This may sound counterintuitive at first, but I’m thankful for two aspects of my eating disorder, which I believe helped me make the choice to aim towards recovery: the development of binge eating after chronic food restriction and the physical inability to purge through self-induced vomiting. Like many individuals diagnosed with anorexia nervosa that go on to develop binge eating, I tended to choose high-fat foods and sweets as my “go-to” food items. I had always enjoyed such foods and was a notorious junk food aficionado as a young girl (way before any eating disorder symptoms developed). Once the bingeing behavior started, I couldn’t stop.
Sitting with the discomfort after a binge made me seriously consider whether this was something I could maintain for any lengthy period of time, and that’s when I started getting help. In a sense, I believe my affection for sweet foods, and propensity to binge on them, was a “life saver” of sorts. I also think these behaviors got me used to eating foods that I had deemed “forbidden” while I was restricting. With this forced confrontation, I was determined to start developing a healthy relationship with these foods again.
Given my history, the recent article by Witt and Lowe (2013), examining the power of hedonic hunger (the drive to eat to obtain pleasure in the absence of an energy deficit) among anorexia and bulimia nervosa patients to lead to binge eating, caught my eye. I was particularly interested in how this article may inform recovery outcomes, and hypothesized that those who found food to be more “pleasurable” would be more likely to develop binge eating behaviors and may eventually be more likely to develop a healthy relationship with food again.
The authors examined how individual differences in subjective ratings of attraction and motivation to consume highly palatable foods may relate to the development of binge eating behaviors among individuals with AN and BN. They assessed these differences using the Power of Food (PFS)11 scale, a questionnaire used specifically assesses motivation TO eat, but NOT how much food is actually consumed, providing a measure of food motivation independent from food consumption patterns.
Assessing the role of hedonics in food-related motivation can be tricky. Pure hunger from low energy balance can also enhance motivation to eat and influence subjective ratings of the rewards anticipated from food consumption. This influence can be hard to disentangle from motivation to eat because food is pleasurable. The PFS scale has been shown to be predictive of the consumption of palatable foods, but not food in general. In studies of overeating in obese populations, it has been shown to predict “loss of control” over food intake, but not BMI in these populations.
Taken as a whole, the PFS seems to assess hedonic drive to overeat palatable foods; it doesn’t seem to reflect patterns of food intake that are related to metabolic influences or general hunger states. However, this scale has only been used in obesity studies in the past, and has yet to be used to examine how hedonic motivation to consume food may impact symptoms of AN and BN and how it may affect recovery from these disorders.
The authors administered the scale to 119 AN and 144 BN patients admitted to a residential treatment facility. Then, they monitored fluctuations in hedonic hunger and weight change during treatment, controlling for the impact of variables such as pre-treatment BMI.
WHAT DID THE AUTHORS FIND?
- Higher PFS scores were associated with an INCREASED LIKELIHOOD of subjective and objective binge eating among both AN and BN patients.
- Higher PFS scores were associated with HIGHER BMI in the AN sample.
- Higher PFS scores PRIOR to treatment were associated with weight gain in the AN but not BN sample.
- The BN group had the highest PFS scores, followed by anorexia nervosa binge/purge subtype, and anorexia nervosa restricting subtype, suggesting that the hedonic drive to eat may contribute to different eating disorder symptoms.
So, it seems like having a higher level of hedonic hunger is good for recovery outcomes in anorexia nervosa? My personal experience validates by this assertion. I feel like having an affinity for palatable foods before my eating disorder made me more capable of regaining the ability to enjoy food again. However, I must remember to not let my personal experience bias my interpretation of the results. In fact, the authors never assert that this study was meant to examine treatment outcomes, but rather to assess whether the PFS could be informative in an eating disorder sample.
It is important to emphasize that this study only examined individuals in a treatment setting and used BMI change as the primary indicator of compliance with treatment. It is not known whether those individuals that gained more weight actually felt like they were more recovered. Personally, I would love to see a follow-up on these patients to see if those in the AN population with higher PFS scores were more likely to maintain a recovered state. It is likely that some crossed over to a diagnosis of BN, but the question is how many? I’m really interested in seeing if this scale could be a useful indicator of recovery prognosis.
References
Witt, A.A., & Lowe, M.R. (2013). Hedonic hunger and binge eating among women with eating disorders. The International Journal of Eating Disorders PMID: 24014479
I don’t know how much of this I buy.
I do think the onset of bingeing in AN-R is probably, if you study a large enough sample, predictive of a better outcome. I’ve been thinking about that a lot.
I also think that binge eating in BN is NOT just the result of restricting. In fact, I know it isn’t. I’ve talked to enough people, and I have my own lived experiences. Does restricting and limiting yourself of specific foods or restricting calories make it worse, hells yes. It can make the frequency and extent of bingeing/purging way worse, but not restricting *at all* doesn’t mean the bingeing and purging will necessary go away.
But, I’m not so sure hedonic hunger is the reason. I suspect what hedonic hunger is a proxy of is anxiety and impulsivity.
I really need to look this up, but I wonder if you were to look at all these measures people commonly look at among AN and BN patients, what percent of the variability can be explained through anxiety levels and impulsivity? If you were to do a principal component analysis, I’d bet those two would either be the main two components OR be pretty close. Someone MUST have done this already, right? I really need to find time to look this up.
So, I’m not sure if it is hedonic hunger OR just anxiety levels OR something else OR maybe those two relate to each other, I don’t know. That’s not to say one isn’t anxious about bingeing (before, during, or after), but perhaps the anxiety toward food (and I would say, everything else) is not as severe?
Yes to the factor analysis! Impulsivity or less anxiety about food, coupled with a bit of restricting behavior, could totally mimic the effect of “hedonic hunger”, and perhaps even explain more variance than the hedonic hunger measure. I also wonder if this has been done, now? My inner stats-geek is intrigued.
Thanks!
Hmmm, as a nutrition therapist, I have noticed the following situations. In AN clients, bingeing seems to occur in response to months or even years of restricting and especially because sweet foods are the most restricted and calorie dense. Emotion seems to be involved in some binges or is the tipping point of deprivation-driven eating; sometimes clients binge because they are too darn hungry, whether they feel it or not.
With BN, restriction is not always the driver but a lot more connected to emotion, however, it always needs to be explored how much restriction-based thinking there is around certain foods. Most of my BN clients have foods they try to avoid, which are the foods they binge on. And often, they will eat more of the avoided foods because they think they shouldn’t be; kind of a way to eat as much as they can because they plan to avoid it in the future.
Bottom line, beliefs around food need to be explored.
I would agree with your observations. When I was diagnosed with AN, I started bingeing pretty early on (within a year, I’d say), and it is not that I felt hungry before the binge, but when I started eating, it is like all of the hunger just flooded back. I couldn’t stop.
With BN, I also agree. I don’t know to what extent it is applicable to everyone, but it is definitely applicable to me. I do still binge on foods that I feel somewhat guilty eating. I can eat them in normal portions if I am say out with friends and everyone is having that — no problem. And I usually don’t feel guilty then, either. At the same time, I do genuinely enjoy purging and find the whole bingeing/purging process to be anxiolytic. So, it is not JUST that, but I know I definitely need to work on integrating the foods I tend to binge on in my day-to-day eating so that I decrease the frequency of bingeing on them.
It is not that I think that would be a panacea and end everything completely, because of course there are other factors (anxiety-relief, purging), but at least *that* driver would be decreased or vanish completely.
Thanks for your comment Tracy!
Thanks for offering your experiences, Tracy!
What you said got me thinking, I wonder how much of this “hedonic” factor is imbued with a whole range of complex emotions. Perhaps I’ve always associated food with a sense of comfort, and thus may rate it hedonically “pleasing”. Perhaps the anxiolytic properties of the food, or some other emotion terms, would be better factors to explore in a survey. I’m increasingly convinced by Tetyana’s factor analysis proposal.
Fascinating. I do think, though, that it is problematic to see starting to binge after a period of anorexia as positive, as both starving and bingeing are symptoms of eating disorders. If the only way an anorexic is able to get her weight back up to a normal level is through bingeing, she hasn’t really recovered.
I know for me, after struggling with anorexia through my preteens, I hit upon binge eating in high school. I could starve myself all day, eat chocolate or whatever at night as a way to reward myself, and maintain a normalish weight. Of course, bingeing was really just a crutch and a way of eating without having to confront the anxiety of truly eating normally. It functioned to allow me to remain anorexic in behaviors for 90% of the day while getting to fly under the radar by keeping my weight closer to normal.
Thanks for your comments.
I hope this post didn’t come across as promoting of binge eating. By no means does binge eating mean recovery. The data from this report certainly don’t indicate that individuals who binge recover, but have higher BMIs. We would need much more data regarding the cognitive, behavioral, and physiological characteristics of the patients before we could begin to make that assertion. That being said, I thought it would be interesting to discuss how the manifestation of binge-eating may lead a person to re-evaluate his or her eating disordered behaviors; perhaps even entering into the pre-contemplative stage of recovery. I think this happened to me, but it sounds like your experience was totally different. I’m glad you shared this alternate perspective, which would be important to assess in future studies of binge eating and recovery outcomes among AN patients.
Thank you for sharing a bit about your experience with binge eating following restriction, Liz. It is something I would really like to see more literature, both scholarly and otherwise, about.
From what we know, people and animals tend to go through a period where they eat more than typical and become a higher weight than their natural weight for a period of time after restriction. They needn’t binge to do this. I do always wonder if the women I know who say they are recovered from anorexia and have managed to stay at a low-normal weight, never going through a period of eating more than usual and gaining more weight for a little bit, are really recovered. Because from my experience, it seems one’s mind will stay more obsessed with food, and one will still have to stay hungry, if they don’t eat enough to become “overweight” for a period of time. (again, different than binge eating).
I know other women whose binge eating after anorexia spurred them into recovery. For me, I already very much wanted to recover from anorexia when I started bingeing. No matter what I did, though, I couldn’t let go of calorie counting, and found the thought of gaining any more weight than the minimum for my height unbearable. My eating patterns had also got very messed up, and I was physically very hungry the first day I binged. Plus, I was dealing with life changes and severe depression.