I debated only briefly whether it was appropriate to discuss the sensitive issue of excessive eating in a publication devoted to the admiration of large people. But the kind encouragement of the editors, many letters from readers, as well as the fact that I have always maintained that I would be remiss as a physician if I did not acknowledge that there are negative health and emotional sequelae for some large people, led me to tackle this issue.

Let me begin by emphasizing that if people have consciously chosen to be large and understand the potential sequelae...God bless them. Any examination of excessive eating as a disorder should be aimed at those who are either uncomfortable, have health problems, or simply want to change.

Definitions

By strict definition a Compulsive Overeater is an individual who is driven to eat "in excess" and either does not or cannot take action to stop.

Binge or Impulsive Overeaters, on the other hand, will eat inordinate amounts of food usually within the time span of two hours. They want, at some point, to stop whether or not they have the control to do so.

The problem is that there is some blurring of definitions and, depending on which of the scanty pieces of scientific literature you refer to, Pathological Overeating Syndrome equals Binging equals Compulsive Eating. The lack of data is mostly due to the fact that researchers have spent most their time dealing with the more classic eating disorders, such as Bulimia and Anorexia.

Just so that we have it straight: A person with Bulimia may binge, but he or she will also have a preoccupation with weight or size leading to self-induced vomiting, starvation and the use of laxatives and/or diuretics.

Anorexia refers to an unfortunate morbid fear of being fat, and is associated with literal starvation.

In order to simplify the issue I will use terms such as binging and compulsive interchangeably when focusing on the troublesome aspects of overeating.

Symptoms

Most Binging involves large caloric intakes (often more than 20,000 calories at a sitting), large amounts of food, usually in the afternoon and/or evening, lack of control, and rapid consumption beyond satiety. There is a true compulsion in that overpowering thought intrusions of specific foods or their preparation can occupy the whole working day. The binging often occurs in private as there is embarrassment and guilt. Binges are often present at night, in a favorite place; often in front of the T.V.

There is undoubtedly a conditioned stimulus component to the problem, where rituals tend to repeat themselves. I have a dog who used to wake me up in the middle of the night hoping to get me to eat something so she might get a leftover treat.

Tasting forbidden food often leads to "all or nothing" thinking, that is, "if I had one cookie, I might as well eat the box". While the binge may be started by exposure to sweets, contrary to popular belief, most meals are high in fat and protein, i.e. buckets of chicken, pizzas, steaks, etc. A trance-like state is often described. Termination of the event occurs either at interruption of privacy or with an uncomfortable bloat. It isn't uncommon for bingers to go for high fiber foods or try to fast in the hope that this will help them "right" the damage they have done.

Compulsive eaters cannot stand to see food wasting; they must finish it. When surveyed many compulsive eaters talk about the circumstances prompting an eating binge. They include tension, the taste of binge-provoking food, being alone, craving specific foods, boredom, and eating exposure at social events.

Who

Females from 20 to 50 are classically depicted as bingers, but I suspect large numbers of males are also involved, hiding in the closet out of embarrassment. There is no race or ethnic prevalence. People who suffer tend to have low self-esteem and an inclination to impulsivity. Binge eaters may be perfectionists.

Interestingly there is some relationship with Seasonal Affective Disorder and even Premenstrual Syndrome. 25 percent of fat people admit to some episodes of binging. The classic story involves a family history or tendency toward obesity, dieting, ravenous hunger, binging, guilt, dieting etc. There are usually concomitant profound feelings of weight dissatisfaction and poor coping mechanisms.

Why

Diets, or some other form of severe food restriction, are the most common element. The $39 billion dollar diet industry likely plays a major role in propagating the problem. Physical and emotional abuse in childhood is often the initial trigger in the process. Parental discord and cohort bullying/teasing are typical stories. One of the most familiar tales involves children whose parents refused to allow them to eat dinner with the rest of the family.

There are a number of scientific theories on compulsive eating that involve chemical transmitter problems. The brain registers emotions such as sadness and feelings like hunger in response to certain chemicals coming in contact with specific receptors. If the chemicals are in short supply or stuck somewhere in the process, a number of medicines can start the flow again. This is how anti-depressants work. It is also postulated that this is why many of the depressive syndromes including Seasonal Affective Disorder (cabin fever) and Premenstrual Syndrome (PMS) often have eating disorder features.

The behavior therapists feel that binging is mostly a matter of conditioning. For example, childhood trauma leads to insecurity. Eating is a form of comfort, but may lead to obesity and shame. The shame often leads to dieting which results in rebound ravenous hinging and the vicious cycle goes on. After awhile, just the mere taste, smell, or even the thought of the "comfort" food may lead to this cycle.
Contrary to popular media stereotypes of the wicked villain (like Jabba the Hut and Henry the Eighth), there is little scientific evidence linking compulsive overeaters with hedonistic pleasure seekers. Most fat bingers are not evil gluttons.
It is most likely that the cause of compulsive eating is multi-factorial and involves a mix and match of all of the aforementioned.

What Seldom Works

Diets. The famous claims of late that certain drugs such as Methylamphetamines alone or in combination will curb appetite and lead to weight loss are overblown. The weight loss might be a mere 20 pounds and people usually must stay on the drugs (which are not without serious side effects) indefinitely. Of course, if overeating is a symptom of a serious underlying condition such as major depression, there is a place for medication.

"12 step" type programs seldom work because they tend to treat food like a poisonous substance and advocate abstinence. One doesn't have to have a drop of alcohol for breakfast or a "power lunch", but food must be eaten to survive, aside from its presentation at virtually all social events in life. Therein lies the dilemma with these programs.

Treatment

Although some of my colleagues suggest medication for people who desire or must change their eating habits, I am not a fan of diet pills. On the other hand, serious depression or mood disorders associated with binging can benefit from pharmaceuticals.

Monoamine Oxidase Inhibiters (more popularly known as MAO Inhibitors) are helpful in some anorexics and bulimics, but carry precautions especially with regard to food interactions. Certain wines and cheeses may react with these drugs to produce dangerously high blood pressure levels. Serotonin Uptake Inhibitors (like Fluoxetine) that cause free flow of the chemicals in the brain I referred to earlier, have also met with some success. Supportive-Expressive Psychotherapy recognizes that each overeater has some prevalent stressors in his or her life and works on coping strategies.

The Cognitive-Behavioral Approach

Cognitive-Behavioral Therapy involves monitoring an individual's habits and readjusting them. Loneliness, boredom, and unstructured time are problems which must be addressed in any form of therapy.

To begin with, one must get rid of negative body image, and regular eating habits are essential. Start with regularity; no more than three to four hours between meals and snacks, no skipping, always eat in the kitchen while sitting. Leave food on the plate, discard leftovers, and never be coerced into extra helpings. Eat with others whenever possible. Food preparation is often useful, i.e. get unprocessed items instead of ready-made foods. Learn to restrict momentum. Try one chip at a time. Get rid of the "all or nothing" mentality. Never restrict calories because rebound binging is inevitable.

Use alternative behaviors and distractions to replace a binge. Walking is best. It promotes a feeling of control and enhanced self-esteem. Swimming is not bad but requires more preparation and there is often threatening public exposure.

Develop strategies to avoid "triggers" or "stresses". Always plan shopping in advance. Leave credit cards at home and take only the money needed. Avoid super-markets, visit specialty stores, and carry food home. Stock adequate supplies of acceptable foods like rice, beans, or fiber cereals.

Get into self-gratification alternatives. How about sex or hot bathing? Try games, especially social in nature.

Relapses

Accept the likelihood that as a fat person you may never be thin, or the vicious cycle of dieting and binge eating will recur. Immediate cessation is neither reasonable nor successful. Maintenance means accepting relapses and restarting the program.

Sensitive Issues

While it is wonderful that fat admirers exist in this world, many people have written to me about a sensitive problem. They often refer to a loved one affectionately as a "feeder." But partners of compulsive eaters should realize that as food facilitators they may be placing their loved ones in a tenuous position.

Health problems, pregnancy, or simply a change in self-image or philosophy may cause compulsive or binge eaters to want to alter their behavior. This is very difficult if a family member or live-in has an erratic eating lifestyle, thin metabolism and/or impulsive shopping habits. Similarly, leftovers or the presence of "dangerous" foods may be too much to tolerate for a binger who is trying to change.

Fat admirers have a special responsibility to be sensitive to these situations and should seek professional guidance.

Heretic Doctor

There, I've done it. Even heretic doctors have to listen to the needs of their patients and their own hearts, whether or not those needs conform to a particular or popular philosophy.

I trust that I have dealt with this delicate issue appropriately. Only your feedback will tell me. Whatever your need or choice, be happy and celebrate life. ß

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Heretic Physician