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Why Does The Food Addiction Model of Obesity Management Lack Good Science?



obesity-questionmarkYesterday’s guest post on the issue of food addiction (as expected) garnered a lively response from readers who come down on either side of the discussion – those, who vehemently oppose the idea and those, who report success.

Fact is, that we can discuss the pros and cons of this till the cows come home, because the simple truth is that the whole notion lacks what my evidence-based colleagues would consider “strong evidence”.

Indeed, I did try to find at least one high-quality randomized controlled study on using an addictions approach to obesity vs. “usual” care (or for that matter anything else) and must admit that I came up short. The best evidence I could find comes from a few case series – no controls, one observer, nothing that would compel anyone to believe that this approach has more than anecdotal merit.

Yet, the biology (and perhaps even the psychology) of the idea is appealing. Self-proclaimed “food addicts” that I have spoken to readily identify with the addiction model and describe their relationship to “trigger foods” as an uncontrollable factor in their lives that calls for complete abstinence. Animal studies confirm that foods do indeed stimulate the same parts of the brain that are sensitive to other hedonic pleasures and substances.

So why the lack of good data? After all, the idea is hardly new – intervention programs for “food addicts” using the 12 steps or other approaches have been around for decades.

Can it be simply the lack of academic interest in this issue? I find that hard to imagine – but nothing would surprise me.

Is it perhaps because addiction researchers do not take obesity seriously and obesity researchers don’t like the addiction model?

I certainly don’t buy the argument that there is no commercial interest in such an approach – if there were strong and irrefutable evidence, I’m sure someone would figure out how to monetize it.

So again, I wonder, why the lack of good data?

Honestly, I don’t know.

I’m open to any views on this (especially if substantiated by actual evidence).

@DrSharma
Berlin, Germany

7 Comments

  1. Researchers don’t take food addiction seriously as it’s not sciency, we food addicts believe that it’s a disease with three aspects, physical, emotional and physical.

    The profit motive should be removed, as good 12-step groups will follow the 12 traditions, so if Pepsi or Weight Watchers can’t make a buck, it does not get researched.

    I have lost hundreds of lbs using the support and program found in OA. That said, I have been offered a sponsorship deal with the weigh and pays, etc. It would harm my recovery if I were to put profit over helping my fellow suffer. And I didn’t come because I saw statistics, I came because I saw hope. Not everything needs to be explained by reports.

    Some things that may help:

    OA ran a survey of its membership that may help: https://www.oa.org/pdfs/member_survey.pdf

    Also, there’s some materials for referring health-care professionals: https://www.oa.org/mediaprofessionals/to-referring-professionals/

    Anyone can attend an “open” meeting, if you want to see for yourself.

    Also, I question the scare quotes around “food addict”. This is something that is self identified. Certainly, you wouldn’t write: “Caitlin Jenner, a “woman” on television.”

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  2. I think that the comment about “there would be a way to monetize it” ignores the most basic principles of the 12 step programs!! The moment ANY outside interest, even the noblest and best intentioned one tries to find its way into a 12 Steps program, it will totally distort the way it works. It works because it is free, and GENUINELY disinterested. It works because it is selfless, and service-oriented. And because it is ONLY peer based. Whomever talks to you will only do it from their experience. And no, it is not possible to welcome any scientist to do research in any 12 step group. That researcher would be an outsider, and the basis of the program is that it is completely anonymous, self contained and regulated, and free of any outside influences.

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  3. As much as most of us in the Medical Field believe in being Evidence-Based, there are a few rare times that we have to remember that “Absence of evidence is not evidence of absence”. It’s possible that it is just hard to quantify & measure.

    It’s like the difference between “disease” in the old days and “syndrome” in the new era. In disease, you need to have a specific proven pathophysiology. Not unlike in syndrome where you don’t need to prove it at all.

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  4. I wasn’t able to respond yesterday — too many appointments! It is well that I didn’t. It’s interesting to see others’ opinions.

    My thought: The component parts of this equation have been researched. Representing the 12-step program is AA. Note in the Wikipedia article, the first five footnotes are devoted to AA research. How to do research despite the anonymity, what the research tells us. https://en.wikipedia.org/wiki/Effectiveness_of_Alcoholics_Anonymous

    Alcohol, however, is different from food. You have to eat something. We have seen research on various foods, how they work in the brain. In particular, we have seen research on the S foods: sugars and starchy carbs. It is my understanding that most 12-step approaches work on eliminating these foods.

    We have also seen research on the effectiveness of various diet combinations with regard to macronutrients. Generally, five years out, people who eliminate any particular food group entirely, in large percentages, have relapsed and regained. Giving some credit to the 12-step people, it is very difficult in our food-saturated social systems to maintain restricted diets without support. The ubiquitous pressures: “A cookie isn’t gonna kill you, and I made these especially for you.” Sure, you can answer “If you really knew me, you’d have made me a salad,” but that is not a socially acceptable answer. Hence, the 12-step programs, where people can vent such thoughts. And they cope with the stinking parade of cookies on a case-by-case basis, helping one another and calling on a higher power.

    If you look at population studies, you see between 3% and 20% success in long-term maintenance, depending on whether it’s empirical or survey research. These percentages have remained constant for decades (despite improvements in bariatric surgery). The 20% success rate comes from the National Weight Control Registry, and 12-steppers are welcome to join that anonymous mass and quietly share their successes there. They do not, however, represent the majority of that group.

    Alton Brown calls weight-loss maintenance “shooting Zombies.” You shoot, you shoot and you shoot, and you try to rest, but then there are always more Zombies. The 12-step programs provide an arsenal for those people who have food addiction, but not everyone has food addiction. Not everyone who gets fat does it by succumbing to whole boxes of cookies. Some people just gain two to three pounds a year every Christmas. Others gain in a pattern similar to their grandmothers, indicating genetics. Others gain after an accident changes how they can exercise. Or after surgery that alters their gut microbiome. Or after the onset of diseases, such as CPOS or diabetes. Others gain for no apparent reason — but may have been exposed to any number of obesegens that have “broken” their endocrine systems. You ran a post a while back in which one researcher had identified 104 causes of obesity, and I know readers came up with additional causes, at least I did. One year, you devoted a week of your blog posts to substituting the word “obesities,” plural, for “obesity.”

    All of us who are maintainers have to shoot the Zombies. 12-step programs are not a panacea and have not, despite admirable publicity, changed the population statistics for weight-loss maintenance in the last 50 years. I am happy for those who are able to find comfort and support there and success in managing their weight after radical loss. I cringe, however, when they become too zealous. I also think that zealousness contradicts their premise that they cannot boast. They do. Simple as that.

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  5. I’m late to the party again, and I apologize if what I say has come up in previous comments. I haven’t read them all. I also apologize for places I’m surely preaching to the choir.

    My biggest problem with the food-addiction model and why there’s so little (if no) hard research about it is that, simply, it’s easy, and it fits into the “Everyone Knows” model of obesity beliefs.

    Since the early days of modern medicine there have been uphill climbs to disprove and then convince others of “Everyone Knows” factoids. Heck, you can say that for just about any science.

    It is a commonly held belief that obesity is solely a problem of loose morals and gluttony. The concept of food addiction goes right into that — the idea that every fat person is sitting around constantly stuffing their face because they just cannot stop.

    Are there people with food addictions? Of course! But now you run into the problem of “If all you have is a hammer, everything looks like a nail.” Just because the last 10 fat patients had a food addiction doesn’t mean the next 10 will, too.

    Given how many pieces CAN go into obesity, from genetics, gut bacteria, insulin resistance and other fat storage issues, mental health, medications, diseases, seemingly-little things like sleep quality, and, yes, food addictions, and more, I am waiting for the day that someone figures out that obesity is, scientifically, like cancer: It is not one single thing. It does not have one single cause. It is not cured by one single method. And the more we keep trying to “fix” the problem with one-cure-for-everyone solutions that just don’t work, the longer the issue will exist.

    Then the problem may be that certain types of obesity may be more study-able, and then more curable/fixable than others, but one step at a time.

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  6. The OA model is severely limited, as its ONLY focus is alleged food “addiction.” While I was a member, I did have some helpful insights, for example, that cream and sugar are trigger foods for me. I was using coffee and tea as a vehicle for these substances, rather than the other way around.

    However, what I saw overwhelmingly at OA meetings was people glorified as “old timers” and “sponsors” (mentors) who may have appeared to have their eating under control—but were actually suffering from pretty apparent OCD/eating disordered behaviors around avoiding those foods, and continuing to weigh and measure everything. Food and their own bodies. I also met a fair number of exercise anorexics, who avoided their favorite foods only by excessive exercise.

    The “food addiction” model is not holistic, and OA is based upon AA. Food is necessary for our survival, alcohol is not. Abstinence is not a viable model for healthy eating or for mental and physical health.

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