Eating Disorders

Why Dieting Has No Place in Binge Eating Disorder Treatment

The eating disorder field continues to struggle with fat-phobia.

Posted Feb 25, 2020

If you struggle with binge eating, you have likely tried dieting as a way to gain control over your eating. And, if you are like most dieters, you have likely discovered that diets don’t work.

You may be able to stick to the diet plan for a certain amount of time but inevitably the pendulum swings back in the other direction, you fall off the diet wagon, and you feel more out of control around food than ever before. Most dieters blame themselves for this cycle—if only I had more willpower, self-control, and discipline!—but this cycle of restriction followed by binge eating is the typical outcome for dieting. In fact, it is one of the reasons that dieting is one of the strongest predictors for binge eating disorder. Research suggests that women and girls who diet are 12 times more likely to binge eat. While not everyone who diets goes on to develop an eating disorder, almost everyone struggling with an eating disorder reports a history of dieting.

So, why are some eating disorder experts recommending dieting as a treatment for binge eating disorder?

This is a question being asked by many eating disorder professionals after a recent case study was published in the Journal of Eating Disorders suggesting the use of the keto diet in the treatment of binge eating disorder. The article was publicized in a tweet by the Academy of Eating Disorders (AED), one of the leading professional eating disorder organizations. The tweet was met with outrage on social media and it wasn’t long before it was deleted and a half-hearted apology was issued but the whole debacle highlighted something very concerning within the eating disorder community.

Diet-culture and fat-phobia continue to permeate our field and inform treatment recommendations.

Let’s look at the study that caused all the uproar. The article, a case-study by Carmen et al (2020) titled “Treating binge eating and food addiction symptoms with low-carbohydrate Ketogenic diets: a case series,” followed three patients with binge eating disorder who were treated by two different doctors with different variants of the keto diet. The patients had a ton of support in adhering to the diet; two met weekly with their doctor.

After following keto for six to twelve months, the three patients experienced significant decreases in binge eating symptoms and lost weight. But at what cost? One of the patients reported continued obsessive thoughts about food but resisted eating in response to these thoughts and another patient reported eating only one meal per day and did not experience symptoms of hunger. Researchers did not assess for emergence of restrictive eating disorders. Despite these less than ideal outcomes, the study was hailed as a success because the patients had lost weight and stopped binge eating. The message is clear: When you are fat in our fat-phobic culture, losing weight is all anyone cares about.

How objective was this study? It’s hard to say that a case study of three patients is objective at all—this is why most peer-reviewed studies involve large sample sizes and randomized controlled trials. It’s not clear if the researchers handpicked three patients who were the “success stories” and decided to write about these, neglecting the countless others who had even less optimal outcomes. But what is clear is that some of the researchers have a strong financial investment in demonstrating the success of keto. Both of the treating doctors in the study and co-authors of the article disclosed financial interests in keto businesses. The editor-in-chief of the journal is a consultant to Weight Watchers.

These financial conflicts of interest are not uncommon. In 2017, the International Journal of Eating Disorders published a study concluding that the Noom app is a beneficial adjunct to binge eating disorder treatment. For those of you not familiar, Noom is a weight loss app that markets itself as a non-diet program (spoiler alert: it definitely is a diet). As we know, dieting is contraindicated for people struggling with binge eating disorder, so the use of a weight loss app (even one adapted for the treatment of BED) seems like an odd intervention choice. The lead author of the study? A leading eating disorder researcher who is a fellow of the AED and is an equity owner of Noom.

Now I get it, being a researcher can be a tough life and grant funding needs to come from somewhere. I’m not saying that the financial investment from the diet-industry biases the study results. But I’m not saying it doesn’t either. And this is why we need to get diet-industry money out of eating disorder research. It makes it nearly impossible to know if study results are influenced by the financial investments that the researchers have for a particular study outcome.

Bottom line: We know that dieting is harmful for people struggling with binge eating disorder. When we recommend that higher weight individuals engage in behaviors known to be dangerous, it’s hard to see this as anything other than weight-bias. It leads to subpar medical care for people in larger bodies, contributes to mistrust of the medical system, and basically does a boatload of harm. How can we expect anyone to recover from an eating disorder when we are encouraging the very same behaviors that are making them sick in the first place? It’s kind of like suggesting that having a lot of sex would help reduce the risk of unwanted pregnancy. It’s not only ineffective, but it’s also making the problem worse. As a field, we need to do better. We need to hold our organizations and journals accountable, to speak out against the infiltration of diet industry interests in positions of leadership, and to do the hard work of examining the fatphobia that runs rampant within our field.