Chewing and Spitting Food

What is Chewing and Spitting?

Chewing and spitting (CHSP) is a disordered eating behavior involving the chewing and spitting out of food. It can occur with a variety of portion sizes, although when in public the individual usually will only use smaller portions. It will typically be foods that individuals do not allow themselves to ingest for emotional or physiological reasons, which studies have found are usually foods higher in fats or sugar, or with a higher caloric content. It often relates to fears regarding what may occur if the person allowed themselves to eat that food, such as feeling pleasure and then overeating. It can have the effect of mimicking the physiological or emotional response of having just eaten.

The behavior of chewing but not swallowing food is a disordered action found to be more common with restrictive eating disorders and less common with binge eating disorders. It can also indicate the severity of the eating disorder, as studies have found that individuals with more severe symptoms of eating disorders engage in CHSP more often. This is discussed further below. The CHSP behavior is not specifically included in the DSM-V (the Diagnostic and Statistical Manual used by mental health professionals to identify mental health conditions). Chewing and spitting has been reported across a range of eating disorders found in the DSM-V including anorexia (AN), bulimia (BN), binge eating disorder (BED), and other specified feeding or eating disorders OSFED. It is also found in individuals without eating disorders, such as athletes following strict diets, people with diabetes, and those who have undergone bariatric surgery.

What is the Function of Chewing and Spitting Food?

chewing and spitting food

The CHSP behavior allows pleasure for the person eating yet in a controlled and restrictive way. These individuals often struggle with allowing themselves to enjoy food which feels pleasurable, and the behavior allows the meeting of needs without the feeling of becoming “out of control.” It can be used as an attempt to comply with a meal plan in eating disorder recovery, yet the individual becomes overwhelmed with the amount or type of food on the meal plan and is unable to follow through. By using this behavior, rather than restricting food, it can also avoid confrontation with people about their eating disorder by creating the façade of eating.

When a person chews and spits, hunger cues are naturally engaged, which results in a false sense of satisfaction. This means the person may feel they can allow more food in at other times during the day, so it forms part of the binge-purge cycle. It can also operate as an emotional purging or creating the feeling of being empty. In some cases, it is used as a form of self-harm or self-punishment; for instance, the person will allow themselves to take the food momentarily while believing he or she does not deserve to eat the entire portion. As eating disorder sufferers often also have other psychological disorders, it is common for the action to be connected to trauma, which should be addressed by a specialist as part of treatment.

What are the Consequences of Chewing and Spitting Food?

Reported side effects of CHSP include swollen jaws, increased risk of mouth ulcers and cavities, the individual consuming more food than anticipated, spending large amounts of money on food which is not consumed, increased risk of stomach ulcers, and malnourishment. CHSP may result in weight gain if the individual unintentionally ingests calories; such weight gain may lead to emotional distress. The secrecy of the behavior itself can also have a psychological toll, often manifesting in the form of shame and guilt. Individuals who CHSP in larger quantities may experience social isolation due to the compulsive need to continue to spit food portions, a behavior which cannot be done discreetly. This can also occur in binge CHSP episodes. It can become compulsive and difficult to stop doing, often used as an emotional coping tool. This can later be brought on again if the person is undereating or experiencing a time of emotional stress.

What Have Studies About CHSP Found?

Studies have used self-report questionnaires to evaluate chewing and spitting behaviors in individuals with anorexia nervosa, bulimia nervosa and EDNOS (now OSFED). It has been found that 34% of individuals admitted to CHSP behaviors prior to inpatient admission, with 19% of these doing so several times per week. Those who CHSP more than once a week were younger, more likely to abuse laxatives, engaged in over-exercise, skipped meals, and restricted calories. These behaviors were only found in the AN group. Additionally, individuals who did so more than once per week were more likely to have suicidal thoughts and tendencies. The CHSP behavior is therefore not limited to BN individuals, and often those with AN who engage in CHSP also have a more severe manifestation of their disorder than people with AN who do not use CHSP.

In people without eating disorders, chewing and spitting can affect the gut-brain hormones which promote hunger and create feelings of pleasure or reward from food. In people with AN, studies have found that the changes in hormones can actually lead to a stronger hunger signal for a longer period of time after the chew and spit. This means that AN sufferers may, in fact, feel an increased lack of control over their eating because they feel even more hungry, which will affect their strict control of food intake and lead to more CHSP behaviors. Interestingly, long-term CHSP behaviors have been found to decrease the body’s hunger response, which may explain why individuals who have been using CHSP for many years do not feel the same hunger cues.

CHSP is a common behavior and often linked to anxiety over the loss of control and perceptions of overeating. The amount of food that is CHSP and the frequency of CHSP can have clinical implications. Studies have found that individuals who perform CHSP actions for large amounts of food in one sitting (over 1000 calories), and more than once per week, are more likely to have another purging diagnosis, such as BN. These people, even when treated for bulimia, still engaged in excessive restriction and over-exercise. They also had higher levels of body hatred, had a stronger drive for thinness, were more likely to suffer from depression, and showed more abnormal psychotic behavior than those who did the CHSP act less than once per week. So the frequency of the CHSP behavior and the amount which is spit out can indicate more severe eating disorder symptoms and more serious health problems.

chew and spit

What are the Possible Treatment Interventions?

It is important for families to be aware of signs of chewing and spitting in their loved ones. These may include: finding traces of undigested food in their room, the bathroom, or in the garbage; secretive behavior at meal times; showing shame during eating, and insisting on eating alone or away from home. If you, or someone you know, is showing any signs of this behavior, it is important that it is brought to the attention of a health professional trained in eating disorders.

Treatment options must be carefully considered by looking at the individual holistically. Effective treatments have been found to predominantly involve following consistent and structured eating patterns, and tailoring a meal plan to avoid times these behaviors are more likely to occur. This means that in higher levels of care, there may need to be more observation and structure around times the individual may struggle, such as immediately after eating. Group therapy has been found useful, by creating a space in group settings to be able to challenge the shame and secrecy about behaviors and discuss the function of them. This further creates opportunities for acknowledgment and redirection around the behaviors in a non-shaming way. Redirecting the behaviors with distraction methods or mindfulness techniques has been found effective. Treatment may include particular therapies, such as DBT and ACT, which may assist the individual with reversing ingrained behaviors, accepting emotions, and practicing mindfulness skills.

If the person usually uses CHSP only for particular foods, finding opportunities for exposure therapy to these foods can be effective in changing their current associations with the food, neutralizing the person’s view of the food, or replacing it with a positive emotion. Talk therapy can be helpful in addressing the behavior with curiosity, questioning its causes and functions so the person can better understand what purpose it currently serves, and decreasing the associated shame. It can be helpful to write a feelings journal, which includes notes about behaviors, events, and other triggers for the CHSP action, and then working to replace these with healthy coping mechanisms. Self-reflection and asking questions such as, “What are my fears about not being able to chew and spit?”, or “What am I really saying/feeling when I chew and spit?” can lead to a deeper understanding of the origin of this behavior. Due to the often severe consequences of chewing and spitting food, it is important that these behaviors be identified and treated quickly. An individual who has been engaging in this behavior for a longer period of time may feel more shame and be less likely to ask for help, though intervention at any point is important.

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Additional Reading:

Using Challenge and Fear Foods in Eating Disorder Recovery
Navigating Eating Disorder Treatment
Normal Eating
Intuitive Eating
Mindful Eating
GI Symptoms in Eating Disorders

About The Author:

Brittany Jane, RDN, LCP is an eating disorder specialist in Australia with an online telehealth service available internationally. She focuses on a holistic, individualized approach to nutritional rehabilitation and therapy in the treatment of adolescents and adults.

References:

Absah, I., Rishi, A., Talley, N. J., Katzka, D., & Halland, M. (2016). Rumination syndrome: Pathophysiology, diagnosis, and treatment. Neurogastroenterology & Motility. 29(4). doi: 10.1111/nmo.12954.

Aouad, P., Hay, P., Soh, N., Touyz, S. (2016). Chew and Split (CHSP): A systematic review. Journal of Eating Disorders. 4(1): 23. doi: 10.1186/s40337-016-0115-1.

Guarda, A., Coughlin, J., Cummings, M., Marinilli, A., Haug, N., Boucher, M., & Heinberg, L. (2004). Chewing and spitting in eating disorders and its relationship to binge eating. Eating Behaviors, 5(3): 231-239. doi: 10.1016/j.eatbeh.2004.01.001

Makhzoumi, S.H., Guarda, A.S., Schrever, C.C., Reinblatt, S.P., Redgrave, G.W., Coughlin, J.W. (2015). Chewing and spitting: a marker of psychopathology and behavioral severity in inpatients with an eating disorder. Eating Behaviors. Vol 17: 59-61.

Smith, G.R. & Ross, R.L. (1988). Chewing and spitting associated with a protein sparing modified fast and psychosocial stressors. Psychosomatics. 30(2):224–6. doi: 10.1016/S0033-3182(89)72305-7.

Song, Y.J., Lee, J.H., Jung, Y.C. (2015). Chewing and spitting out food as a compensatory behavior in patients with eating disorders. Compr. Psychiatry. Vo. 62:147-51. doi: 10.1016/j.comppsych.2015.07.010.

Written – 2018