Eating disorders are complex conditions influenced by a combination of biological, psychological, and social factors, not a single cause. It's widely understood that both bulimia nervosa and BED are characterized by episodes of binge eating. The interplay between strict dieting, subsequent binges, and conditions like bulimia nervosa is a multifaceted issue that requires a nuanced understanding. When author Glennon Doyle revealed her struggle with anorexia nervosa in 2023, she said that she was shocked by her new diagnosis, having spent years of her life believing she had bulimia nervosa.
The Misconception of Restriction
While there’s a general understanding that food restriction is part of anorexia nervosa, many people fail to recognize that it’s a core component of other eating disorders, like bulimia nervosa, binge eating disorder (BED), and avoidant restrictive food intake disorder (ARFID). It's a common misconception to view restriction solely as a characteristic of anorexia nervosa. Equip Dietitian Gabriela Cohen says, “It’s true that restriction is a significant component of anorexia nervosa, however, I can confidently say that it’s present in all eating disorders, either in the form of actual behavior or mentality." This understanding is crucial in recognizing the underlying mechanisms that drive various eating disorders.
Restriction Beyond Anorexia
Restriction doesn’t necessarily have to mean limiting food in order to avoid weight gain; it can also be physiological or psychological. Equip Dietitian Caitlyn Neuendorf agrees, explaining that all types of eating disorders can be rooted in restriction. In patients with ARFID, many are restricting food variety, volume, or both. She says that even if a person is eating throughout the day, if they’re mentally restricting-meaning they only focus on nutrients, avoid foods they think they “shouldn’t” eat, or make food rules for themselves-their brain still registers that as restriction. Even in disorders like Binge Eating Disorder, restriction plays a significant role. “In patients with BED, there is often both a physiological and psychological restriction going on concurrently.”
Understanding Different Eating Disorders
To fully grasp the connection between restriction and binging, it's essential to define and differentiate between various eating disorders.
Anorexia Nervosa
This is the eating disorder most of us associate with restriction, and for good reason, as restricting food is a defining characteristic of the disease. Those with anorexia nervosa severely restrict their food intake, often eliminating entire food groups and adhering to strict food rules. There are two types of anorexia nervosa: restricting subtype and binge-purge subtype.
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Bulimia Nervosa
Bulimia (boo-LEE-me-uh) nervosa, commonly called bulimia, is a serious, potentially life-threatening eating disorder. Bulimia nervosa is defined by repeated episodes of binge eating and purging. People with bulimia binge eat, which means people feel like they've lost control over their eating. This means they eat large amounts of food in one sitting. This often occurs in secret, and they often feel very guilty and shameful. Then they try to get rid of the food and extra calories in an unhealthy way, such as vomiting or misusing laxatives. Someone with bulimia nervosa often feel a loss of control during binges, and shame after them. You may judge yourself severely and harshly for what you see as flaws in your appearance and personality.
In most cases, binges are preceded by periods of restriction, and the biological hunger that results from that restriction can both trigger a binge and contribute to the out-of-control feeling. If you have bulimia, you probably focus on your weight and body shape even when you're trying to think about other things. It's important to remember that an eating disorder is not something you choose. Bulimia is a complex illness that affects how your brain works and how you make decisions.
Binge Eating Disorder (BED)
Just like with bulimia nervosa, those with BED engage in repeated episodes of binge eating accompanied by a sense of loss of control, followed by feelings of shame. Binge eating disorder (BED) is characterized by regular binge-eating episodes during which individuals ingest comparably large amounts of food and experience loss of control over their eating behavior. The worldwide prevalence of BED for the years 2018 - 2020 is estimated to be 0.6-1.8% in adult women and 0.3-0.7% in adult men. BED is commonly associated with obesity and with somatic and mental health comorbidities.
Binge eating disorder is characterized by frequent, recurrent episodes of binge eating (such as once a week or more over a period of several months). A binge eating episode is a distinct period of time during which the individual experiences a subjective loss of control over eating, eating notably more or differently than usual, and feels unable to stop eating or limit the type or amount of food eaten. Binge eating is experienced as very distressing, and is often accompanied by negative emotions such as guilt or disgust. However, unlike in bulimia nervosa, binge eating episodes are not regularly followed by inappropriate compensatory behaviours aimed at preventing weight gain (such as self-induced vomiting, misuse of laxatives or enemas or strenuous exercise).
Many people with binge eating disorder eat faster than normal. They may eat alone so others don't see how much they are eating. Unlike people with bulimia, those with binge eating disorder do not make themselves throw up, use laxatives, or exercise a lot to make up for binge eating. If a person binge eats at least once a week for 3 months, it may be a sign of binge eating disorder.
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Avoidant/Restrictive Food Intake Disorder (ARFID)
In all the diagnoses above, restriction is related to thoughts and fears around weight gain and body size. With ARFID, this is almost never the case, but the restricting behavior is still there. People with ARFID restrict both the type and amount of food they eat, usually due to anxieties about negative consequences of eating, extreme issues with food texture/taste/smell/etc, or a lack of interest in food. People with ARFID don't eat because they are turned off by the smell, taste, texture, or color of food. They may be afraid that they will choke or vomit. They don't have anorexia, bulimia, or another medical problem that would explain their eating behaviors.
The Cycle of Restriction and Binging
Most people with eating disorders not only assign morality to foods, but also tie their own self-worth to what they eat and don’t eat. This means that their days are governed by strict food rules, leading to mental exhaustion, physical hunger, and almost inevitable “slip-ups.” And when a slip-up happens, “since we know we ‘shouldn’t’ be eating that food, the now-or-never mentality kicks in, which leads to a binge, followed by the same-restriction cycle,” says Cohen. This explanation clearly shows the way in which restriction contributes to binge eating disorder.
This cycle doesn’t have anything to do with self-control or willpower; it’s a biological inevitability. After a period of food restriction, the biological drive for food is a survival tool. When you don’t eat enough, that sends signals to the brain that food is scarce, causing it to seek out large quantities of food when possible. Goldstone, Anthony P et al. “Fasting biases brain reward systems towards high-calorie foods.” The European journal of neuroscience vol. 30,8 (2009): 1625-35.
Diet Culture and its Impact
“Society praises restriction,” Cornacchini says. “When my eating disorder started, I got more compliments than notes of concern. People applauded my ‘healthy willpower’ and my weight changes. Cornaccini’s experience is unfortunately relatable to many who have been diagnosed with anorexia nervosa. After all, we live in a world that’s dominated by diet culture, a system of social beliefs and expectations that values thinness over everything else. While this insidious messaging affects us all, it can be particularly dangerous to those who are predisposed to develop eating disorders.
“We can start by noticing and changing how we talk to others and ourselves about what we’re eating and our bodies,” she says. “Are you praising others’ weight changes or even your own? Are you commenting about what others are eating? What is your internal dialogue surrounding your own food choices or body?
Read also: Weight Loss with Low-FODMAP
The Purpose of Restriction
But despite all those negative consequences, restricting does serve a purpose for people with eating disorders-as with all disordered behaviors, as destructive as restricting may be, people turn to it for a reason. For many, restriction is a coping mechanism gone awry.
Addressing Restriction in Treatment
Regardless of the purpose it’s serving, restriction is always one of the first things we tackle in Equip treatment. At Equip, patients and their loved ones work closely with a registered dietitian to address restriction head-on. Diversifying the types of food a patient will eat, expanding beyond “safe” foods.
The Broader Implications of Binge Eating Disorder (BED)
Binge eating disorder (BED) is an eating disorder that was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 20131 and the International Classification of Diseases (ICD) in 20192. The core psychopathology characterizing BED includes regular binge-eating episodes during which individuals ingest comparably large amounts of food in a discrete time period (such as within any 2-hour period), whilst experiencing loss of control over their eating behaviour1. To fulfill the diagnosis according to DSM-5 criteria1, these episodes have to occur at least once a week for at least three months and have to be associated with distress regarding binge-eating (Table 1). Moreover, DSM-5-defined binge-eating episodes are associated with at least three of the following five characteristics: eating much more rapidly than normal, eating until feeling uncomfortably full, eating despite not feeling physically hungry, eating alone because of embarrassment about the amount and negative feelings after overeating1.
BED and the eating disorder bulimia nervosa (BN) are both characterized by regular binge-eating episodes1; however, the regular use of one or more inappropriate compensatory behaviours to prevent weight gain (such as self-induced vomiting or fasting) is part of the diagnostic criteria for BN1, whereas individuals with BED do not regularly compensate using inappropriate methods. The first description of binge eating is attributed to the American psychiatrist Albert J Stunkard in the late 1950s237, while another American psychiatrist, Walter W Hamburger, a few years earlier laid the foundation for the understanding that obesity entails also emotional aspects238. These early notions focus on binge eating as a behaviour, and it took two decades until binge eating was introduced as a core symptom of an eating disorder, bulimia nervosa (BN), in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)239.
Fourteen years later, BED was included as a research diagnosis into the fourth edition of the DSM240, including a more specified definition of binge eating as a core psychopathology and a time criterion. BED was finally recognized as an official diagnosis in DSM-5 a decade later1. Compared with the research criteria, the DSM-5 criteria include a loosening of the time criterion with binge eating episodes occurring at least once a week over three months necessary to fulfil the diagnosis. BED is also included in the International Classification of Diseases 11th Revision (ICD-11)2. The ICD has loosened criteria around the ‘large amount’ of food ingested, allowing subjective binge eating2, which will put challenges towards consistent application of diagnostic criteria.
Health Implications of BED
BED is associated with a considerable burden of disease and excess mortality15,24. Reports of specialist clinics in Europe estimate that the standardized mortality ratio associated with BED is 1.50 (95% CI 0.87-2.40)9 to 1.77 (95% CI 0.60-5.27)8. Despite this high mortality ratio, the healthcare needs of individuals with BED are rarely met. In a nationally representative study of US adults, past-year health conditions commonly co-occurring with BED included obesity, hypertension (31%), various heart conditions (17%), arthritis (24%), elevated cholesterol (27%) and triglycerides (15%), diabetes mellitus (14%), smoking (40%), sleep problems (29%) and general poor health.
Obesity and metabolic syndrome are common consequences of BED. The metabolic syndrome refers to a clustering of at least three of the following five medical conditions: abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein. BED is common in individuals with Type 2 diabetes27 and candidates for obesity surgery28. Studies of individuals with BED demonstrated increased metabolic and inflammatory markers associated with increased morbidity and mortality29. Up to 20% of patients with type 2 diabetes mellitus (T2DM) have an underlying, yet often undetected, eating disorder, the most common of which is BED 30. This is especially relevant as binge-eating behaviours worsen metabolic markers, including glycemic control30. Moreover, type 1 diabetes mellitus (T1DM) and other autoimmune disorders are also more common in individuals with BED than controls31.
Individuals with BED in the general population report a range of gastrointestinal (GI) symptoms, including dysphagia, acid reflux, bloating, abdominal pain, diarrhea, constipation and lower GI urgency34. BED seems to be associated with both upper and lower GI symptoms, independent of the level of obesity34. Additionally, respiratory (30%) and musculoskeletal problems (21%) are significantly increased in patients with BED compared with the general population35. Moreover, patients with BED-particularly due to obesity and increased risk for T2D-have multiple risk factors for cancer, including colorectal cancer, esophageal adenocarcinoma, pancreas and liver cancer, as well as cancer of the gallbladder, kidney, postmenopausal breast, endometrial, thyroid, ovarian, and prostate cancer29. Other health concerns in patients with BED includes urinary incontinence as well as polycystic ovarian syndrome (PCOS), which is associated with insulin resistance and increased risk of infertility36.
Mental Health Comorbidities
BED often co-occurs with other mental health conditions. In a nationally representative study of US-based adults, 94% of individuals with BED met diagnostic criteria for at least one additional psychiatric disorder37 and 23% of individuals with BED had attempted suicide 38. Common comorbid mental health conditions of BED include lifetime mood disorders (70%), post-traumatic stress disorder (32%) and anxiety disorders (16%) 37. Disorders characterized by poor impulse control39 are also frequent, including borderline personality disorder37, alcohol use disorder 37 and pathological gambling40. Attention-Deficit/Hyperactivity Disorder (ADHD) also co-exists with BED41.
Psychiatric comorbidity is associated with more severe BED pathology as patients with BED and comorbid mood disorders are less likely to remit43 and, therefore, might need different or additional treatments. Of note, mental health comorbidity does not moderate weight loss in patients with BED43. Most research on BED has been conducted in the US, where BED is prevalent in all socioeconomic groups44. Issues with weight and weight-related teasing, body dissatisfaction and dieting are key risk factors for binge-eating45. Over-evaluation of weight and body shape is associated with greater BED-related functional impairment46. Moreover, people who have experienced poverty, violence, traumatic events, combat, food insecurity or major mental illness seem to be at an increased risk of BED47-52.
Societal Factors
Several mostly US-based reports suggest that the prevalence of BED might be higher in black and Latino populations 7,53-55 and among sexual minorities compared with the general population. 56-58 Furthermore, in the US and Australia, recent immigrants were at a lower risk59 and indigenous people60 at an equal or higher risk for BED than the general population. Stigma and stereotypes associated with gender, mental health, weight, age and various disadvantaged positions, such as disability and lack of resources, may decrease the visibility of BED61.
Biological Factors
The pathogenesis of BED is still unclear. Pathways regulating food intake might be involved in overeating in BED (Figures 3 and 4). Hunger and satiety are regulated by the gastrointestinal, endocrine and nervous system through the integration of hormonal, neuronal, metabolic, behavioural and cognitive signals63. At the neuroendocrine level, a central structure for homoeostatic control is the hypothalamus64 (Figure 3). Ghrelin is secreted from the gastrointestinal tract in conditions of low nutrients, increasing motivation to seek food, whereas leptin acts in the central nervous system enhancing satiety signals64 (Figures 3 and 4). From hunger to satiety states, a cascade of endocrine satiety signals, in addition to ghrelin and leptin, support meal completion through the release of peptide hormones such as cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1) and peptide YY (PYY)65,66 (Figure 4).
Eating behaviour is regulated by a complex interaction of the gastrointestinal, endocrine and central nervous system. Different peptide hormones, including ghrelin, leptin and insulin, promoting hunger and satiety signals are directly secreted from the gastrointestinal tract and predominantly communicate with brain regions involved in homeostatic regulation and reward system functioning. Research on alterations in gut-brain communication in binge eating disorder (BED) is in its infancy; however, putative dysregulated peptide hormone functioning has been hypothesized to be associated with altered hunger-satiety signalling in individuals with BED.To date, few studies have evaluated the neuroendocrinological alterations in BED or other forms of overeating (such as grazing). However, in populations with loss of control eating, which is also a characteristic of BED, dysregulated peptide hormone functioning has been reported, including lower levels of fasting ghrelin, higher levels of leptin a…
Seeking Help and Breaking the Cycle
Restriction may look simple and harmless on its surface-who would bat an eye if someone declared they were cutting out sugar for a month?-but in reality, it can become a disordered compulsion that fuels an eating disorder (and not just anorexia nervosa). The good news is that, with the right support and tools, everyone struggling can break free of the restriction cycle.
If you have any bulimia symptoms, seek medical help right away. Talk to your primary healthcare professional or a mental health professional about your bulimia symptoms and feelings. If you're not sure if you want to seek treatment, talk to someone about what you're going through. This could be a friend or loved one, a teacher, a faith leader, or someone else you trust.
Supporting a Loved One
If you think a loved one may have symptoms of bulimia, talk with the person openly and honestly about your concerns. You can't force someone to get help, but you can give encouragement and support. People with bulimia can be at any weight. For example, they could be average weight or overweight.
Prevention Strategies
Although there's no sure way to prevent bulimia, you can steer someone toward healthier behavior or professional treatment before it gets worse. Promote and support a healthy body image in your children, no matter what their size or shape. Discourage dieting. If you notice a loved one or friend who seems to have food issues that could lead to or suggest an eating disorder, think about talking to the person about these issues and ask how you can help.
Avoid dieting around your child. Family dining habits may influence the relationships children develop with food. Eating meals together gives you an opportunity to teach your child about the pitfalls of dieting. Talk to your child. Some sites encourage teens to start dieting. It's important to correct any wrong ideas like this. Encourage and reinforce a healthy body image in your child, whatever their shape or size. Talk to your child about self-image and offer reassurance that body shapes can vary. Don't criticize your own body in front of your child. Messages of acceptance and respect can help build healthy self-esteem. They also can build resilience ⸺ the ability to recover quickly from difficult events. Ask your child's health care provider for help. At well-child visits, health care providers may be able to identify early signs of an eating disorder. They can ask children questions about their eating habits.