Melissa Rivera always turned off the cameras before she binged. Newly married to a husband who traveled frequently, the 23-year-old med student, who had recently moved six hours from her friends and family, comforted herself with food. “I’d get this whole pizza that I would eat myself,” she says. Each time, she turned off the house’s security system so her husband wouldn’t see the coping mechanism she’d used since she was eight years old. “At some point, I realized, ‘This is killing me. I cannot do it anymore,’” she says. She sought help from counselors at the University of Texas, where she was a student. Rivera suffered from binge eating disorder (BED), but says the school’s experts weren’t able to help. She says a school dietitian encouraged the very behavior that kicks off the bingeing cycle: restriction. “‘You have to eat so many grams of meat, you have to eat at most a cube of cheese per day,’” Rivera recalls the dietitian telling her. “I never did what she said.” Finally, at the end of 2016, Rivera searched online and connected with Edward Tyson, a local eating disorder specialist. But after years of struggle, she was skeptical about how much he could help. “Everything sounded like a beautiful promise, but it seemed impossible that he’d get me to this nice place that he was talking about,” Rivera says. “I’m happy to say that he did.” She has been binge-free since January.

One out of every 35 adults suffers from binge eating disorder, almost twice the combined rate for anorexia and bulimia. It is characterized by repeated episodes of eating large quantities of food quickly and to the point of discomfort; a feeling of a loss of control during the binge; and guilt following the binge, but without any consistent purging behavior. Up to 40 percent of people trying to lose weight suffer from BED and up to 70 percent of patients with BED are medically obese. The good news is that BED is highly treatable, particularly with the help of cognitive behavioral therapy: Nearly 80 percent of patients abstain from bingeing after 20 sessions. And, unlike most calorie-restricting diets, the success of CBT holds for many patients over time. However, a 2013 study in Biological Psychiatry found that less than half of lifetime bingers receive treatment. There are millions of overweight Americans who could find actual sustainable help with their eating issues—and not berate themselves for a lack of “willpower”—if more clinicians could identify the disorder and recommend treatment. No diet or exercise plan can fix binge eating disorder: It lives in the brain. I suffered from the disorder myself from about high school until my early 20s. Ever anxious to lose a few pounds, I’d put myself on a strict diet, then eventually give in to temptation and eat as much as I could of whatever I could get—a whole pizza, cookies nabbed from someone’s pantry, a family-sized combo of General Tso’s chicken with fried rice and egg rolls. My mentality was that the next day I’d start the diet anew, so I “might as well” eat as much as possible since who knew when I’d ever have that food again. With many ups and downs, between the ages of 18 and 25 I put on nearly 50 pounds.

BED is an equal opportunity disorder, affecting men, women, young, old, and all races. However, the recent Netflix eating disorder film To The Bone is a microcosm of the short shrift BED is given in popular culture. The movie focuses on a waifish, big-eyed anorexic staying in a residential treatment home, zooming in to ogle one patient with a feeding tube and a bulimic who keeps a bag of vomit under her bed. The presence of BED is hardly acknowledged; one overweight character, Kendra, suffers from it, but she has only a handful of lines, and is otherwise unexplored, an unexplained jar of peanut butter her main companion. At one point, Kendra tries to join a conversation with fellow patients but a rude housemate shuts her down with “Sorry: This conversation is for rexies only.” Even though in real life the bingers far outnumber anorexics, popular culture seems far more fascinated by the idea of wasting away, as Sophie Gilbert explored in The Atlantic. Part of the issue is BED’s relative newness on the mental health scene: It was only recognized as a formal diagnosis by the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) in 2013. “People seek a level of care that’s lower than what they actually need and then they give up,” says Julie Friedman, a health psychologist at the Eating Recovery Center in Chicago. (I am a former patient of Friedman’s.) “Somebody who really should be in residential therapy goes to an individual therapist and they’re frustrated. They give up and go back to dieting. It’s like trying to treat cancer with vitamins.”

Successful treatment of BED is not always synonymous with dramatic weight loss, but eliminating the habit of consuming thousands of calories at a time on a regular basis typically results in modest weight loss. And even if it doesn’t, it’s still a major health improvement to cut back on the types of foods people typically binge on (like pizza or meaty breakfast sandwiches or ice cream), the sodium, fat, and sugar of which are hard on the body. “When you eat big volumes of food, particularly foods that are highly processed, which is what most people binge on, it causes a lot of stress on your body,” says Friedman. “The inflammation in your body affects everything from your cardiac status to your brain to your butt to your bones and your joints. It compounds any health risk.” The psychology of addiction in BED patients is still being understood, but I remember, when I was in recovery, thinking how much easier it would be if I could go cold turkey on food. Unfortunately, bingers need their drug to live—which is why they need help modulating the way they think about it and use it. “Imagine telling a coke addict to take three large doses and then two smaller doses per day,” says Tyson—Rivera’s therapist from Texas. “‘Don’t take too much and don’t take too little.’ That is not willpower; that’s torture.” No diet or exercise plan can fix the disorder: BED lives in the brain. “There does seem to be a difference in the brain of someone with binge eating disorder compared to someone who doesn’t have it,” says Jillian Lampert, the chief strategy officer at the Emily Program, a eating disorder affiliate of the University of Minnesota that provides residential and outpatient care. “They’re interested in food in a different way. If food is very interesting, you’re likely to want more. But then it doesn’t deliver on its promise, so we go back and eat more, because we didn’t get it right. It breeds this cycle where people overeat and feel compelled to overeat. They’re looking for the reward.” The way Lampert explains treatment to her patients is, “Your brain is wired a little differently from some people’s. It’s neither good nor bad, it just is. We can help you to have an owner’s manual and say ‘I remember on page 57 when I’m around this certain set of foods and I’m stressed out, it’s harder for me to make decisions around eating.’” “When you have a thought, those are just thoughts. Am I that hungry? No, I ate, I’m fulfilled. I don’t need to act on that.” Michael Meginness didn’t acknowledge his BED until he had been at at Chicago’s Eating Recovery Center for over a week. The 35-year-old Ohio father of four figured that he was eating three meals a day, so he was perfectly fine. Except that his typical breakfast included two meaty breakfast sandwiches and a bowl of cereal. “My brain’s telling me ‘I’m eating three meals’ but in actuality I’m eating three meals per meal,” he says. Finally, he went to treatment after his wife gave him an ultimatum. After working with Friedman, he says, “I had a realization that maybe I do have an eating disorder. Going through the treatment was a new start.”

When Rivera met Tyson’s dietitian, she requested the structure she had been given at UT. “If you can give me a meal plan, that’s what I’m going to follow.” Instead, Rivera recalls, “She laughed and said, ‘That’s not the approach we’re going to take.’” For the first time, all foods were “legalized” for her—the only rule was to eat three meals a day and three snacks. “[The dietitian] encouraged me to eat protein, fat, and carbs every meal. ‘If you’re going to eat a donut and a sausage, I’m cool with that.’” De-restricting meals was a step toward stopping the restrict-and-binge cycle. In therapy, Meginness worked on a strategy called “catching your thoughts,” he says. “When you have a thought, those are just thoughts. It’s what you do after that helps makes those decisions. I can treat it as the truth or treat it as the lie. Am I that hungry? No, I ate, I’m fulfilled. I don’t need to act on that, I can throw [that thought] out and move on.” In therapy Meginness also addressed the difficulties in his marriage. “I had to prepare myself that when I was released, my wife might not stay with me and the kids. Could I accept that, and continue with recovery? It was really tough. [Friedman] was like, ‘You need to make the choice: Are you going to do this for yourself whether or not you go home to a family?’” Once he decided to pursue treatment no matter what, his wife recognized that he was choosing to treat his disorder. “Actually now we’re in a thriving marriage.”

Body acceptance is also a major part of BED treatment, says Lampert, especially in a culture that prizes the big reveal of “Half Their Size!” features in magazines. Her patients often say, “I don’t feel like I’ll ever be enough, so what’s the point.” But Lampert says, “You can accept your body and delight in what it does while you work on making it feel better. ‘I can take care of myself today: I don’t have to wait until I lose weight.’ Those small wins can accumulate into a mastery of ‘I can do this.’” Rivera inexplicably began to gain weight after she was in treatment with Tyson; eventually she was diagnosed with polycystic ovary syndrome, a hormonal disorder that can cause weight gain. Once that was under control, she started to lose weight again. If it wasn’t for the mental health foundation she had established earlier, she says, she may have given up. “Even though my body was changing to what I considered a negative, just being able to keep up with legalizing food and going to treatment gave me a lot of strength,” she says. According to Tyson, a binger who stops the cycle will lose about 10 percent of their body weight. That’s not sexy enough for a reality TV show reveal, but it’s a significant health improvement, which can improve blood pressure and heart health. “It’s not a rapid 100 pounds, but what I tell patients is that the goal here is to feel in control. If you’re not eating 1200 calories three times a day during binges, will that drop your weight? Sure, but it’s not sudden.” For many bingers, weight loss is simply a nice bonus that comes with improving mental health. I may have lost 50 pounds since I first sought treatment for BED, but for me the major victory was being able to eat a cookie, or three, or seven, and let it just be that. It doesn’t mean I don’t deserve to exercise, or to eat healthily, to be loved or to love myself the next day.

So why isn’t therapy given the same amount of press as a weight loss tool that Whole30 and CrossFit receive? “If you have someone who is suffering on their own time, that makes it really hard to get authorization for care.” First, says Tyson, clinicians need to catch up on BED in order to be the first line of defense for their patients. “If people know they’re not going to be treated like ‘Oh, another obese patient who is not going to do what I want them to do,’ that will decrease the shame,” he says. The poor success rate of calorie-restricting diets has been well-documented, and he is frustrated by physicians who continue to recommend them to their patients. He says that the arrival of the binge-cessation drug Vyvanse, a stimulant also prescribed for ADHD that Friedman says helps some bingers manage eating-related impulsivity, has helped raised the profile of BED (Tyson is on the drugmaker’s board), but he warns that clinicians must not recommend the drug alone. “As long as you also recommend the therapy and the dietitian, then they stay in treatment and they’ll see success.” “In a perfect world we’d be screening people for their eating behaviors and not so much about their weight,” says Lampert. “Their behaviors would tell us more about the place where we make change.” It doesn’t help that overeating isn’t always seen as a disorder. When I first began treatment I felt ridiculous admitting that I, a functional adult, could let my whole week be dictated by a bowl of tortilla chips and a pitcher of margaritas. Friedman frequently hears reluctant patients says things like “I don’t fit in—I won’t even fit into the chairs.” She says, “The issue is that people don’t associate people struggling with their weight with eating-disorder treatment. Their perception is really antiquated, all these anorexics needing to be fed.”

Sufferers of BED tend to be high achievers who can’t accept that they can’t just force themselves to stop through sheer willpower, which Tyson says is ironic. “These are patients who have done incredibly difficult things—philanthropic work, mission work, endured very difficult circumstances—so to say that it’s something about lack of willpower, that’s just not the profile of these people.” The high functionality of most bingers points to another reason more people with BED don’t get the help they need: insurance. Friedman notes that she fights with insurance companies “every day” over patients insurers see as being too functional to receive psychiatric care. “They go to work every day, but then they come home Friday at 5 and spend all weekend binge eating, with no quality of life, no social support. When you’ve got an 18-year-old who can’t finish her first year of college—that gets authorized easily. But if you have someone who is suffering on their own time, that makes it really hard to get authorization for care.” Lampert says that it takes a minimum of 12 sessions of CBT for a patient to see results, with the average length of stay at the Emily Program lasting a year to a year and a half. But that kind of help is not always accessible. Rivera had to pay out of pocket for her work with Tyson, which included medication for depression and ADD. She was paying $250 a month at one point for her prescriptions. Fortunately, her husband is an ER doctor. “If I didn’t have his support, I would never be able to afford treatment. I’m so grateful that I was able to get to this place but then I think how many people are there and they can’t afford it. They’re just being told how much self-control they’re lacking.” Don’t be fat, but also don’t act like you care about your weight too much. Sometimes that stigma comes from the insurance companies themselves. “Usually when I’m asking for more intensive treatment, I’m told, ‘This patient can go to Weight Watchers,’” says Friedman, who notes that the current level of care criteria that insurers use are based on anorexia or bulimia. Insurers then say, “They haven’t lost weight, they haven’t thrown up, so they don’t need treatment.” She says therapists have been working to create a new criteria of care that addresses functional impairment and distress over weight.