It’s Not about the Diet

Most therapists have been taught that if we can help clients understand the emotional triggers of their overeating, they’ll be able to control their behavior and lose weight. Some of us, when working with clients on the continuum from occasional overeating to binge-eating disorder, build strategies around nutrition, portion control, and exercise habits. But more often than not, weight loss—should it occur—is fleeting. In fact, the pursuit of weight loss typically triggers and sustains overeating.

My focus with clients who have overeating and weight concerns is to help them learn how to have a healthy relationship with food. Typically, these clients have internalized the cultural message that their bodies are “wrong,” and that shame is reinforced when the dieting solution they’ve pursued, which usually works initially, almost always fails. We therapists need to recognize that when we reinforce the notion of weight loss as a marker of success, we set our clients up to leave therapy with even more shame about one more failure.

When Joelle called me to set up an appointment, I could hear the cycle of shame in her voice. “I’ve got to get my eating under control,” she told me. “I’m a middle-school librarian, and in the summers, when I’m not working, I’m really good at sticking to my diet. But as soon as I go back to school in September, everything falls apart.”

A few days later, Joelle walked into my office. She had long hair and was dressed casually, in a pair of jeans and a loose shirt. “I learned a lot about dealing with conflict with my previous therapist, and my marriage has gotten so much better,” she explained. “but I can’t stop my overeating, and I keep getting heavier.”

From the start, I was clear with Joelle—as I am with all my clients—that we could work on ending her preoccupation with food and weight, and if weight loss occurred in the process, it’d be a side effect, not our measure of our success. “There’s really no way to tell whether you’ll lose weight,” I explained. “The factors determining body size are so complex. No matter what, though, I can help you be more at peace with food and work on your body image and health concerns. We can even look at how to deal with some of the pressures in our culture about weight. How does that sound?”

“Sounds interesting,” Joelle responded.

First, it was important for me to hear the specific details of her eating experiences—not only to understand her situation, but because it would help reduce her shame as I listened without judgment and without trying to fix her problem with strategies that she’d probably already tried. “Tell me a bit about your eating patterns,” I started.

Looking uncomfortable, she crossed her legs, uncrossed them, and then said, “It’s hard to talk about because it’s so embarrassing. Yesterday, for example, I stopped for an Egg McMuffin at McDonalds on my way to work. You’d think that’d be enough, but then I drove through two more fast-food places for more breakfast sandwiches, and I was stuffed by the time I got to work.” After having a salad for lunch, she didn’t eat again until she got home. Since her husband was working late, which he often did, she didn’t bother to cook dinner. Instead, she grabbed some cereal and then finished a box of Oreo cookies. “I know these things are bad for me,” she added. “I really shouldn’t keep cookies in the house. They’re just too tempting.”

“You know,” I responded gently, “that’s part of the problem. You tell yourself that cookies are a bad food and ban them, but then when they’re available they glitter for you. If you’re like most people, once you start eating them, your diet mentality tells you that you might as well have the whole box, since, starting tomorrow, you can’t have them again.”

“That’s exactly what happens to me,” Joelle said. “When I’m in control, it’s like a high: I lose weight and get lots of compliments. But I can’t keep it up, and I end up eating the foods I was staying away from and gaining all the weight back.”

I felt the heaviness in my heart that often arises when I hear the pain of someone caught in this struggle. “You think it’s your fault, but it’s part of the pattern for almost everyone,” I said. “If you’re like most of my clients, when the weight comes back, the people who gave you the compliments are silent, and you end up feeling shame. Then the negative body thoughts come back, leading to the next cycle of food restrictions.”

Joelle nodded her head, tears welling up in the corners of her eyes.

Attuned Eating

At the core of eating problems is a disconnect from the internal, physical cues of hunger and satiation. We’re born knowing how to eat, but all kind of factors, including dieting, can interfere with our natural ability to honor these signals. Joelle’s overeating certainly had an emotional component, but I knew she had to learn the nuts and bolts of attuned or intuitive eating.

“How do you know when you’re physically hungry?” I asked Joelle in our next session. She shrugged and looked puzzled. “Some people describe feeling lightheaded, getting a headache, or finding it hard to concentrate,” I offered, “but that means they’ve waited too long to eat. Usually a gnawing or empty feeling in your stomach is a good signal that you’re hungry.”

“Well, I don’t think I ever get hungry now—at least not often. Sometimes when I’m dieting, I get a ravenous feeling, but I really hate that sensation.”

“So how do you decide when to eat?” I asked.

“Sometimes I eat because it’s my lunch break or because something looks good, or because I’m upset, but usually I don’t even think about it. I just eat.”

Clearly, Joelle could no longer tell the difference between her physical and emotional hunger. “How does your stomach feel right now?” I asked, using the opportunity to have her tune in while we were together.

“I ate before I came here, so I feel full.”

I suggested that over the next week she could check in with her body every 20 to 30 minutes and ask, “Am I hungry?” in the attuned way we’d just done during our session.

The following week, as she walked into my office, Joelle blurted out, “I just don’t like to be hungry.” It turned out that it wasn’t enough for her to learn about the concept of listening to physical hunger. We had to understand why she was so frightened of hunger, and then work on solving that problem. When I asked her to tell me more, she revealed that after school, as an only child, she’d often come home to an empty house, where she’d be by herself for hours, even past dinnertime. “Sometimes there was no food in the refrigerator, and I was so uncomfortable,” Joelle described through her tears. “But other times there was plenty, and eating was a way to pass the time until someone came home.”

“It’s easy to understand how you’ve come to fear the discomfort of not being fed,” I told her. “But now you’re in a position to make sure that you have enough food available.” As we talked about what would happen if she waited to feel hungry before eating, I noticed Joelle’s body tighten up.

“What if I’m with students in the library and I suddenly get hungry?” she asked, looking distressed. Then a lightbulb seemed to go off in her head. “I think that’s why I eat so much on my way to school,” she added. “I want to make sure I don’t ever have to be hungry with no way to get food.”

Given this revelation, I asked if Joelle could keep food with her in the library so that if she became hungry at work, she could eat enough to take the edge off until she could have a meal. She agreed to try it. Then I proposed she wait for hunger on weekend mornings when she could be sure food would be available. This would help her learn how to tell when she was physically hungry. But she also needed to learn how to ask herself what she was hungry for. When she noticed a cue for physical hunger on weekend mornings, would she be satisfied by something hot or cold, mushy or solid, sweet or bland, salty or spicy?

“It was so delicious,” Joelle reported of the oatmeal with berries and Greek yogurt that she’d prepared for herself the next Sunday. By taking away the judgment and giving herself permission to eat all types of foods, she could tune in to what her body needed and experience how much better that felt.

Of course, sometimes the diet mentality crept back in, but this allowed us to work on correcting how she talked to herself. For instance, one week she told me, “I got a couple of Egg McMuffins on my way to work this morning, which I know was bad. It was just too heavy, and I ended up with a stomachache.”

“I know it may sound like semantics,” I quickly jumped in, “but it’s not that you were bad. What you’re saying is that it felt bad. What would have felt better?”

Joelle thought for a moment and replied, “Today, my body needed all that protein. If I’d stopped after one, I think I’d have been fine, but what should I do if something tastes so good that I don’t want to stop?” she asked.

I reminded her that it was up to her to decide how she wanted to feel. “I use the acronym AIM to help people,” I explained. “‘A’ stands for attunement, where you notice your physical hunger and choose the foods that’ll satisfy you. ‘I’ is for setting an intention about how full you want to feel at the end of your eating experience. It helps to visualize the food you’re about to eat and think about the level of comfort you want to achieve when you’re finished—as well as 15 or 20 minutes later. ‘M’ is for mindfulness, where you bring awareness to your eating experience without judgment, distraction, or expectation. You’ll deepen the pleasure of the experience as you savor the taste and sensation of food, and you’ll become better able to notice when you reach the level of comfort that you’re AIMing for.”

Health at Every Size

Joelle settled into the work of staying curious about any episodes of overeating, and I was impressed by her willingness to view them as opportunities to learn more about her issues with abandonment and connection, instead of seeing them as failures. I checked in regularly about her experiences of honoring her hunger and fullness so she’d continue to integrate this newfound attunement.

Over time, I felt confident that Joelle wouldn’t return to previous diet behaviors, but she started to complain that while she’d stopped gaining weight, she wasn’t losing any either. At that point, we spent some time examining how social pressures to be thin are often unrealistic and damaging to her body image. Rather than using the number on the scale as the criterion for success, it’s positive self-care behaviors that should be the benchmark.

To help Joelle understand this, I introduced her to the evidence-based Health At Every Size (HAES) framework, which has gained momentum in recent years.

Given that there’s no research to date showing that any weight-loss program leads to long-term success, the HAES paradigm offers a positive way to address health concerns without pursuing weight loss. The HAES paradigm promotes sustainable behaviors, such as attuned eating, exercise, good sleep patterns, and mindfulness practices, but it also addresses themes of respect for people of all sizes, the intersection of weight and other oppressions, and the effect of weight stigma on health and mental health.

To make sure Joelle had access to information and support beyond my office, I gave her a list of several books, blogs, and articles, including “Weight Science: Evaluating the Evidence for a Paradigm Shift,” published in the Nutrition Journal in 2011. I even pointed her toward a HAES Facebook group so she could become part of an online community working toward challenging myths about weight and health.

Joelle began to reject cultural stereotypes about weight and came to see herself as a person who respected her body and did her best to take care of it, but her weight concerns were triggered again six months later. “I want to get pregnant, and my doctor told me I need to lose some weight in order to have a healthy pregnancy,” she told me. “I know I can’t diet again, but I’m not sure what I should do.”

I asked Joelle to review what types of behaviors would support her health, and she talked about her resistance to physical activity. Like many clients, she’d turned exercise into a diet, where she’d do it for a while and then feel guilty and quit after missing a time or two. I encouraged her to focus on what types of movement felt good to her, and she eventually began to swim regularly and participate in a yoga program for rounder bodies. She interviewed a new obstetrician, who agreed to focus on her health status without using weight as a measure. During her pregnancy, she read up on nutrition and adjusted her diet without falling into the trap of deprivation. Soon, given her increased ability to stay in charge of her eating and the imminent birth of her baby, we agreed on the date of our last session.

“How are you feeling about ending our work together?” I asked.

“I think I’ll be okay. When I’m starting to struggle with eating, I imagine your voice and think about what you’d say to me.”

“Those thoughts are really your own now,” I responded.

She smiled. “When my coworkers tell me about their diets and I see them losing weight, sometimes I think I still want to get lower than my prepregnancy weight, once this baby is born. Then I remember that I’m happier in my life now then I’ve ever been, even when I was thinner.”

As she left my office for the last time, I reflected on how far she’d come in building a healthy relationship with food and what a good job she’d done of taking care of her body as she went through her pregnancy. I knew that, like all of us, she’d be up against cultural forces that might make her doubt herself if her weight ultimately settled somewhere higher than the thin ideal. But I believed that her willingness to move toward letting go of her internalized body shame would make her less susceptible to cultural messages that can retrigger the diet–binge cycle and a focus on thinness as a measure of personal value.

Case Commentary

By Leslie Korn

Judith Matz has identified many of the essential cognitive and affective states that underlie bingeing, providing a solid foundation to support Joelle’s recovery. I commend her for identifying the larger social issue of weight stigma in our society by encouraging Joelle to focus on the goal of health, rather than weight loss. However, I’m concerned that she overlooked the possibility of nutritional imbalances and food sensitivities that could overwhelm Joelle’s self-regulation strategies over the long term.

Just as different cars require different types of fuel to run efficiently, everyone has a different body type and individualized nutritional needs. Binge eating is frequently associated with craving starchy, high-sugar carbohydrates. People who crave wheat and grains experience mood elevation upon eating these foods. Joelle’s type of bingeing—eating several breakfast sandwiches on her way to work—might be linked to gluten sensitivity as well as hypoglycemia. If I were consulting with Joelle, I’d try to address this pattern by having her substitute more protein and fat for the starchy carbohydrates in her diet.

Joelle describes eating a salad at lunch perhaps in response to the morning binge, but the lack of protein required to sustain glucose levels (and mood) results in a drop in energy and mood and more easily precipitates another high-glucose binge by dinnertime. Thus, Joelle would certainly benefit from a comprehensive nutritional assessment, including a laboratory assessment for gluten sensitivity. If her therapist wasn’t trained in nutritional interventions for binge eating, she could collaborate with a specialist in mental health nutrition.

Nutritional strategies for Joelle might include eating a hypoglycemic diet of small, protein- and fat-rich meals (with gluten-free grains) as needed, usually every three to four hours, and satisfying her interest in sweet foods with root vegetables, like baked sweet potatoes. As Matz suggests, she should continue to tune in to her mood, energy, and satiety. However, I don’t agree with the suggestion to wait to eat until she’s hungry. People should fill up the gas tank in the car before it becomes empty, and it’s the same with bodies.

Nutritional supplements, too, would help Joelle relax and reduce cravings. These might include a chromium- and vanadium-rich B-vitamin complex, the amino acid 5-HTP, and a magnesium-rich mineral source. Joelle would likely benefit from a relaxing magnesium sulfate (Epsom salt) bath in the evening if she’s feeling stressed or anxious.

While I admire much of Matz’s approach, I believe addressing the nutritional issues possibly underlying Joelle’s bingeing could enhance the efficacy of her work in this case.

Illustration © Sally Wern Comport