As a follow up to Charlene’s post on eating hyper-palatable foods during eating disorder treatment , I asked Liz–SEDs’ resident expert on animal behaviour, particularly in relation to binge eating and drug addiction–to look at some of the studies that Julie O’Toole mentioned as evidence for Kartini Clinic’s guidelines of avoiding hyper-palatable foods for the first year of eating disorder recovery. If you missed Dr. O’Toole’s post, please do take a look. Here’s the main conversation that led to this post:
In the comments, I asked Dr. O’Toole,
I agree that eating cheetos and sugar-y drinks is ubiquitous but not exactly healthy, and I too question many versions of “normal eating” that people promote (and *everyone* has an opinion), but I wonder — if there’s any evidence for not allowing hyper-palatable foods to patients for a year? And what does the Kartini Clinic consider to be hyper-palatable? Why not just allow it in small portions and occasionally?
Dr. O’Toole’s response:
I am, of course, painfully aware that most places do not temporarily restrict palatable or hyper-palatable foods, but let me see if I can assure of the evidence base used for this recommendation.
First there is the Minnesota Semi Starvation Study (MSSS): In his two volume treatise on human starvation, Ancel Keys discussed the consequences of “ad lib”referring with access to calorie dense, sweet, high fat foods. He discussed cases of bingeing that resulted from this practice and the resultant weight gain. Among the many, many discussions throughout this well known and massive work, Keys says (page 127) “The tendency toward overeating following a period of reduced food intake has been noted repeatedly under conditions of natural starvation when food suddenly becomes available again in large quantities. The experiences of semi starved explorers document particularly well the surprising lack of self-control even in the face of clear knowledge that the overindulgence will certainly result in discomfort and may have fatal consequences….”
The Biology of Human Starvation Vol. 1 University of Minnesota Press 1950 (page 127) Ancel Keys et al. Please do check it out and especially the graph illustrating the weight curve for when the “patients” were re-feed on a plan (v.s. “ad lib”), and then once they were given access to ad lib feeding of anything they wanted. This graph shows that eating (and weight) normalized after about 1 ½ years—although, once ad lib feeding of anything they wanted was introduced they gained weight way past their own norm; it just took about 1 ½ years for all that to normalize and the weight to re-adjust.
In the words of one “survivor” of this study: “we got fat”. Why is it necessary to let that happen? Take a look, I’d be interested in your interpretation.
The term hyper palatable food comes from the research arena using animal models of eating behaviors and refers to the high calorie/high fat/sweet dessert and snack items very prevalent in our culture (usually Oreos are used with rat studies) . At Kartini Clinic we pass no judgment on most of these hyper palatable foods as “bad”, per se, but rather do not build them into the initial food plan in order to bypass that temporary period when the brain seems “on fire” and vulnerable to bingeing and the oft reported effects of overeating and weight gain. Once the system has reasserted its own homeostasis, the parents and child can eat as fits their culture and wishes.
The parent forum Around the Dinner Table refers frequently to children who are refed using high calorie desserts and who can’t seem to stop gaining and eating once their goals are met. This can be very distressing.
A few good references for the effects of PF (palatable foods) on ingestion can be found at http://www.ncbi.nlm.nih.gov/pubmed/9356889, http://ajcn.nutrition.org/content/65/3/717.full.pdf, [and] http://www.ncbi.nlm.nih.gov/pubmed/12213501 — and the statement in the abstract for this last article saying: “Subsequent experiments revealed that binge eating did not occur if only chow was available (Experiment 3) or if restriction-refeeding (R-R) did not proximally precede stress (Experiment 4)”
I guess you could say, we give only chow…..
In the previous post, Charlene looked in-depth at the Minnesota Semi Starvation Study as it relates to the current issue. In this post, Liz looks at the animal research that Dr. O’Toole cited as evidence in support of the Clinic’s guidelines. In particular, Liz focuses on the last paper Dr. O’Toole cited. – Cheers, Tetyana.
In her post, Dr. O’Toole critiques a recovery clinic for handing a patient Cheetos and a soda as part of the meal plan, specifically, as a “challenge food”. While she makes a very fair point that these foods should be enjoyed in moderation, a point that I don’t think anyone disagrees with, I was struck by her rigid requirement of avoiding any “hyper-palatable” foods during the first year of recovery. To quote Dr. O’Toole: “At Kartini Clinic we do not offer our patients ‘hyper-palatable‘ foods for a year following re-feeding.”
First, what are “hyper-palatable” foods and how are they defined? And second, what is the evidence that avoiding “hyper-palatable” foods, particularly for a year, is helpful?
It turns out, Dr. O’Toole derived this terminology from animal studies of binge food intake.
In these studies, the term “hyper-palatable” refers to foods that are high in sugar and fat, and that animals are prone to over-consuming in certain circumstances. Several researchers have used (relatively) cheap and readily available Oreo cookies in studies of feeding behavior as an alternative to purchasing specially made, high-fat rodent diets from a vendor. The use of Oreo cookies to model binge food intake appears to be as effective as using the specially ordered alternatives, but other substances may also be used (e.g., Crisco).
Regardless, what is important in these studies is that the researchers can reliably induce enhanced intake of these foods and examine brain activity associated with this experimentally-controlled behavior. The goal for the researchers is to understand how specific variables (e.g., degree of calorie deprivation, exposure or lack of exposure to high-calorie foods, stress levels) may interact with our neurochemistry to promote binge eating.
The point of this research is NOT to specifically model human behavior, nor inform best treatment practices.
An example of this type of research is Hagan et al.’s 2002 study titled, “A new animal model of binge eating: Key synergistic role of past caloric restriction and stress”. I point out this article in particular because Dr. O’Toole cited it to support her practice in not allowing “hyper-palatable” foods, like Cheetos, Sun Chips, soda, and, most importantly, Oreo cookies, for at least a year.
Dr. O’Toole’s noted that the animals in this particular study did not binge eat when they were given only chow after a period of food restriction and exposure to a stressful situation. Thus, if recovering individuals are only given the human equivalent of “chow” (e.g., rodent pellets) to eat, they will not binge.
First, let’s examine the goal of this study. Hagan et al. (2002) sought to develop a tool to specifically examine the combined impact of stress, a history of food restriction, and exposure to hyper-palatable foods on binge food intake. Thus, they sought to develop a model where animals would binge eat only when these three factors are available:
The goal of this study, therefore, was to test the hypothesis that dieting and environmental stress interact in a synergistic manner to produce binge eating and that access to [hyper-palatable] food is critical to this response. To test this hypothesis, rats were subjected to brief cycles of caloric restriction followed by ad lib [ad lib = without limit] refeeding prior to being exposed to an acute episode of stress via foot shock.
To get this specific “synergistic” interaction, the researchers had to be very particular about how they controlled the rats’ feeding environment. For example,
- The rats had to undergo several cycles of food restriction and re-feeding in order to develop the heightened consumption of Oreos.
- The rats had to be exposed to stress (in this case, an irritating foot-shock) to show this effect.
- The stressful condition had to occur after a restriction and re-feeding cycle.
- The rats had unlimited and unrestricted access to hyper-palatable food.
Furthermore, the rats that had experienced food restriction only enhanced their intake of Oreos when the cookies were made available four hours following the stressful situation. They didn’t show “binge” consumption of Oreos when the cookies were made available 24-48 hours after the stressful situation.
This highly-controlled model of binge food intake is a far cry from the human condition, and its not intended to be an exact model of disordered eating in humans.
The intention of the researchers was to develop a model where the significant factors driving binge food intake were the combined impact of stress and a history of food restriction. With this model, the researchers can potentially uncover brain activity that is associated with this particular predictor of binge food intake.
If we follow Dr. O’Toole’s logic a bit further and assume that the feeding patterns of the animals in this particular study have direct implications for the treatment of eating disorders, then it would mean that individuals recovering from eating disorders would not develop binge eating when exposed to hyper-palatable foods as long as they didn’t experience a panic attack or encounter a stressful situation a few hours prior to eating.
I’m confident that Dr. O’Toole has the best of intentions and has helped many individuals recover from their eating disorders. In this post, I simply wanted to highlight one component of her treatment plan (avoiding sugary, high-fat artificial foods for a year) that, at least to me, does not seem as empirically supported as she claims.
Of course, in this post, I focused only on one article that Dr. O’Toole cited. Nonetheless, I do want to remind readers to be critical of the “evidence” that can often be used to support clinical practices. Just because a clinician cites a scholarly article in support of his or her practice does not mean that the article necessarily supports the claims that are being made.
References
Hagan, M.M., Wauford, P.K., Chandler, P.C., Jarrett, L.A., Rybak, R.J., & Blackburn, K. (2002). A new animal model of binge eating: key synergistic role of past caloric restriction and stress. Physiology & Behavior, 77 (1), 45-54 PMID: 12213501
I don’t think occasional hyperpalatable food is a problem, but I also don’t see a clinical practice limiting it for a defined period as a problem. In fact, I think it helps build a sense of trust in patients.
I would consider any patient needing refeeding as one who has undergone “repeated cycles of restriction” and *is* under one long stress episode, both as part of the illness and in the ongoing process of treatment, refeeding, therapy, body and behavior changes.
If a person has been starved of nutrients and calories, why would a treatment plan waste the opportunity to offer menu items of the highest quality nutrition vs items that are largely empty calories? There are many nutrient-dense choices among non-junk foods … just because a food isn’t a hyperpalatable packaged food or dessert doesn’t mean it’s low-calorie. But it is likely to have more fiber, vitamins and minerals, protein and a better balance of refined and/or natural sugars, fats, carbs.
Everything about treatment is a process that begins with more structure, so the idea of limiting the hyperpalatable doesn’t seem like a bad idea for this time when you’re building new habits; repair organ and body systems; restore normal gut function and tolerance; and learning to internalize intake and foods to sustain recovery, health and energy beyond the acute stages of treatment. Once patients get started and begin internalizing some of the new meal patterns and food choices, adjusting to their changing bodies and accompanying emotions, a year out doesn’t seem an indecent goal for beginning to incorporate the “extras” like junk foods.
By that time, patients will have their own evidence that food hasn’t caused them to blow up overnight; that they can trust themselves, their team, and their bodies to allow the occasional treats. They’re less likely to ditch the whole program/vow to lose weight/reach for uber-restriction out of fear they will lose control and (for anorexics) “become bulimic,” a big fear and trigger. To put those challenges in front of patients when they’re early/vulnerable in treatment/refeeding seems like a physical and psychological set-up.
On the other hand, to know that the team has a plan and a structure to help you … is a reassurance and offers something that seems less “reckless” to an anorexic and also appeals to the need for control and the tendency to worry about the future and, therefore, pull back today, just to be safe. If your team says: “We’re going to start slow; we’re going to focus on nutrients and the best re-building blocks we can put together (bang-for-the-buck beyond straight-up calories); we’re going to monitor you; and as your body slowly heals and you are able to internalize baseline habits for health and energy, then we are going to start working on those fun foods, junk foods and incorporating impromptu eating/eating “off-script”/off plan. But that won’t be for about a year, so you don’t have to worry about that. One step at a time. You will be much more confident in your ability to handle these challenges, and your body will be ready.”
People live full lives without hyperpalatable foods, now and throughout time. But they’re omnipresent in Western culture, so learning to incorporate and manage them as part of an overall healthy life and lifestyle is important. Obviously, some patients who might have a binge background may need to work with individual therapists/teams to incorporate some things sooner. But patients with severe restriction likely aren’t worrying they won’t get to have soda or oreos … they’ve been going without them (or anything else, sometimes even water) for a long, long time. The immediate priority should be foods that best rebuild organs and restore the essentials, including healthy fats and carbs (and I consider a year to still be “immediate” for someone with severe and/or enduring restriction).
Patients have the rest of their lives to work on hyperpalatable foods, but they’ll never get there if they leave treatment early or never get to a minimal restoration of body, mind, cognition, emotion, physical function and social interaction.
Hi m,
Thanks so much for your thoughtful comment. I’ll address your comment in parts.
I would consider any patient needing refeeding as one who has undergone “repeated cycles of restriction” and *is* under one long stress episode, both as part of the illness and in the ongoing process of treatment, refeeding, therapy, body and behavior changes.
This may be a difference of opinion/a question of what exactly we are modeling in rats. I would not consider a patient needing refeeding as someone who has undergone *repeated* cycles of restriction. It is possible, but it is not necessarily the case. If someone lost weight and has not regained it/been treated previously, then I would consider that to be one episode of restriction — not repeated cycles of restriction and refeeding. Secondly, the foot shock is an acute stress paradigm, not a chronic stress paradigm. I can see arguing that simply being ill and having to undergo treatment is a chronic stress episode, but (a) the foot shock is acute stress, and (2) how do we then differentiate between individuals who have had additional stressors (trauma, for example) in addition to their illness?
If a person has been starved of nutrients and calories, why would a treatment plan waste the opportunity to offer menu items of the highest quality nutrition vs items that are largely empty calories? There are many nutrient-dense choices among non-junk foods … just because a food isn’t a hyperpalatable packaged food or dessert doesn’t mean it’s low-calorie. But it is likely to have more fiber, vitamins and minerals, protein and a better balance of refined and/or natural sugars, fats, carbs.
Oh, absolutely!! I don’t think there’s any disagreement here. I think the vast majority of the meal should be of the highest quality nutrition. The issue is: Is there value in specifically LIMITING a large number of foods for an ENTIRE year? I don’t think anyone thinks we should be refeeding on “junk” food. But having a dessert, even once a week or every few days?
Everything about treatment is a process that begins with more structure, so the idea of limiting the hyperpalatable doesn’t seem like a bad idea for this time when you’re building new habits; repair organ and body systems; restore normal gut function and tolerance; and learning to internalize intake and foods to sustain recovery, health and energy beyond the acute stages of treatment. Once patients get started and begin internalizing some of the new meal patterns and food choices, adjusting to their changing bodies and accompanying emotions, a year out doesn’t seem an indecent goal for beginning to incorporate the “extras” like junk foods.
Well, I think that depends on how long the individual has been ill for and what their eating was like during their eating disorder. What if they never restricted themselves of junk food during their illness? What if they had bulimia nervosa and did eat those junk foods (and perhaps outside of binges, too)? If we are talking about treating someone who has had an enduring and chronic course, sure, I can see the argument being made for waiting for a year (especially depending on how long weight restoration takes place and if there are other comorbid issues that need to be treated as well that may take precedence over, say, introducing junk food), but what if someone has been ill for <6 months?
The major problem I have with avoiding hyper-palatable foods for a year is that it REINFORCES the fear and avoidance that patients have about these foods. Yes, building trust with treatment providers is important. But, we are not talking about refeeding only on junk food. We are not talking about providing unlimited access to hyper palatable foods -- which WAS the case in all of these animal studies AND in the Minnesota Semi Starvation Study. We are talking about introducing fear foods to extinguish the fear that many individuals have about those foods. By limiting that food for a year -- for everyone who enters treatment -- and by saying things like "we won't let you get fat" (what if the person's natural weight is > BMI 25? And what *is* fat?) treatment providers only reinforce the fears. That, in my opinion, is counterproductive.
But patients with severe restriction likely aren’t worrying they won’t get to have soda or oreos … they’ve been going without them (or anything else, sometimes even water) for a long, long time.
But that’s the thing: Have they been? Some, sure. But all? No. Patients with bulimia nervosa probably haven’t been. Patients with anorexia nervosa binge-purge type probably haven’t been. Patients who have been ill for <6 months, even <1 year probably haven't been. Patients who have been ill but didn't limit themselves of those foods (just restricted calorically) probably haven't been. Why the assumption that this is the case for everyone? Surely, it is the case for some, and I do think for those with severe and enduring AN, introducing hyperpalatable foods is not the priority, probably not until weight restoration has been achieved, but discharging them from treatment without introducing those foods only sets them up for relapse.
Patients have the rest of their lives to work on hyperpalatable foods, but they’ll never get there if they leave treatment early or never get to a minimal restoration of body, mind, cognition, emotion, physical function and social interaction
Sure, I agree that minimal restoration and function is incredibly important, and it is absolutely fine to get to that stage first before introducing hyperpalatable foods. Indeed, probably preferable. But how are they supposed to work on hyperpalatable foods if they haven’t eaten them for a year? On their own? After they’ve left treatment? After they’ve been specifically restricted of it for a year? Besides, as Charlene mentioned in her last post, limited food variety is a predictor of relapse after treatment.
Thanks again for your comments, M. Like Tetyana said, we are mainly taking issue with the promotion of completely eliminating hyperpalatable foods for one year. I do not know what Dr. O’Toole’s treatment program is like, but I cannot imagine being exposed to a diet that did not include those items and then have to encounter them once I left treatment. There doesn’t seem to be a good body of evidence (or any?) to support this practice, and it could lead to more orthorexic-like behaviors in the future. For me, a goal of recovery is to not be afraid of ANY food whatsoever. Any push toward limiting specific foods pushes me away from recovery and encourages falling back into disordered eating patterns. I wouldn’t want to be in a treatment program that reinforces that behavior, albeit unintentionally.
All of my comments were on the presumption that the patient would be continuing with treatment, just not as an inpatient or day-patient … that they would continue working with the team/dietitian/therapist and with family support to continue growth and progress in recovery and maintenance. It seems better that way also, because the patient has already climbed several “mountains,” so to speak in treatment: beginning to eat normally; increasing intake; gaining weight; accomodating negative thoughts and having already built a bank of tools/self-talk for coping, based on the successes of the first steps/steps-so-far in refeeding. You’re not enforcing a fear of fat or junk food or endorsing orthorexic thoughts, but you do promote first-things-first and move according to plan.
My comments *were* skewed toward severe anorexia and chronic or enduring anorexia, both because that is my experience and because treatment more intensive than outpatient seems to be characterized by admissions of these kinds of patients; patients with significant medical or other complications … and, therefore, the triage of all patients who meet diagnostic criteria seems seemingly skewed toward the more and more compromised patients filling beds for longer periods of time, therefore meaning others seeking/needing care aren’t going to be at the top of the waitlist because there are others whose symptoms/case is worse. “Worse” looks worse all the time, and in the meantime, those who are still “better than worse” decompensate. So, by the time you’re looking at structured treatment that meets insurance criteria for approval and treatment programs, you’ve probably got someone whose first issues aren’t incorporating these foods.
I’m not saying it’s right, but most of the patients I see in the more acute settings/higher LOC, are mostly restricting anorexics/dominant restricters or purging restricters. Primarily bulimic patients with higher BMIs or BMI that is low but not super-low aren’t admitted as quickly, or they’re admitted for stabilization and to learn meal-planning or the program ins-and-outs, and then they’re graduated to PHP or day-treatment or a less-structured residential program. In all of those cases, regardless, I’m thinking any patient that needs to be admitted for refeeding should be followed by a team for more than a year.
“I’m thinking any patient that needs to be admitted for refeeding should be followed by a team for more than a year.”
I totally agree! Heck, even those of us that haven’t been admitted for refeeding still take years to recover, and could benefit from having a team (of course, the logistics surrounding the cost of such treatment is a whole other issue). I would also agree that perhaps it does take some individuals much than a year to be able to get to the point of consuming hyperpalatable foods and it may not be appropriate to introduce those foods early on.
However, the issue I’m taking with Dr. O’Toole’s treatment program is her seemingly rigid restriction of these items for ANYONE who enters her clinic, and her claims that such a restrictive policy is justified by the literature. Maybe her practices do little to no harm on the individuals that go through her program, but her emphasis on “modeling healthy eating” and fear of foods deviating from the “five ingredient rule” seem to be a way to set up more orthorexic behaviors, in my opinion. If someone made the “five ingredient rule” salient to me when I was recovering and touted that as the way to health and recovery, I would STILL be obsessed with food, and likely prone to relapse (as if I wasn’t already prone enough). That’s not recovery to me.
M, I think you make a valid case in regards to a very specific population of individuals, and I definitely appreciate your comments (really!). I also noticed that your comments are specifically directed toward insurance contracted facilities, which the Kartini Clinic is not. So we are likely talking about treatment options for different types of patients.
I definitely think avoiding these foods during high risk periods in refeeding is wise – my treating team have often limited my energy intake, particularly carbohydrates, as I’m a high risk candidate for refeeding syndome and nearly always have gotten it. But there is no justification I can think of for a whole year. If anything, I would imagine it would make bingeing MORE likely due to the forced restriction/deprivation.
An important difference between rats and humans is that humans are very aware of the other food choices they are missing out on and are exposed to them often in the course of normal life (other people eating, food shops, media, other patients in the hospital not on an ED protocol etc). The rats can’t crave what they don’t really know exists.
I HATED being forced to eat “junk food” in treatment. I tried to weasel my way out of it and threw rather embarrassing temper tantrums. But you know what? I think it’s important, if only to learn that you can eat something that is supposedly “bad” and live to tell about it. I think that in a safe environment, it is important to introduce triggering foods to learn how to handle them exactly so that when you leave an inpatient or more “controlled” setting, you don’t find yourself in an all-or-nothing setting. But what is this ad-lib refeeding? I find it hard to compare a rat who has only simplistic cognitive function being driven by starvation to binge on “hyperpalatable foods” with a human being, perhaps subject to the same drives but also with a history of a psychiatric disorder who has been through large amounts of therapy, potentially takes psychotropic medication, has the capacity to make self-reflective thoughts, and besides all this, has to buy food, cook food, store food, and probably go to work or school or interact with society and can’t spend all day sitting in a cage eating either grinded up oreos or rat pellets.
On that note, I will add that since I am in outpatient therapy at the moment and have been bulimic for 10 years, the whole “goals of care” are different than they might be for someone with AN-R and /or in a controlled inpatient setting, and while I haven’t given up on recovery, on a day in and day out basis, I pursue my recovery with more of a harm reduction type focus, and so for that matter, I do tend to avoid foods that trigger me to binge, which are largely in the “hyperpalatable” food category because much as I may wish otherwise, I am not in a situation where I can eat a single portion of the food and not binge and purge, which can set me off for days, and it seems like I’d rather avoid it than eat the food. I’d like to move towards adding those foods back down the line, but I’m not there yet. It’s different for inpatients because when someone is watching your every move, it is safe and controlled, and the damage from one slip can be mopped up and talked about before it pours over for days and days, and it’s probably different for different behavior patterns and for shorter duration eating disorders. Just my experience…
There’s certainly a lot of conflicting info out there!
I’m quite interested in the MinnieMaud approach which emphasises ad-lib intensive refeeding and no bad foods. It draws on the Minnesota study, too but comes to a different conclusion to Kartini!
To this restrictive eater, Kartini sounds like a treatment centre with an anorexic mindset. Fear of fat? Banning of certain foods? Rigid IGWs?
I’m not sure how useful that would be to me.
Personal anecdote time: my only period of binging ( I dont even like sweets but my body was demanding them) came when I was dropped from treatment too early. After years of severely low weight I reached a target weight that was still too low and clearly my body wasn’t repaired, it took years to get my circulation and blood pressure back into normal range. I felt the binging was body-driven not mind-driven and gaining visceral fat, then subcutaneous fat, then lean muscle was a necessary process. I went slightly above my IGW and only then did my mind and body start to feel repaired. It was the longest lasting period of ‘recovery’ I’ve had.
Not saying binging wasn’t traumatic but it was temporary and having got through it and knowing it didn’t last and most likely was biologically necessary makes it less scary a part of weight restoration for me.
That said, I’m an adult with a long history of R-AN, not a scared teenager or child in treatment for the first time.
Thanks for your thoughts, Kasen, and for sharing your personal history. Interesting point about the BP and circulation. I’m having similar issues with that (although I’ve always had poor circulation). It’s helpful to know others struggle with getting back to “normal” for quite some time.
I also think that an important thing to point out about the Hagan et al. (2002) study is that the rats were more or less trained to binge eat on oreos because they were freely available for only a limited amount of time. It would therefore be adaptive for a starving animal to consume as much as possible of the foods before they were no longer available. I do think that we can mold our feeding circuits to associate calorie-rich foods with binge intake and overfeeding if we have a history of strictly avoiding them, except during binge episodes. I’m so struck that the Kartini Clinic wouldn’t allow me to “re-learn” how to consume those foods in a non-binge manner during the first year by exposing me to them intermittently, not allowing me to have unlimited access to them when made available, and exposing me to them when I’m not in a semi-starved state.
Thanks Liz. Very true about the rats being trained to binge eat and it doesn’t compare at all with an autonomous human being influenced by a dynamic environment + their idiosyncratic history of disordered eating.
I havent read the study in question but I’m highly suspicious of any behavioural studies on rats because in my experience hardly any studies take into account the rats behaviour isn’t going to be ‘normal’ when they’ve been reared intensively, and are usually kept in unstimulating, lonely, stressful conditions. While we expect them to be as reliable and predictable as any other piece of lab equipment….
…actually, maybe that is a good analog of modern human living 🙁
I guess I just feel that fat-phobic treatment guidelines involving off-limits bad foods that must be avoided or else fall into a trap of binging…that would have just colluded with my ED and its need for rigid control.