Arya M. Sharma, MD

Yesterday, I posted on the recent Senate Committee call on the FDA to ease the path to approval of new obesity, which it described as “a significant unmet medical need.”

In my commentary, I suggested that one solution to better balancing risk and benefit would be to subcategorize obesity into meaningful subtypes, ideally based on an objective aetiological framework.

In a paper just published in Appetite, Caroline Davis and colleagues from Toronto’s York University provide evidence suggesting that ‘food addiction’ (FA) may be a valid clinical sub-phenotype of obesity.

The researchers examined the validity of the Yale Food Addiction Scale (YFAS) - the first tool developed to identify individuals with addictive tendencies towards food - in a sample of obese adults (aged 25-45 years) and non-obese controls.

The YFAS is available here - the instruction sheet for interpreting the test is available here.

In their analysis, the researchers focused on three domains relevant to the characterization of conventional substance-dependence disorders: clinical co-morbidities, psychological risk factors, and abnormal motivation for the addictive substance.

Not only were their results strongly supportive of the ‘food addiction’ construct demonstrated validity of the YFAS, in addition, those who met the diagnostic criteria for food addiction had a significantly greater co-morbidity with Binge Eating Disorder, depression, and attention-deficit/hyperactivity disorder compared to their age- and weight-equivalent counterparts.

Those with FA were also more impulsive and displayed greater emotional reactivity than non-FA obese controls. They also displayed greater food cravings and the tendency to ’self-soothe’ with food.

As the authors conclude:

“These findings advance the quest to identify clinically relevant subtypes of obesity that may possess different vulnerabilities to environmental risk factors, and thereby could inform more personalized treatment approaches for those who struggle with overeating and weight gain.”

From a treatment perspective, these would be the patients, who would perhaps be most responsive to behavioural and pharmacological treatments aligned with an addiction paradigm.

In contrast, non-food addicted obese individuals will likely be far less responsive to these approaches.

Thus, while it may make sense to expose individuals with food addiction to drugs like buproprion, naltrexone, or rimonabant, non-addictive obese individuals may neither respond well nor warrant the risk of these drugs for treating their obesity.

As long as we continue on the path to developing obesity treatments using an outdated and simplistic ‘let’s-get-anyone-with-a-BMI-higher-than-X-to-lose-weight’ approach, we will never get a good handle on risk benefit ratios, let alone, get any closer to ‘aetiology based’ treatments.

AMS
Lisbon, Portugal

Davis C, Curtis C, Levitan RD, Carter JC, Kaplan AS, & Kennedy JL (2011). Evidence that ‘food addiction’ is a valid phenotype of obesity. Appetite PMID: 21907742

Ingestive behaviour is largely governed by two biological systems: the homeostatic system involving hunger and satiety and the hedonic system involving appetite and reward.

The latter system is also involved in other hedonic behaviours ranging from alcohol and recreational drug use to other “pleasurable” activities like sex, shopping, or gambling, all of which can manifest themselves as addictions.

It may therefore not be surprising, that Caroline Davis and colleagues from York University, Toronto, in a paper just published in the International Journal of Obesity, report that a common genetic variant of the mu1 opiate receptor is associated with increased preference for sweets and fatty foods.

The researchers studied the relationship between variants of the OPRM1 gene and measures of food preferences and eating behaviours in 300 healthy adult men and women recruited from the community.

Individuals with the G/G genotype of the functional A118G marker of the OPRM1 gene reported higher preferences for sweet and fatty foods compared with the other two groups. These food preferences were clearly related to all measures of overeating, which in turn accounted for a substantial proportion of the variance in BMI.

Thus, the authors conclude that some of the diversity in the preference for highly palatable foods can be explained by genotypic differences in the regulation of mu opioid receptors that play a key role in the appetite and reward system (in addition, these receptors may also have a role in regulating the homeostatic system).

Obviously, individuals carrying this genetic variant may have a much harder time saying “no” to sweets and fatty foods, than individuals without this variant. Even if the number of people with this genetic variant may have not changed in recent years, the current abundance of cheap sweet and fatty foods clearly poses a far greater challenge to carriers of this gene.

I wonder how many of my readers would suspect that they may have this genetic variant of the opiate receptor gene and, if they do, I’d love to hear how they cope with passing up the sweets.

AMS
Edmonton, Alberta

Davis C, Zai C, Levitan RD, Kaplan AS, Carter JC, Reid-Westoby C, Curtis C, Wight K, & Kennedy JL (2011). Opiates, overeating and obesity: a psychogenetic analysis. International journal of obesity (2005) PMID: 21266954

Regular readers will recall that last week I attended a scientific symposium on addictions.

One of the books I picked up at that conference, and read on my flight to Montreal yesterday, is A. J. Adams’ UNDRUNK: A Skeptic’s Guide to AA.

While this book is a very quick and highly readable introduction to AA (Alcoholics Anonymous), about which I knew very little, today’s post is NOT about this book.

Rather, it is about a definition of alcoholism that I came across in the book, which apparently is the WHO definition for this condition.

The definition reads as follows:

“Alcoholism is a primary chronic disease with genetic, psycho-social and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol despite adverse consequences and distortions of thinking, mostly denial.“

Let us look at this definition of alcoholism and see what aspects of it (if any) apply to obesity.

No doubt, as readers of these pages know, obesity is most definitely a chronic condition, whose development and manifestations are influenced by genetic, psycho-social and envrionmental factors. In some cases obesity may be more genetic, in others more psycho-social and sometimes purely environmental, but certainly, obesity would fit the bill as far as this statement goes.

And yes, obesity is often progressive and fatal. Most people, let alone those struggling with obesity, experience progressive weight gain over time. Sometimes periods of rapid weight gain are followed by periods of weight stability or even weight loss, but in the long term, no one with obesity would carry their excess weight had they not progressively gained it over time (and often continue to do so).

And yes, obesity is no doubt fatal. This may not seem as obvious as in the case of the alcoholic who dies of liver cirrhosis or totals his car (and himself) whilst DIU, but when you start looking at the many ways in which obesity can kill you, from heart attacks to cancer, there is no doubt that obesity is fatal (often after ruining most of your life first - another similarity to alcoholism).

Many of my patients would also be the first to admit that their weight problems stem directly from their continuous or periodic impaired control over their eating (or drinking of caloric beverages - including alcohol). This is not a moral judgement - whether their loss of control is genetic, psycho-social or simply a consequence of our obesogenic environment, it is still a loss of control. Were they able to control their intake of excess calories, they would obviously not have the problem.

And of course many people who struggle with excess weight are preoccupied with their drug (food). Whether they are thinking about their next meal, trying to suppress their cravings, planning their diet, feeling guilty about their last binge, hoping to find the strength to say no to that dessert or second helping, or simply giving in and longing for the comfort and satisfaction that they get from eating - no doubt food is on their mind - one way or another.

And all the obvious adverse consequences don’t seem to deter. I have yet to meet a patient who wants to be obese (even the patients, who admit that their excess weight protects them from unwanted attention). Even those, who do not relate their many health problems to their excess weight, cannot but help thinking how much easier life would be, would they not have to carry around their excess weight for the world to see, every single step and moment of their waking day (and interestingly, not just the waking day - given the profound effects of excess weight on sleep).

Finally, is it not the profound distortion in thinking that keeps the commercial weight loss industry in business? The idea that obesity can be “cured” with some magical potion or herb that will burn fat or rev up metabolism or suppress appetite. The idea that, “If I can only kick-start my weight loss and lose the first 10 lbs, the next 100 will surely follow”. The illusion that the next diet will be the last for sure. The fantasy that if I only lost some weight, my brain would readjust its “setpoint” and I could return to the weight I had as a 21 year old. The unrealistic expectation, that an hour in the gym each day will help melt away the lbs, or skipping meals will help cut calories.

But most of all I see denial - denial to see excess weight as a problem, even when it clearly affects your health, your well-being, your appearance, your self-image, your sex life, your relationship, your happiness. Perhaps, in an ideal world, excess weight should have none of those negative consequences, but in reality it does. The options are to either wait till the world changes (and becomes fairer to people with excess weight) or to step out of denial and seek the help you need to conquer those lbs (and I am not talking about signing up for the next commercial weight-loss program).

Many, if not all of us have accepted that alcoholism is a disease. Does obesity, not often meet the very same criteria?

Unfortunately, however, one important difference remains - in obesity, food abstinence is not an option (even if some of my patients have done just fine by completely giving up certain foods).

I look forward to what my readers have to say to this striking analogy.

AMS
Montreal, Quebec

As my regular readers know, this week, I am attending a Scientific Symposium called “Recovery From Addiction“, organised as part of the Alberta Family Wellness Initiative of the Norlien Foundation.

Anyone familiar with addictions is well aware of the discussions in this field about harm reduction (or controlled use) versus abstinence. In people where obesity is a consequence of an addiction, abstinence of course is not an option. Thus, the default in weight management is harm reduction.

Obviously, this does not make obesity management any easier. In alcohol dependence, abstinence is an option - no one would try to manage their alcohol addiction with a “drinking plan”. But in “food-addiction”, clients are often presented with and are expected to follow “diet plans”. When they fail to stick with these “plans”, they are simply labelled as non-compliant and often discharged from these programs.

In addition, it appear to me that “compulsive overeating” is perhaps as often a “process” addiction as it can be a “substance” addiction.

Readers may be aware that a process addiction is an addiction to an activity or process, such as eating, spending money, gambling, or working too much rather than an identifiable agent or substance. Unfortunately, these addictive behaviors can be as debilitating as those associated with substance addictions.

However, while with substance addictions, clients can be expected to simply give up or reduce use of the substance and can be monitored for compliance, process addictions provide much of their reward from the behaviour itself.

Sometimes, these behavioural patterns of process addictions can be transferred to other seeminlyg unrelated activities. Thus, as one speaker presented at this conference, people with gambling addictions, can get the same “reward” from running a yellow light, people with shopping addictions, an get hooked on the simple act of trying to find bargains or comparing prices. Thus, “eating addicts” can get “addicted” to the process of fantasizing about, finding, buying, preparing, and eating food - it may not be one food that they are addicted to, because their addiction it to the processes around acquiring food and eating it and not to a particular food or food group.

This adds a level of complexity to applying an addiction model to obesity, that may not be quite appreciated by the people who pass out the well-meant but useless “eat-less-move-more” (ELMM) mantra.

Indeed, it appears that applying an addiction model to obesity requires a level of sophistication that may well surpass what is normally provided in weight-loss programs.

Overall, I was fascinated by the many things I learnt at this addiction conference - the similarities between many of the issues relevant to treating addictions and obesity are striking and I must admit, often blindingly obvious.

My advice to anyone in the business of weight management - read and familiarize yourself with the addiction literature and embrace treatments that have worked in addictions (including relapse prevention) into your practice (and I mean more than just embracing motivational interviewing).

Hoping that someone, who meets the criteria for food (=substance) or eating (=process) addiction will change their behaviour simply by teaching them about healthy eating, is just as futile as hoping that a crack addict will stop using after attending a seminar on the dangers of crack use.

AMS
Banff, Alberta

This week, I am attending a Scientific Symposium called “Recovery From Addiction“, organised as part of the Alberta Family Wellness Initiative of the Norlien Foundation. My interest in this meeting (where, for once, I am not a speaker on the program), comes from the close links between mental health, addictions and obesity that I regularly note in my patients.

As someone with no formal training in diagnosing or treating addiction disorders, this symposium is turning out to be most interesting.

Yesterday, much of the program focussed on the link between trauma and addictions; on how addictive behaviours (including food addictions) can result from a wide range of traumatic experiences.

I was particularly interested in the presentation by Stephanie Covington from the Institute for Relational Development at the Center for Gender and Justice, La Jolla, CA, who talked about the important differences in both the nature and behavioural impact of trauma between genders.

Some of these differences are profound and should be noted by anyone dealing with trauma in men and women. For example, while much of the mental, physical or sexual trauma in men is often inflicted by strangers, women often experience these traumas from very people they love and want to be close to. Perhaps not surprisingly, women often have a history of domestic violence, something men are far less likely to have experienced.

This perhaps explains the very different responses that men and women have to trauma: while men tend to respond to trauma with destructive actions (aggression, violence, rages), women tend to respond more often with retreat (isolation, dissociation, depression, anxiety). Interestingly, both genders can respond with self-destructive action (substance abuse, eating disorder, deliberate self-harm, suicidal actions). Overall it appears that women are more likely to respond to trauma with depression than with classical PTSD as defined in DSM IV.

While men will use addictive behaviours to escape and distance themselves from the realities of their lives, women will often manifest addictive behaviours in order to maintain a relationship, to fill a void of what is missing in a relationship, or to self-medicate the pain of abuse or betrayal.

These important differences have a direct relevance for addressing addictions (or obesity) in group settings, which is why Covington made a strong case for running separate groups for men and women.

Overall, Covington made a strong case for using a trauma-informed gender-responsive intervention for women in addiction treatments. Thus, in a paper published in the Journal of Psychoactive Drugs back in 2008, Covington and colleagues found that applying manualised programs (Helping Women Recover and Beyond Trauma), founded on research and clinical practice and grounded in the theories of addiction, trauma, and women’s psychological development, resulted in significantly less substance use, less depression, and fewer trauma symptoms, including anxiety, sleep disturbances, and dissociation.

Covington also notes that the way that women look at the classical 12-steps approach to dealing with addictions, is very different from how men approach the 12-steps. These differences are nicely summarised in Covington’s book A Woman’s Way Through The Twelve Steps.

All of this not only reconfirms my own views on the close links between trauma, addictions and obesity but also made me realise that anyone working with obese clients must be well versed in assessing trauma history, addictions and understanding these powerful emotional and neurobiological influences on ingestive behaviour.

On a closing note, Covington recommended that when working in a setting where there are likely to be many trauma patients, it may be important to do a walk-thru to ensure that the physical environment of the clinic does not have subtle triggers of traumatic memories.

Simply prescribing a diet plan to someone who is using food as a coping strategy is neither useful nor respectful. Relating back to my post yesterday on the secondary prevention of obesity, I sincerely believe that addressing mental health and addictions will be an important part of the solution.

I, for my part, will certainly be paying more attention to the literature on trauma and addictions from now on.

AMS
Banff, Alberta

Covington SS, Burke C, Keaton S, & Norcott C (2008). Evaluation of a trauma-informed and gender-responsive intervention for women in drug treatment. Journal of psychoactive drugs, Suppl 5, 387-98 PMID: 19248396