Tackling Binge and Emotional Eating in an Office-Based Program

Presentation Summary: Binge and emotional eating are common behaviors that contribute to significant psychological distress and are often associated with overeating, overweight, obesity, and related cardiometabolic conditions. They are present in persons of various age groups, gender, and socioeconomic status. A study of American adults found that over 20% of participants reported eating emotionally often or very often. The DSΜ-5-TR outlines specific diagnostic criteria for binge eating disorder, but does not specify criteria for emotional eating, which is commonly defined as eating to avoid difficult emotions. Emotional and binge eating exist along a continuum and are often underreported and underdiagnosed. Many patients engage in eating behavior in secret and may not report their symptoms or seek help due to shame and fear of judgment. Additionally, many healthcare providers do not have sufficient training in eating disorders and do not routinely screen for them.

While disorders of eating behavior are commonly encountered in primary and specialty care, most providers are not able to provide the necessary care due to insufficient training and time, and concerns about reimbursement. When binge or emotional eating disorders are identified, current treatment options include self-help books or programs, guided self-help programs, and individual- or group-based psychotherapy. Self-help books and programs can be effective, but patients may feel isolated due to a lack of peer-to-peer support or interaction. Individual- or group-based psychotherapy programs are also effective but may be cost prohibitive due to insufficient insurance coverage and access to care. In addition, traditional disordered eating treatment generally advises against restrictive diets, irrespective of weight status, advocating instead for inclusive diets that incorporate all food groups, eliminate food rules, and emphasize moderation. Strict food rules are frequently considered eating disordered behaviors. However, many people dealing with eating disorders are deeply concerned about their mental and physical well-being and are striving to balance the seemingly competing priorities of healthful nourishment and satisfaction with food. To meet these challenges, we launched a novel program to help participants with binge and emotional eating behavior. For the purposes of the program, we defined binge and emotional eating as any eating behavior that is associated with two core features – a sense of a loss control over food intake and subsequent harm to mental or physical health. Persons with anorexia nervosa were not eligible to participate in the program. The program incorporated a multi-disciplinary approach and was led by a clinical psychologist, internal medicine physician, and registered dietitian – all versed in plant-based nutrition and lifestyle medicine. The program duration was 12 weeks and included weekly 60-minute online meetings with 30 to 40 participants. Each weekly meeting included live instruction, peer-to-peer interaction, and support. Participants were assigned weekly homework to foster progress and accountability. The program was based on the principles of cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). A unique feature of the program was the incorporation of plant-based nutrition education. Participants were taught about the benefits of minimally processed plant-based foods, and the role of nutrient density and processed foods in satiety and food addiction. However, it should be noted that participants were not specifically asked to avoid or restrict any foods or food groups.

An essential feature of any treatment program is that it is cost effective for the participants and the instructors; the program was structured so that it provided a relatively low-cost option for the participants while generating enough revenue to make the program financially viable. The cost of the 12-week program was $349 per person, which is equivalent to $29 per session. This cost is significantly less than the cost of traditional individual or group psychotherapy sessions and lower than the cost of most primary care or medical nutrition therapy co-pays while encompassing the expertise of all three healthcare professionals. Assuming an average of 35 participants per 12-week cohort, the program generated over $1,000 per session, which covered the costs of the instructors’ time. The online video meeting format allowed participants across the country to participate in real time. Thus far, we have completed two cohorts of the program with a total of 70 participants. Participants were recruited through advertisements in various social media platforms and the Physicians Committee on Responsible Medicine newsletter. Approximately half of the participants were following or had followed plant-based diets in the past. Most of the participants had tried other intervention programs without success and reported significant improvements in their eating behavior as they completed the program. As a next step, we are planning a similarly structured cohort to track and measure clinical outcomes as part of a research study. Such a program could prove to be a valuable model that other practitioners can use to integrate CBT, DBT, and plant-based nutrition education in the treatment of binge and emotional eating.