Is ‘Food Addiction’ a Subtype of Obesity?
Wednesday, September 14, 2011
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
Wednesday, September 14, 2011
To some of us obese / exobese (I am just overweight now), have known addiction or addiction like has been the major issue all our lives. Of course, low impulse control is a part, as are binges, regardless of the frequency, opportunity, or social occasion.
As the first step in treatment of addiction is removal of the substance, removal of all alcohols, sugars, wheat and grains, and omega 6 oils is the first step. Yup. Yup. That can’t do much that is not good.
All we need is a bunch of big names and the government to endorse that course of action, and we have LCHF by default.
Wednesday, September 14, 2011
I hope that someone comes along and says this better than I can, but I really wonder how you could separate “food addiction” from the normal way that people react to food restriction. If you look at Ancel Keys’ work, you’ll see that mentally and physically healthy people who have been subjected to semi-starvation (in this case, I believe it was around 1500 calories a day for young men) display a lot of the behavior that I’ve heard associated with “food addiction.” Along the same lines, many people binge eat during or after dieting, and it seems to be more a physiological response to weight loss and/or food deprivation than anything mental.
I’m not saying that “food addiction” doesn’t exist (although some people would say that you can’t be addicted to something that you need to live: oxygen addiction! Sleep addiction!), but in our culture of weight loss dieting and food restriction, I think that it’s important to acknowledge how those behaviors can result in eating that feels out of control.
Wednesday, September 14, 2011
As a dietitian, I recall exactly 2 people who came in for weight or diabetes counselling who didn’t have some level of food addiction in 25 years of practice. Couldn’t tell you why they didn’t and everyone else seemed to. Maybe those 2 were the ones who didn’t have a history of dieting.
I agree with DeeLeigh that dieting has set folks up to act like addicts and Ancel Key’s starvation study showed exactly how obsessive behaviours can be. The problem with medicalizing a behaviour is that a normal and reasonable response to an event (dieting) becomes a medical problem (food addiction) with a treatment (Overeaters anonymous).
Interesting how we(medical professionals) fit things into the paradigms we already use, rather than developing a deeper understanding of what is going on. “If you do this (diet, binge, starve, stuff, mindless eating, etc) , then notice how you react” is what we should be speaking to our clients about . “What can you do differently? How do you react now? Is that how you want to react? “what do you know about your own patterns? What shapes them? What are you willing to try?” Indeed, motivational interviewing is the model that clinicians should be adopting. The medical model doesn’t fit as high body fat levels/weight is an issue with medical consequences, not a medical issue in itself, just like alcohol abuse is not a medical issue, it just has medical consequences too.
Wednesday, September 14, 2011
The easy way to test for food addiction to get off the common food addiction groups for two weeks, as the Maffetone Two week tests. You will know what you are addicted to on the second and third days. That is no sugar, no grain, no omega 6 oils. Add alcohol, chocolate, nuts, cheese, and processed meat at some point.
Living on meat, vegetables, and fruit is an eye opening experience. Add some multi-vitamins magnesium, fish oil, vitamin D and whatever else you like.
Food addiction has been studied to death. Try reading Wheat Belly; Sugar Nation; Good Calories, Bad Calories; Paleo Solution; or watch Andreas Eenfeldt, MD latest video.
Ultimately, you will likely need to get off sugar, grains and omega 6 oils.
Ancel Key’s study used normal weight people. This later Six Nation Study was fudged or just cherry picked. The medical community need to answer some of the obvious questions, like why do they have such a fear of saturated fat, and do not support LCHF and Paleo.
Thursday, September 15, 2011
Another complication: no matter how you define “food addiction,” you’ll probably find that it’s not all that strongly related to BMI. You’ll find that many thin people meet the definition and that many fat people don’t. You’ll also find people who do AND don’t have metabolic syndrome that meet the definition. So, calling it a “subtype of obesity” won’t make much sense.
Thursday, September 15, 2011
It is interesting that a methamphetamine addict is often very thin. But we do not label the addict an anorexic. And when the addict is recovered we don’t say the addict is not an addict. They continue to be a recovered addict. This is where the term obesity has the disconnect. Do we say those who have lost the weight continue to be a recovered obeser – obesetite? No. They disappear off the radar screen and are considered normal – when in fact they are struggling every day with their underlying obesity.
On another note, I would think that most obese people did not start to diet until they were at least 30 or 40 pounds overweight or more. And of course then they gained back 50 pounds, etc. So what to do and when and how – and we are back to needing help far earlier than health care is able – or willing – to provide.
Thursday, September 15, 2011
The tension between addiction as a useful construct or harmful construct has, I think, to do with who is doing the diagnosing. If a person is experiencing difficulties in life due to how they are eating, and seek treatment for it, and the construct of food addiction allows them to better understand what is happening for them, and to guide their treatment, I can see how that would be useful. But once we identify a “new addiction” — our society tends to leap into judgment mode and want to ferret out all of those who have the addiction — to clearly identify who does and who doesn’t have that addiction.
From a medical perspective, identifying which individuals are “food addicted” may help uncover new treatments that may allow them to lead healthier lives. From a sociological perspective, identifying a new addiction creates a new subgroup of people who are subject to scrutiny, judgment and stigma. I’m not sure the “net effect” on population health is positive or even neutral.
Perhaps a different word is needed when talking about food, as DeeLeigh referenced, as “food” is a very broad category, and we all need food to survive.
For people who find the addiction paradigm helpful in their own health improvement, is there another word that could capture what you are experiencing that could help identify the problem and lead to treatments that wouldn’t trigger our society’s massive freak out?
Thursday, September 15, 2011
Another point I would like to make about this is the concept of “Adverse Childhood Experiences.” The studies about ACEs confirm what I have observed, that people who have a larger number of difficult or traumatic experiences as children are more likely to have health problems as adults. For more information about these studies, the CDC has a web page about them.
Part of the findings were that for the people who had the largest “score” on the ACEs screening tool were the most likely to engage in behaviors that could lead to early death or serious illness, “For example, a male child with an ACE Score of 6 has a 4,600% increase in the likelihood of later becoming an iv drug user when compared to a male child with an ACE Score of 0.” (Felitti, V. 2002) The causes of addiction are essential when considering the treatment (and indicate that perhaps stigmatization exacerbates the trauma, even if the treatment ultimately improves lives).
My anecdotal observation is that for some, and by no means all, people who use food to self-soothe, when they were children they accumulated quite a few ACEs, and when choosing a route to self-soothe or self-medicate, they choose one far less likely to damage their children or family members than what they had witnessed. So, growing up with a parent with serious untreated mental illness, or alcoholism, caused trauma that needed soothing at the time (and was really unlikely to have been appropriately recognized or treated at the time) and that led to reliance on “substances” available that would not get them into trouble, which might have been slices of toast with margarine, for example.
I am not suggesting that all fat people were abused as children. What I’m saying the ACEs research shows is that traumatic experiences in childhood (including the death of a parent) lead to a need for soothing behaviors, and that these soothing behaviors in turn can lead to their own set of problems — none of this is exclusive to fat people. From this ACEs perspective, there are two different and important directions — one is to do all we can to prevent trauma in early life, and when it happens, to have it addressed as quickly and well as possible. The other is to acknowledge that this trauma causes “lasting damage” that doesn’t have a simple remedy, and that people are doing the best they can to not recreate the trauma. So, if alcoholism was a problem in the family of a child, and that child self-soothes with food, and that becomes a pattern that, in combination with a genetic propensity to gain weight, and an environment that both pushes food through advertising and stigmatizes fatness, that child grows up to be a fat adult but does not become alcoholic, that person has truly done the best they could, and what treatment would be best for them.
One other thought is that people with more ACEs would be more likely to have a higher EOSS score, so they may have fatness in combination with other health problems that may make them more likely to seek treatment for fatness, so they may be more likely to show up in doctors’ offices that fat people without many ACEs.
Tuesday, September 27, 2011
It is wonderful that people are talking about this issue – thank you for all the thoughtful input. We indentify as a food addiction treatment program and we explain about the differences between bad habit, eating disorder and food addiction. We find that brain chemistry problems are present in all our food addicts, as suggested by the research of Bart Hobel and Mark Gold/Nicole Avena. There are several more parts of the condundrum . People often have inherited brain chemistry imbalances, so they were raised by impaired parents and usually have Adverse Childhoo Experiences. Their sensory discomfort causes eating driven by diverse brain chemistry imbalances that cause differing presentations only some of which include obesity early on. Unfortuneatly, early intervention is dieting, and so 20-30 years later we see a majority of obese, over determined cases addicted & disordered