Art by Maria Raquel Cochez, Self Portrait with Mcflurries, acrylic on canvas, 2007
If Julia Child represented the giddy artistry of cooking with a glass of wine in one hand, Jane Brody represented food at its healthiest. I earnestly struggled to improve myself via her cookbook and her pieces in The New York Times.
And then I found out she’d been a binge eater—and it wasn’t all celery, either. “A half-gallon of ice cream was only the beginning,” she wrote in a confessional piece in the Times. “I was capable of consuming 3,000 calories at a sitting. Many mornings I awakened to find partly chewed food still in my mouth….My despair was profound, and one night in the midst of a binge I became suicidal. I had lost control of my eating; it was controlling me, and I couldn’t go on living that way.”
According to the National Institute of Mental Health, binge eating affects from 2 to 5 percent of the population, more than anorexia and bulimia combined. Yet it’s only been listed in the Diagnostic Standards Manual as an eating disorder since 2013.
People eat vast amounts of food and feel out of control, unable to stop the binges. They overvalue shape and weight. But they don’t engage in regular purging.
Until now, the only drug known to help had serious side effects. But Dr. Denise Wilfley, Scott Rudolph University Professor of Psychiatry at Washington University School of Medicine, co-authored a study recently published in JAMA Psychiatry.
The drug Vyvanse (lisdexamfetamine dimesylate)—which has been used for at least a decade to treat ADHD, with minimal side effects—had a real effect on binge eating. When participants took a sufficient dose every day for 11 weeks, half of them did not binge at all in the final four weeks.
Some of the drug’s success is probably the placebo effect—just receiving attention and treatment of any kind is helpful, and the subjects are now paying clearer-eyed attention to their own behavior, instead of hiding it because it seemed so shameful. But Wilfley says the study’s results are far stronger than any improvement the placebo effect could produce.
Vyvanse works on the dopamine and norepinephrine systems in the brain, so it tackles both reward-seeking behaviors and decision-making. The drug seems to build in a pause, helping people avoid acting on impulse, feel more in control, and avoid mindless eating.
But that doesn’t mean the problem’s purely biochemical.
Even though there’s a genetic predisposition to binge-eating disorder, personal problems—tension in a marriage, a tough transition away from high school friends to a big impersonal university—can set off the binges. For Brody, 23 at the time, it was the stress of her first newspaper job, miles from home. “My love life was in disarray, my work was boring, my boss was a misogynist. And I, having been raised to associate love and happiness with food, turned to eating for solace.”
We’ve all done it. And Wilfley’s been studying eating disorders, with a focus on binge-eating disorder, since the late ’80s. She’s compared different types of therapy—cognitive-behavioral works better than behavioral weight-loss treatment alone, she says, and interpersonal therapy works very well indeed, by improving the quality of social ties. “We work on building healthy relationships,” she explains. “The patients say food is their friend; food can be relied on. And sometimes interpersonal relationships are unpredictable and not very satisfying. We try to get them to reach out to others for that support and comfort. By building these secure relationships, we not only help them reduce their eating-disorder symptoms, we drastically improve their overall quality of life.” She credits the use of interpersonal therapy, and in previous studies, she’s found it to be as effective as cognitive-behavioral therapy and better than behavioral weight loss treatment.
With the right kind of psychotherapy, “about 60 percent of people fully recover,” Wilfley says, “so you have a pretty good shot at a fairly potent effect. Plus, studies have documented that treatment gains are maintained five years after treatment with interpersonal therapy. Patients report that the tie to food starts dissolving as they start replacing it with social ties instead of turning to food for comfort.”
So—to play the devil’s advocate—why turn to a pill?
“The data are more robust for the psychological treatments—there’s a bigger impact, and they’ve been studied for a longer period of time,” she begins. “The problem is that often the therapies aren’t in widespread use.” The patient receives therapy that isn’t specialized enough to target an eating disorder, and winds up feeling even more helpless. With a pill, there’s consistency (the term of art is “fidelity”), so a patient gets the same benefit even if he or she can’t seek out the right kind of specialized therapy.
In addition to her work as a scientist, Wilfley has been involved with policy efforts in Missouri. Her great frustration is the lack of adequate, reimbursed care for the treatment of childhood obesity. “It’s easy to get into the cycle,” she says. “Kids are teased and isolated, and they start using food for comfort.” There aren’t enough therapists who know how to address childhood obesity, and thereby reduce the chance of a binge-eating disorder developing. “Even if parents find one, the therapy’s often not covered by insurance,” Wilfley adds with a sigh. “I always thought, you do a study and you publish it in JAMA. It’s a lot more complicated than that. You do all this work as a scientist, and it doesn’t get to the public.”
Wilfley is working to make psychological treatments for binge-eating disorder more widely available. She’s evaluating different ways to train clinicians across the country in interpersonal psychotherapy. And with the Missouri Eating Disorders Council as a partner, she’s hoping to educate counselors throughout the state in interpersonal psychotherapy, offering an online training program to raise the standard of care. She is also helping people access support through the Healthy Body Image Program, which makes evidence-based cognitive-behavioral therapy accessible via a mobile app or online program. HBI is currently available to students at the University of Missouri-Columbia, Truman State University, Missouri Western State, University of Central Missouri, Missouri Southern State, and Missouri University of Science and Technology.
Meanwhile, Wilfley has a grant to try to influence children’s decision-making with a computer game that rewards long-term choices. “If they make quick, impulsive choices,” she says, “they lose the game.”
