Is Obesity Like Alcoholism?
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… Read More »
Food and Eating Addictions May Not Be the Same
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… Read More »
Gender Differences in Trauma and Addictions
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,… Read More »
Junk Foods Trigger Food Addiction in Obesity?
Readers of these pages will be quite familiar with my previous posts on food addiction. A new paper by Paul Johnson and Paul Kenny from the Scripps Research Institute, Jupiter, FL, just released online in Nature Neuroscience, demonstrates that in rats development of obesity is coupled with a progressively worsening deficit in neural reward responses (as seen in cocaine or heroin abuse). In drug users, this decreased neural reward response is considered crucial in triggering the transition from casual to compulsive drug-taking. In their experiments, the researchers found compulsive-like feeding behavior in obese but not lean rats, and showed that this compulsive overeating was even resistant to disruption by an aversive conditioned stimulus. The researchers also found down regulation of dopamine D2 receptors in the striatum (an area of the brain involved in reward behaviours) in a manner similar to what has been reported in humans addicted to drugs. Genetic knockdown of striatal D2 receptors also rapidly accelerated the development of addiction-like reward deficits and the onset of compulsive-like food seeking in rats with access to palatable high-fat food. Together these data clearly demonstrate that overconsumption of highly palatable foods can trigger addiction-like neuroadaptive responses in brain reward circuits that can drive the development of compulsive overeating. As I noted in several media interviews on this article yesterday, “while not all forms of obesity can be reduced to food addiction, anyone dealing with obesity needs to be aware of the possibility that they may be addicted to certain foods and must therefore approach their obesity in the same manner as they would approach any other addiction. Unfortunately, in contrast to substance abuse, food abstinence is not an option“. I can certainly now see why diet plans for treating food addiction are about as successful as drinking plans are for managing alcoholism. AMS Edmonton, Alberta
Is Obesity an Addiction?
Regular readers of these pages are well aware of the close link between addictions and some forms of overeating. This topic is now nicely addressed in a commentary by Valerie Taylor (McMaster, Hamilton), Claire Curtis and Caroline Davis (both York University, in this week’s edition of CMAJ. As they discuss, “The concept of food addiction, which more accurately may reflect addiction to specific components of food, can be described in much the same way as other addictive behaviours. Both food and drugs induce tolerance over time, whereby increasing amounts are needed to reach and maintain intoxication or satiety. In addition, withdrawal symptoms, such as distress and dysphoria, often occur upon discontinuation of the drug or during dieting. There is also a high incidence of relapse with both types of behaviour.“ To further support their arguments, they cite the many imaging studies showing that specific areas of the reward or mesolimbic system, such as the caudate nucleus, the hippocampus and the insula, are activated both by drugs and by food. Thus, the easy accessibility of highly palatable foods together with our innate preferences for such foods, can increase the likelihood that vulnerable people will “misuse” food, in much the same way that addicts misuse other drugs to blunt negative emotional states, such as depression, anxiety, loneliness, boredom, anger orinterpersonal conflict. While the concept of addiction should not negate the role of free will and personal choice, it does provide a rationale for the including addiction screens as a routine part of assessment for obesity. It may also help explain the success of lifestyle programs that incorporate pharmacotherapy or behavioural strategies specifically designed to address the addictive component of this illness. Thus, as pointed out by Taylor and colleagues, there is not only considerable overlap among the medications shown to interfere with food and drug abuse in animal models, but the many behavioural interventions developed for managing addictions (motivational interviewing, cognitive behavioural therapy and 12-step programs), are increasingly recognised as also being helpful in managing obesity. Health professionals and decision makers charged with tackling the obesity epidemic would do well to familiarise themselves with the science of addictions and utilize learnings from addiction management in their counseling of patients presenting with excess weight. AMS Edmonton, Alberta