the production of saliva. Often it is the parotid gland (the gland commonly affected in mumps) that swells most, giving the person’s face a somewhat rounded, chubby appearance. People with parotid swelling tend to see their face as “fat” and may assume that the rest of their body looks the same way. Naturally this increases their concern about shape and weight, thereby perpetuating the eating problem. The swelling of the salivary glands is reversible and gradually goes away as eating habits improve.

Damage to the Throat. As described in Chapter 4, most people induce vomiting by mechanically stimulating the gag reflex. This can be a difficult and long process requiring some force. Superficial injuries to the back of the throat can result, and these may get infected. Complaints of recurrent sore throats and hoarseness are therefore not uncommon.

Damage to the Esophagus. Very rarely, violent vomiting tears the wall of the esophagus, the tube that leads from the mouth to the stomach. There is a remote risk of rupture of the esophagus. This is a medical emergency. If there is a significant amount of fresh blood in your vomit you must seek medical advice.

Damage to the Hands. One other mechanical effect of self-induced vomiting is seen in some people who use their fingers to stimulate the gag reflex. It is damage to the skin over the knuckles of the hand. Initially abrasions appear on the hand due to it rubbing against the teeth, and eventually scars form. This is a highly characteristic abnormality known in medical textbooks as “Russell’s sign” because it was first described by Gerald Russell in his classic paper on bulimia nervosa.

Fluid and Electrolyte Imbalance. The physiological effects of frequent vomiting can be serious, and especially so among those who attempt to “wash out” their stomach by repeatedly drinking and vomiting until there is no sign of food in what they are bringing up. Repeated vomiting affects hydration, as I discussed earlier, and electrolyte levels too (sodium, potassium, etc.). The electrolyte disturbance of most concern is hypokalemia (low potassium) since it can result in potentially dangerous heart beat irregularities. If your heart beat is irregular you should seek the advice of a physician.

The symptoms of fluid or electrolyte disturbance include extreme thirst, dizziness, swelling of the legs and arms, weakness and lethargy, muscle twitches and spasms, and even epileptic seizures. Although up to half of those with bulimia nervosa have fluid and electrolyte abnormalities of some sort, most have none of these symptoms, and the disturbance is mild. It is also important to note that all these symptoms can have other causes so their presence is not necessarily indicative of an underlying fluid or electrolyte abnormality.

Electrolyte disturbance is reversible; it promptly goes away once vomiting stops. Rarely does it require treatment in its own right, and any treatment should be supervised by a physician. You should never try to treat it yourself.

A small number of people induce vomiting chemically. For example, they may drink salt water to make themselves sick. This is particularly inadvisable since it is another cause of electrolyte disturbance. Others take the over-the-counter drug Ipecac (ipecacuanha) to induce vomiting, a dangerous practice because several toxic effects can result from its use.

As explained in Chapter 4, people who binge may take laxatives to influence their shape and weight, though the practice is less common than self-induced vomiting. It is pursued mainly by people with bulimia nervosa or anorexia nervosa. Some people take very large quantities, as many as 50 to a 100 at a time.

Regardless of the amount taken, laxatives have little effect on calorie absorption. They act on the lower part of the intestine, whereas calories are absorbed higher up. What they do produce is watery diarrhea and a temporary fall in weight due to the loss of water. (Recall that about 60% of our weight is accounted for by water.) However, the weight loss is short-lived because the person regains the lost weight almost immediately as his or her body rehydrates. Nevertheless, people with bulimia nervosa find the weight loss rewarding, believing erroneously that it is evidence of an effect on calorie absorption.

Laxative misuse, much like self-induced vomiting, produces a variety of fluid and electrolyte abnormalities with symptoms of the type just described. Individuals who both vomit and misuse laxatives are at particular risk. Some laxatives, when taken in high doses over long periods, result in permanent damage to the intestine. Generally, however, the adverse physical effects are reversible.

People who have taken laxatives on a regular basis for some time may retain fluid (water) for a week or so if they stop abruptly. Doing so results in temporary weight gain which can be distressing, and it may lead them to resume laxative taking. It is important that people realize that the weight gain is due to water retention, not fat, and that it will go away within a week or so at the most.

Some people take diuretics (water tablets), usually over-the-counter preparations, in an attempt to change their shape and weight. This is a fruitless exercise since diuretics have no effect on calorie absorption. Like laxatives, they cause fluid loss, in this case through the production of excess urine, and thus they have a short-lived effect on body weight. When taken in large quantities, they can produce fluid and electrolyte disturbance which, as previously mentioned, can be dangerous. Again, this is reversible. As with laxatives, those who stop taking diuretics after having used them for some time may experience temporary fluid retention.

As we noted in Chapter 4, some people with binge eating problems exercise a lot, in large part to influence their shape or weight. This does not usually have adverse physical effects unless it is contributing to them having an unduly low body weight (see below) or it results in “overuse injuries.” Certain types of exercise (e.g., horse riding) can be particularly risky in anorexia nervosa where there is a heightened risk of bone fractures.

Being underweight has many diverse effects on physical health. Their nature depends upon the extent and form of the dietary deprivation.

Brain. Those who are underweight often overlook the fact that they are adversely affecting their brain, both its structure and its functioning. Starting with structure, it has been found in anorexia nervosa that the brain’s grey matter and white matter are both significantly reduced in size. Dieting does not spare the brain—it too is affected. As regards brain function, the brain requires a considerable amount of energy (i.e., calories) to operate properly, something that is in short supply among those who are undereating.

Given these effects of undereating, it is hardly surprising that cognitive and emotional deficits are common in those with anorexia nervosa, and in others who undereat (as we discussed in Chapter 4), abnormalities that are reversed by weight restoration.

Circulation. There are profound effects on the heart and circulation. Heart muscle is lost and the heart is weaker as a result. Blood pressure drops and the heart rate (pulse) declines. There is heightened risk of serious heart beat irregularities (arrhythmias), especially if there are accompanying disturbances in fluid and electrolytes. If your heart beat is irregular or unusually slow (less than 50 beats per minute), you should seek the advice of a physician.

Hormones. Likewise there are profound effects on hormonal function with nonessential processes ceasing. As a result sex hormone production declines markedly and women become infertile (see later in this chapter). There is a loss of appetite for sex and sexual responsiveness declines.

Bones. There is deterioration in bone strength. This is in part due to the hormonal changes, in part due to the decrease in the weight that the bones have to carry, and in part a direct dietary effect. The result is an increased risk of osteoporosis and fractures.

Digestive System. There may be a persistent sense of hunger although this is far from invariable. The sense of taste may be impaired, with the result that some people use large quantities of condiments and spices to give flavor to their food. The gut slows down, presumably so that food absorption is maximized. Thus, food in the stomach takes much longer than normal to move into the small intestine. This may also account in part for why people who are underweight have a heightened sensation of fullness even after eating relatively little.

Muscles. These waste, and weakness can result. This is most obvious when walking up stairs or trying to stand up from a sitting or squatting position.

Skin and Hair. The effects vary. A downy hair (called lanugo) may start to grow on the body, especially on the face, abdomen, back, and arms. There may also be hair loss from the scalp. Often the skin becomes dry and it can develop an orange tinge.

Temperature Regulation. The main change is a decrease in body temperature. Some people feel profoundly cold.

Sleep. Sleep is also impaired. It is less refreshing, and there is a tendency to wake early.

I worry about my eating problem affecting my relationship with my baby and my ability to cope. I hope to have three children, but I don’t like the idea of getting pregnant again. Maybe next time I won’t still be bulimic.

I had done really well with my eating. I had stopped vomiting and taking laxatives the moment I found out I was pregnant. I had also stopped binge eating. And I was trying really hard to eat only healthy foods. And then I was examined by my doctor and, when he was feeling my tummy, he looked up at me and said, “I am sorry I am taking so long, but I can’t tell which is the baby and which is you.” I know he was just joking, but it really upset me. I went home and cried. I ate nothing at all for the next few days, and when, with my husband’s help, I did start eating again, I found that I could no longer resist vomiting afterwards.

I try to control my eating but find it difficult. After making myself vomit I feel extremely guilty as I would never forgive myself if any harm came to my baby—but I am pleased that I have stopped taking laxatives.

Binge eating problems are associated with impaired fertility (see Box 8), but the reasons for this are not clear. Certainly, dieting, weight loss, and a low body weight all affect fertility, but it is not known whether binge eating has an effect too. What is important to stress is that these effects are generally reversible so long as the eating problem is overcome.

BOX 8. The “Dutch Hunger Winter.”

Before babies are born their subsequent development is determined to an extent by the environment in the womb. This prepares them for the circumstances that they are likely to face when born. Some of the changes cannot be reversed and may have a lifelong impact. If, for example, the developing fetus does not receive adequate nutrition, aspects of its metabolism and physiology may alter to prepare it for an environment in which food is scarce. For example, the baby may become particularly good at laying down fat. But if circumstances subsequently alter or, for some reason, the inadequate supply of nutrients was not the result of food shortage, the developmental changes may be detrimental to long-term health.

The “Dutch Hunger Winter” was a famine that took place in the Netherlands during the Second World War when, as a reprisal for Dutch resistance, fuel and food transport to the country was banned. At the height of the famine rations fell to between 400 and 800 calories per person per day. Studies of the Dutch Hunger Winter show that, despite being born with a normal weight, women exposed to the famine during the early stages of their fetal life were more likely to have obesity at age 50 years than those who were exposed to the famine later in fetal life or not at all. Early exposure to the famine was also associated with a threefold increase in the risk of having coronary heart disease by age 50 years in both men and women.

Sources: Painter, R. C., Roseboom, T. J., & Bleker, O. P. (2005). Prenatal exposure to the Dutch famine and disease in later life: An overview. Reproductive Toxicology, 20, 345–352.

Ravelli, A. C., van der Meulen, J. H. P., Osmond, C., Barker, D. J. P., & Bleker, O. P. (1999). Obesity at the age of 50 in men and women exposed to famine prenatally. American Journal of Clinical Nutrition, 70, 811–816.

Roseboom, T. J., van der Meulen, J. H. P., Osmond, C., et al. (2000). Coronary heart disease after prenatal exposure to the Dutch famine, 1944–45. Heart, 84, 595–598.

Similarly, little is known about the effects of binge eating problems on pregnancy. Most of the research has looked at bulimia nervosa. The findings suggest that the binge eating generally improves once the woman knows that she is pregnant. The desire not to harm the fetus is strong, and for some it is sufficiently powerful to prevent them from binge eating throughout pregnancy. Self-induced vomiting also tends to decline in frequency and most people stop misusing laxatives. Interestingly, dietary cravings occur, just as in other people’s pregnancies. These cravings can lead to the consumption of foods that would otherwise be avoided (such as ice cream) and, as a result, they can trigger binges.

Although I really wanted to control my eating, it was very difficult as my body seemed to take over in certain ways. I had cravings for foods that I would never normally eat. I found that I had to submit to them from time to time, which made me feel extremely guilty.

From midpregnancy onward many women with binge eating problems experience some degree of reprieve from their concerns about their appearance and weight. They feel that they are no longer accountable for them; changes in their appearance and weight are inevitable. As a result, some abandon controlling their food intake and overeat instead. This puts them at risk of excessive weight gain which increases the risk of pregnancy complications. It also means that there will be more weight to lose following the birth.

As my pregnancy progressed, I still tried to control what I ate, calorie counting all the time and attempting to keep under 1,500 calories a day. I also exercised every day. I still had regular binges although deep down I didn’t want to cause any harm to my baby. I even had a binge the day that my labor pains began.

On the other hand, a minority remain just as concerned about their appearance and weight, if not more so. The prospect of any change in shape and weight terrifies them, and they fight it. They diet, and some exercise heavily, sometimes as a substitute for vomiting or taking laxatives. As a result, they gain little or no weight, and at birth their babies may be underweight. This has the potential to have adverse long-term consequences for the child (see Box 8).

It is now 3 months since I gave birth. I’ve never felt so exhausted. I try to go for a run three to four times a week and I do lots of stomach exercises. I’d like to lose 15 pounds to get back into my prepregnant clothes. So far, my attempts at dieting have failed. My eating was very controlled when I first came home, but gradually the binges have returned and they are once again part of my daily life.

Following childbirth everything changes. Many find that the improvement in the binge eating problem was temporary and that it returns with a vengeance. This is not surprising as some are determined to get back to their original weight as quickly as possible and therefore resume strict dieting almost immediately. This is their downfall since, as discussed earlier, strict dieting makes people prone to binge and adhering to a diet is particularly difficult at this stressful time. Many will be breastfeeding and so subject to increased physiological pressures to eat; some will be depressed, which makes dieting difficult; and almost all will find their old routines disrupted.

		Activity level
Age (years)	Inactive	Somewhat active	Active
		Women
18–50	1,900	2,100	2,400
Over 50	1,600	1,800	2,100
		Men
18–50	2,500	2,700	3,000
Over 50	2,100	2,300	2,600

CHAPTER 5

Physical Aspects