Continuing with the theme of food addiction, here is another guest post – this one by Dr. Pam Peeke, a Pew Foundation Scholar in Nutrition, Assistant Clinical Professor of Medicine at the University of Maryland, and Senior Science Advisor to Elements Behavioral Health, the USA’s largest network of residential addiction treatment centers. She is author of the New York Times bestseller The Hunger Fix: The Three Stage Detox and Recovery Plan for Overeating and Food Addiction. Her website is http://www.drpeeke.com/
For years, the popular culture has embraced the relationship between food and addiction. It permeates our daily vernacular— “I’m hooked on bread”, “I need a candy fix”, “I can’t get off the stuff”, “I’m a carb addict”. Grocery store shelves are filled with colorful cereal boxes labeled “Krave”, as the food industry capitalizes on the consumers’ never ending hunger for another fix. History was made when a major weight management company aired its first Super Bowl commercial, choosing a “food as drug” theme, narrated by Breaking Bad actor Aaron Paul. Close your eyes, listen to the words, and you’d never guess that food, not drugs, was the focus. Companies and communities, however, cannot validate the phenomenon of addictive eating behavior—only science can do that.
Heeding the call to arms, nutrition and addiction researchers, led by Dr. Nora Volkow, Director of the National Institute of Drug Abuse, have spent the past ten years generating a critical mass of valid and credible science associating specific food products and addictive eating behavior. A tipping point was reached in 2012, when the peer reviewed and edited professional textbook Food and Addiction was published. A month later my consumer book, The Hunger Fix: The Three Stage Detox and Recovery Plan for Overeating and Food Addiction, was released and the single most common response from my readers was “What took you so long?” We needed, and finally benefited from, new groundbreaking research.
We now know that certain foods, namely the “hyperpalatables”–sugary, fatty, salty food combinations— affect the brain’s reward center in a way identical to drugs and alcohol, triggering an abnormally high level of release of the pleasure chemical dopamine. Repeated hyper-stimulation of these reward pathways can trigger neurobiological adaptations that can lead to compulsive consumption despite negative consequences.
In 2009, Yale researchers developed the first assessment tool, the Yale University Food Addiction Scale, or YFAS, to identify individuals who demonstrated an addictive response to specific foods. Subsequent studies using the scale have shown that there is a wide spectrum of people who present with addictive eating behavior, especially in those who are overweight/obese, female, over 35, or who have existing disordered eating patterns such as binge eating disorder or bulimia. Ongoing investigations have noted that among women, there is a 90 percent association between food addiction and prior history of abuse, especially in childhood and adolescence. As well, the incidence of addictive eating in women increases with post-traumatic stress syndrome.
As scientific evidence continues to mount clarifying the connection between food and addiction, attention is now beginning to focus on treatment options. Treatment for addictive eating behavior is of particular interest to me as a scientist and a clinician. I recall one of my patients, a former alcoholic with a disabling sugar addiction, declaring, “If drinking is black and white – I drink or I don’t– sugar is more shades of grey than there are books.” Indeed, in contrast to drugs and alcohol, treatment for the psychobiological challenges of addictive eating is far more complex. In a prior blog, Dr. Vera Tarman addressed abstinence as one treatment option.
Who is the target treatment population? It’s not just obese, compulsive overeaters. It also includes thin, average and mildly overweight men and women experiencing a full range of eating disorders (ED), mood syndromes and substance abuse. Within these groups there are numerous intricate interconnections, interrelationships and co-occurrences. For instance, current research suggests that approximately 50% of those with an ED are also substance abusers, including 57% of men with binge eating disorder experiencing long-term drug and alcohol abuse. Cross addictions abound as people transition from drugs to cupcakes, from alcohol to sugar, and from bariatric surgery to alcohol. This complicated web of interrelationships is one reason that determining the precise prevalence of food addiction is such a challenge.
In essence, the larger the treatment population, the wider the spectrum of therapeutic modalities required, and thus, the greater the need to individualize and customize treatment for addictive eating behaviors. To address this challenge, I have created the Integrative Nutrition and Holistic Lifestyle Program at Malibu Vista in California. This women’s residential treatment program treats women, many of whom have co-occurring mood and food conditions, specifically addictive eating. This pilot program has garnered national attention including a recent NBC Today Show segment.
The program’s blueprint is based upon my three pronged, customized approach to: 1. mental/spiritual wellness (MIND); 2. whole food nutrition (MOUTH); and, 3. physical activity (MUSCLE). Therapists use a wide range of cognitive psychotherapeutic methods to treat mental health conditions including trauma. Body movement modalities include yoga, tai chi, and meditative walks to foster an improved mind-body association. Nutritionally, the chefs have eliminated any refined or processed foods, including table sugar and artificial sweeteners. Our culinary nutritionist, who is both a certified chef and registered dietitian, assesses each woman. This includes completion of the Yale Food Addiction Scale, a metabolic evaluation, and documentation of any history of substance abuse and disordered eating. An individualized plan is created and refined during the typical 4-5 weeks in-residence. Through hands-on cooking lessons and nutrition education sessions, individuals can reframe and redefine their relationship with food. Group fellowship is critical to ongoing support and success. Continued coaching continues upon discharge. For example, Sandie, featured in the Today Show segment, is now off her anti-anxiety medications, no longer binges, has halved her diabetes medication, and has thus far removed over 50 pounds of excess weight.
In honoring each woman’s unique story and the complexities of treating addictive eating behavior, the Malibu Vista team draws upon elements found from a multitude of resources, including but not limited to 12-step programs. Individualized strategies are designed to use a wide range of interventions to optimize body-brain-mind healing. The end goal is to help each person manage the triple challenge posed by the food-mood-addiction triad, and in doing so, create a blueprint for long term recovery, and success in navigating addictive eating’s many shades of grey.
Today’s guest post comes from Dr Vera Tarman, addictions specialist and Medical Director of Renascent, Canada’s largest drug and alcohol rehabilitation facility. She has spoken internationally on the subject of food addiction and is the co-author of Food Junkies: The Truth about Food Addiction (reviewed here). Her website is addictionsunplugged.com.
Countless times during my public talks, the question comes up: “You have to eat! If food is addictive, what can you eat?”
“Yes”, I agree. “ You do have to eat, but not desserts, bagels, pastries, or any junk food. You don’t need sugar, honey, maple syrup or molasses to survive.” How about vegetables, fruits, meats and fish? For most people, even end-stage food addicts, these foods are not addictive. Food abstinence is not about being on a diet, restricting calories, counting points, eating specially packaged foods – it is a recommendation that we eat the foods our body was metabolically designed to eat and enjoy with satisfaction.
Our evolutionary hormonal and neurochemical “checks and balances” have been designed for the natural foods of our ancestors. In other words, we are programmed to desire food when we are hungry and are satisfied when we have sufficient energy reserves from that food. In a perfect nutritional ecosystem, most people can stop with satisfaction when they are full. Willpower, the front-lobe strongman of the brain, is actually quite short-lived and fragile, but works sufficiently well under normal conditions.
The food industry has created foodstuffs that provide an highly efficient delivery system to our brain’s reward center. This manipulation gives us a copious amount of delight immediately: the quick fix. The fiber from fruit and vegetables has been peeled away, the hovering bees that discourage an overly eager hand from taking gobs of honey have been removed, the bark of a maple tree or sugar cane that would have made it impossible to get more than a lick of sap or sugar have been stripped. Our primal brain which is accustomed to moderate pleasure is overwhelmed with the euphoric bliss of highly palatable foods. Willpower sags under the strain.
This is why you choose the apple cheese cake over the apple. Foods have become irresistible, even to a normal eater. To a food addict, they are the kick-start of a downward spiral to endless overeating, misery and self-loathing.
The question that typically follows is, “If you restrict your foods, aren’t you encouraging abnormal eating behavior? Aren’t you depriving people so they will just want those foods even more?” Terms like orthorexia or anorexia are thrown about. Following a meal-plan abstinent of sugar, flour and processed food (which by definition contains sugar, salt, fat) is seen as pathological. The accusations are that a person could become orthorexic, developing the obsessive need to eat biologically healthy nutrition, possibly engaging in multiple cleanses, fasts, or juicing. Or they could become anorexic, with an obsessive focus on weight and food restriction to near starvation levels. Bulimia could also develop as a person stops their favorite food – getting thrown into withdrawal led by mammoth cravings that bring on the next binge.
Food addiction practitioners share the same concerns about these destructive behaviors. These obsessions are viewed as a form of addiction in and of themselves and are seen as replacing food for obsessive food behavior. The food addict is encouraged to stop these behaviors alongside abstaining from their addictive food triggers.
While a non-addicted eater may be able to ‘relearn’ how to curb the use of their favorite foods, the food addict cannot. For those in the population who are more vulnerable to the ‘quick fix’ potency of processed foods – foods that act as if they are a drug – eating a favorite food, however small the portion, is a trigger, a tease. The food addict’s ‘stop’ switch has become battered. In the same way that a type 2 diabetic has developed insulin resistance, the food addict can be regarded as having developed a dopamine resistance. Relapse inevitably follows.
So what would food addiction treatment look like? A meal plan of healthy vegetables, protein, fats and fruit. One excellent example can be found in Dr. Pamela Peeke’s The Hunger Fix: The Three Stage Detox and Recovery Plan for Overeating and Food Addiction which covers a wide range of nutrition interventions, addressing the normal eater who wants to know how to manage addictive foods, as well as the food addict who cannot eat particular food products for fear of relapse. Dr. Peeke will follow up with a post to provide a successful example of this approach currently being piloted in residential treatment centers in the USA.
A food addiction treatment plan may also include ample amounts of food so that the person does not over/under eat. To this end, it may even be necessary to weigh and measure foods. This is not about calorie counting or food restriction, it is about keeping the food addict safe by controlling the amount and type of food choices. The result of such a plan is not deprivation. It has given many a new freedom from the compulsion to compulsively overeat that some of us have lived with for too many years.
Now let me ask you a question. Why do some view meals that are abstinent of sugar, flour, or the practices that ensure that a person eat a healthy amount of food, considered unhealthy? Who is benefiting from this mythology that we are all eating “normal” foods in today’s food environment, with willpower to match what is beyond many people’s capacity to resist?
The food addicts who feel shamed out of their vigilance or medically mandated to “eat all foods in moderation” like everyone else are not being served. Further, I am even concerned about the normal eaters. My prediction is that many ‘normal’ people may follow the same trajectory that the recreational drug user or alcohol drinker might. If they are given increasing amounts of their favored substance over a prolonged period of time, they too could succumb to the disease of addiction. We are creating food addicts in our current food environment.
Recently, I had the opportunity of meeting Vera Tarman, a Toronto addiction physician, who is also a self-proclaimed “food addict” and author of the book, “Food Junkies: The Truth About Food Addiction“.
It is fair to say that talking to Tarman and reading her book (of which she happily gave me a copy) has definitely given me food for thought.
To start with, her book “Food Junkies” is not a typical diet book or even a treatment guide to food addiction.
Rather, it is a rather compelling treatise in support of the existence of a discrete and definable subset of obese (and non-obese) individuals who may well be considered “food addicts” and for whom the only viable treatment is complete abstinence from their respective trigger foods.
To put things simply, Tarman (and her co-author Philip Werdell) describes three categories of “eaters” (the following words my attempt at paraphrasing the central ideas as I understand them):
Normal Eaters: this is by far the largest group of individuals with obesity, who may overeat for no other reason than that they like food, are surrounded by food, pay little attention to food, let themselves go hungry, have food pushed on them, and/or really don’t obsess or worry about food at all. Normal eaters can learn to control their eating through education and coaching and by changing the circumstances that foster poor willpower: better sleep, stress management, improving social skills, changing their personal food environment, etc.
People with Eating Disorders: for this group of individuals, obesity is not the primary problem, rather it is just another symptom of the underlying emotional disturbances that drives their “pathological” eating behaviour. The “spectrum” of these disorders ranges from rather mild “emotional eating” to full blown “binge eating syndrome”. The primary driver of their overeating is psychological (e.g. trauma, grief, abuse, etc.). Once the psychological problem is identified and resolved (or managed, e.g. though cognitive behavioural therapy), they can gain control over their eating behaviour, which in turn can help them control their weight problem.
Food Addicts: this group of individuals is literally “addicted” to certain foods (usually foods high in sugar, flour, fat and/or salt) in the same manner that a drug addict would be considered addicted to their drug, with the same clinical signs that range from denial and loss of control, to physical symptoms on “withdrawal” and relapse that can be prompted by minimal exposure, even years after being “clean” or “sober”.
According to Tarnan and Werdel, this grouping has important implications for clinical management.
While a “normal eater” and someone with an “eating disorder” can eventually learn to practice “moderation”, this is virtually impossible for the true addict – the only viable strategy for them is complete and lifelong abstinence (best coupled with a 12 steps program or something similar).
For the true “food addict”, no amount of education, psychological counselling or attempt at “moderation” will ever lead to success. Any attempt to get the “food addict” to learn how to “use” their “drug” in moderation will be as futile as trying to get a drug addict to learn how to use alcohol or heroin (or any other drug) in moderation (the vast majority will fail).
As to how the “food addict” can practice abstinence, the Food Junkie acknowledges that this is difficult but achievable. Obviously, the goal will be to completely eliminate and abstain from the “trigger foods”, which will vary from individual to individual (and people may well bounce around from one food to the next). Nevertheless, a good place to start is probably with foods that contain sugar, flour, are highly processed, high in fat or otherwise “addictive”.
For some it may mean a low-carb, for others a paleolithic diet, or simply a fruit and vegetable-based high protein diet with some fat thrown in for satiety – here Food Junkies discusses the various options, while acknowledging that there is no hard and fast rule – only, that it can be achieved (a point that the authors illustrate using their own stories and those of their patients).
All of this said, the authors are the first to acknowledge that there is much about food addiction that we don not yet know or fully understand.
For one, making the diagnosis is anything but easy – often, this “diagnosis” can only be made when all attempts at “moderation”, despite best efforts, fail.
The authors also accept that we do not know the prevalence of true food addiction – only, that it may be higher than we think.
If nothing else, the book is a quick and fascinating read for anyone interested in the issue – patient or professional.
It certainly has got me thinking about whether or not “abstinence” may indeed be a viable approach for some of my patients.
For anyone, who has questions regarding this concept, Dr. Tarman has kindly agreed to address these in a subsequent guest post on these pages – so please send me your comments/questions.
Given that most people do not look at obesity as a chronic disease that requires professional management, the most common approach to losing weight is still for people to try to lose weight on their own.
But just how effective are these do-it-yourself approaches to weight management?
This is the topic of a systematic review and meta-analysis by Jamie Hartmann-Boyce and colleagues from Oxford University, published in the American Journal of Public Health.
Self-help programs were defined as self-directed interventions that do not require professional input to deliver (“self-help”) across a variety of formats, including but not limited to print, Internet, and mobile phone-delivered programs.
As such programs come in all shapes and sizes, the researchers also distinguished between “tailored” interventions as those in which participant characteristics were used to provide individualized content (e.g., tailored based on information provided by participants at baseline), and “interactive” interventions as those programs in which participants could actively engage with intervention content (e.g., through online quizzes or entering their own content).
For each intervention, the authors also coded the specific type of self-managment strategies ranging from goal setting to buddy systems.
The researchers found 23 randomized controlled trials comparing self-help interventions with each other or with minimal controls in overweight and obese adults, with 6 months or longer follow-up. Together these studies included almost 10,000 participants in 39 intervention arms.
Although the researchers noted considerable heterogeneity among studies, the average difference in weight loss at 6 months between the self-management and control groups was about 2 Kg, an effect that was no longer significant at 12 months.
Overall the type of program (tailored vs. non-tailored, interactive vs. non-interactive, etc.) did not make any notable difference to the success of participants.
The authors also noted that the only trial that examined a potential interaction with socioeconomic status found that the intervention was more effective for more advantaged populations.
Despite these rather sobering results, the authors come to the rather astonishing conclusion that,
“Results from this review show promising evidence of the effectiveness of self-help interventions for weight loss.”
“Public health practitioners and policymakers should look to implement self-help interventions as a component of obesity intervention strategies because of the high reach and potentially low cost of these programs.”
How exactly, the authors would come to these recommendations is unclear – my view would be that this could be a rather substantial waste of public health funding that could probably be put to much better use.
Based on this paper (despite the enthusiastic conclusions of the authors), my conclusion would be that the vast majority of current self-management programs are probably not worth the time or effort.
This is not to say that self-management does not have an important role in obesity management – it certainly does, but evidently needs to occur under professional guidance.
So, if you do have a medically relevant weight problem – get professional help!
Hartmann-Boyce J, Jebb SA, Fletcher BR, & Aveyard P (2015). Self-Help for Weight Loss in Overweight and Obese Adults: Systematic Review and Meta-Analysis. American journal of public health PMID: 25602873
Yesterday, saw the release of new Clinical Practice Guidelines from the Canadian Task Force on Preventive Health Care to help prevent and manage obesity in adult patients in primary care.
Similarly to the Endocrine Society’s Guidelines for the pharmacological treatment of obesity (see yesterday’s post), the authors use a GRADE system to rank and rate their recommendations.
Key recommendations are summarized as follows:
- Body mass index should be calculated at primary health care visits to help prevent and manage obesity.
- For normal weight adults, primary care practitioners should not offer formal structured programs to prevent weight gain.
- For overweight and obese adults health care practitioners should offer structured programs to change behaviour to help with weight loss, especially to those at high risk of diabetes.
- Medications should not routinely be offered to help people lose weight.
Virtually all of these recommendations are supported by evidence that is rated between moderate to very low, which essentially leaves wide room for practitioners to either do nothing or whatever they feel is appropriate for a given patient.
The guidelines do not discuss the role of bariatric surgery (arguably the most effective treatment for severe obesity) and make no recommendations for when this should be discussed with patients.
The rather subdued recommendations for the use of medications is understandable, given that the only prescription medication available for obesity in Canada is orlistat (why the authors chose to also discuss metformin, which is not indicated for obesity treatment, is anyone’s guess).
Overall, the reader could easily come away from these guidelines with a sense that obesity management in primary care is rather hopeless, given that behavioural interventions are modestly effective at best (which is probably why the authors recommend that these not be routinely offered to patients at risk of weight gain).
Indeed, it is hard to see how primary care practitioners can get more enthusiastic about obesity management given this rather limited range of treatment options currently available to Canadians.
If there is anything to take away from these guidelines, it is probably the simple fact that we desperately need more effective treatments for Canadians living with obesity.