Tuesday, February 26, 2013

The Dark Side of Food Addiction

When it comes down to it, what is the difference between enjoying a terrific meal and the dangerousness of hyperpalatable foods? 

(If you haven’t seen it, go read the Extraordinary Science of Addictive Junk Food recently in the New York Times.) 

Also, looks like a book will soon be out from which the article was taken: Sugar, Salt, Fat (just downloaded it to my kindle).

Drug addiction has three phases. The introduction to amazing hyperpalatable something, the likes of which the brain is primed to find rewarding but has never seen before in such intense form. After the initial binge, there is a withdrawal phase of negative emotions associated with being without the rewarding taste, then the preoccupation and anticipation phase, and a ton of time and energy spent seeking the same sensation as before. In addicts, use changes from pursuing positive reinforcement (chasing the high) to forestalling negative reinforcement (to prevent getting sick from opiate withdrawal. I’ve heard that one a hundred times: “It doesn’t even make me feel good anymore, doc. I just don’t want to get sick.”) This last bit, the physical dependence, really means you have crossed the border from abuse to a true addiction. 

In “The dark side of food addiction” (sent to me by Dallas Hartwig, thank you very much!), the work of Dr. Hoebel is examined. He mostly considered sugar to be the hyperpalatable food du jour, and his views that one could be called “food addicted” are controversial. And in the pursuit of sugar, for example, there are some parallels to that shift from seeking the palatable to seeking an absence of negative, relieving the anxiety or sad feelings of being without the food, and a transition in the brain circuits with the downregulation of certain brain reward systems and amplification of stress or “antireward” systems in the brain.

Obesity, as I’ve said time and time again, does not overlap 100% with food addiction behaviors, and food addiction is not the entire story behind obesity. There are obese people who seem to demonstrate no characteristics of food addiction, and there are normal weight or even underweight people who have very troubling relationships with food. The “Yale Food Addiction Scale” is the main criteria used to gauge levels of food addiction in research. It is a series of questions meant to quantify how much someone overeats certain foods despite efforts to limit eating them, how much the eating interferes with functioning, and how much there are withdrawal symptoms if one abstains from the trigger foods.

The most likely to suffer from food addiction type behaviors are, obviously, the binge eaters and bulimics. This population has a high level of other psychiatric comorbidity, including depression, anxiety, and other substance abuse. In fact, 1/2 of teenage bulimics report suicidal ideation.  Interestingly, in most normal-weight individuals, stress and negative mood states are associated with decreased appetite, which is less true of overweight individuals. Is this little difference some of the reason behind the obesity epidemic? Is this difference why obesity tracks with depression, as does diabetes and the other metabolic disease? Or are there more complications to the comorbidities?* Bulimics have lower mood immediately prior to a binge than on says when no binges occur. So, we are talking vulnerable populations. Not everyone. Could explain while some people remain slender in the modern food environment where food scientists uses volunteers and supercomputers to calculate the perfect crispiness of a Cheeto and the “bliss point” of salt, sweet, and fat.

Who are these vulnerable populations? Scarily, as I’ve discussed before, it may be those who have started out dieting. Attempts to control body weight via exercise, dietary restriction, appetite suppressants, laxatives, etc are associated with increased weight gain in female adolescents, and dietary restriction is associated with long term weight gain in female adults. Drinking diet soda is also associated with weight gain. Self-reported “restrained eaters” tend to over eat more in stressful situations.

High carbohydrate foods (particularly bread, pasta, and sweets)(an aside, rice is almost never mentioned in these papers…is that because these aren’t papers written by Asian/Indian authors or because the rewarding properties of gluten and sugar are creepy? I don’t know) tend to reduce reports of anger, tension, and increase calmness for 1-2 hours after consumption. Thereafter, depending upon the person, you may have a rebound decrease in good feelings. The overconsumption of these foods may also prime the reward and addiction pathways to induce low mood and cravings for the foods when they are not available. I’ve discussed the downregulation of the dopamine receptor and decreased dopamine availability before. 

Unfortunately, a lot of the hard data associated with addiction and withdrawal syndromes to food is found in mouse and rat models. And mice and rats simply don’t crave and eat quite the same way we humans do, though they do appear to prefer that cafeteria diet and, I believe, chocolate ensure. But when you are on a diet or a detox or whatever it is… what do you crave the most, particularly if there is a stressful time of day, or you have a headache (I tend to eat far less when stressed, but I will crave Diet Coke during those times). And in those first days of your New Years’ Resolution, what food do you dream about? Many report dreaming about chocolate, sweets, or cheese.

So what is a solution? Clearly just eating whatever willy nilly doesn’t seem to work to keep the population healthy. And yet dieting induces unhealthy eating behaviors, and dieting that feels restrictive is doomed to failure, precisely because it seems to activate the negative side of these reward pathways, perhaps in response to starvation and stress. 

So one should (mostly) eat foods that one can eat to satiety. For the most part this will nix the designer processed foods meant to entice you to eat more. And many people can get away with special treats every once in a while, just as most people can have alcohol or even a cigarette or two without becoming addicted. The model of “intuitive eating” or mindfulness eating will apply to most people. If you want a special treat, enjoy the heck out of it. Smell it, enjoy the color, take a tiny bite and let the flavor melt on your mouth. Take five minutes to eat a single precious Ho-Ho. (You may find that plasticky chocolate shell and chemicalish cake not as enjoyable as you remembered from stuffing your face as a child). 

There’s a whole book about intuitive eating called “Intuitive Eating.”  I must admit I’ve tried to get a number of my binge eating patients to buy this book and practice the principals, but none of them seemed to take to it very much. I found it interesting that the documentary "Weight of the Nation" featured the mindfulness eating approach so much when I had so little luck with it (my medically compromised bingeing patients seem to do better with more drastic measures, such as weight loss surgery or pharmaceuticals that short circuit the reward pathways, and others seem to do better with a "rehab" abstinence approach.) I've had a great deal of luck prescribing mindfulness strategies and therapies to anxious or self-harming patients, but not to binge eaters.

Some people will be particularly vulnerable to certain trigger foods, and if they are indeed addictive, a rehab/recovery model suggests banning the foods altogether, for life. The problem is, in the short term, this method can increase the risk of further bingeing. But in the long term, with the appropriate support, abstaining from these foods may cause them to lose their seductive power.

In my experience there are two sorts of people. Those who can’t bear to be cut off from any particular foods and would rather count calories, and these folks love their fit bits and food scales and weight watchers apps. Then there are those who couldn’t be bothered, who find calorie counting a horrible nuisance, and prefer to avoid certain types of foods. In reality most people who maintain their weight in the modern foodscape are probably one of these sorts of people. Elderly women who’ve been thin their whole lives tell me how they never have dessert, or if they do, they share it with three other people at the table. Almost everyone is restricting in some way, but if they are doing it successfully, they are utilizing a way that complements their personality and hormonal profile, so they don’t feel deprived.

I think it wise to start children out eating real food (breastmilk) and transition them to real food (meat, fruit, veggies, fish, etc.) and limit their exposure to processed designer scary hyperpalatable crap as much as possible until they can be educated as to the dangers and make their own decisions. When they are hooked young, it is a difficult battle. If they are never overweight, they never have to go on a “diet” though like most people they will have to have some limitations on what they do (like most of us have limitations on the number of martinis we have during lunch). Dieting is not a risk-free endeavor and that should be acknowledged, though the most sensible course in my mind is always going for the nutrient rich, whole foods diet for the majority of what one eats, controlling portion size if you must. If your food needs a label to tell you what is in it or what it is, then you should probably be eating less of it. Makes calorie counting harder when the number isn’t printed right there where you can see it. 

Too simple? Probably. We haven’t talked about food intolerances, metabolic syndrome, or anything like that. Just as there are a raft of “paleo diets” from antiquity and we will never be able to copy them, there is no diet that is one size fits all. One can get most of the way and derive most of the benefit from cutting out processed foods (and I include bread and pasta as processed foods). The dark side of food addiction has to come with the acknowledgement that most people when exposed to addictive substances do not become raging, life threatened addicts. And for most, there is a place for some moderation.



  1. Cravings are interesting and Koob has a good conceptualization of two basic types and the neurocircuitry involved. Type I is paired with a previous environmental cue (I see the Heath Bar - I must have it). Type II is more associated with protracted abstinence and in humans would be associated with dreaming, fantasizing about it, and in some cases evoking physical responses like salivation. Prefrontal (ant. cingulate, prelimbic, orbitofrontal) and basolateral amygdala are thought to be involved.

    In my clinical experience those folks with a euphorigenic experience with either food or eating disordered behavior seem to be a distinct group in that they are much more likely to have addictive behaviors. I haven't seen an imaging study that focused on that issue.

    1. Yes considering the breadth and complexity of the problem, imaging data in humans is very limited.

  2. For those of us who have struggled with these problems all are lives, you have missed the big issue. Food is always in our faces, being pushed on us by family, friends, and the like who are unwilling to accept that food is addictive and a problem. It is an environment problem in addition to chemical addiction problem. The solution is a limited paleo/primal/19 centre diet, and metered meals, and a no available food between meals environment. Not an easy life.

    1. I agree wholeheartedly with Fred, it's one thing to know what I'm supposed to be avoiding, it's a whole other thing when it's there at work, at home, in between work and home. It's everywhere. It's like having a crack dealer on every corner (and at home) when I'm a crack addict trying to give it up!

  3. Nice post Emily.

    I think one place where people (not you) sometimes get confused is they think that if obesity is not an addiction to food, that means reward mechanisms are not involved. I think binge eating and other forms of food addiction are the ultimate expression of food reward mechanisms gone out of control, but the reward system doesn't have to be behaving pathologically to drive food intake in both obese and lean people. That's the whole point of the system-- driving the intake of 'preferred' foods is what it's supposed to do.

    I think controlling the environment and avoiding reward cues is a key factor. Some people can be around tempting food all the time, eat it moderately, and have a constructive relationship with it, but most can't. But this problem is easy to deal with for me: I just don't keep those types of foods around. Very little willpower is required to eat well at that point.

    1. Yes, reward mechanisms will always be involved, just some will be more vulnerable to the extremes. Adults can take responsibility for their own mouths and pantries, but the amount of garbage everywhere (from the school to birthdays to play dates) ready to be shoved down kids' gullets is incredible.

    2. Could obesity be considered one phenotype of a broken metabolism? Maybe the reward mechanisms are hyper sensitive in starvation (or perceived starvation based on hormonal profile)? And, the various eating disorders are just expressions of the deranged hormonal profile? Getting some metabolic markers from people suffering from eating disorders may be good info.

    3. Broken metabolism is a very loosely defined concept as well as a food reward. For that reason I cringe when I read both words.
      I am one of thous who benefits from the serious carbohydrates limitation in my diet. It reduced my appetite a lot and dulled the sense of a hunger, as a result all foods got less "rewarding" for me, plus stabilized my moods. Sometimes I even miss how wonderful food used to taste.

  4. Sort of have to wonder how likely Koob's type 1 (environmental cue) is to become type 2 (which is, basically, internalized environmental cue) if the type 1 resorts to environmental abstinence. Are these really two types, or two manifestations of the same basic mechanism? And there's the problem that if real starvation, an actual, undisputed (outside the breathtarians) need for nourishment, will increase sensitivity to both types of cues, then you have to wonder if an overweight person, for one reason or another, has a genuine need for nourishment that results in this same susceptibility to these types of cues.

    One problem with asceticism--it leaves you more vulnerable to environmental cues. Suddenly the mere glimpse of a bare ankle becomes provocative. In my low-fat dieting days, I would lose weight all week, then on the weekend gain it all back. Most of us don't have the option of living in a monastery. I've been low-carb for about a decade. That brought my base weight down about twenty pounds, from barely obese to barely overweight (by bmi). It stays there without trying, but if I diet down I get pretty much the same thing, I'll end up "ruining" my diet. What's stopped is the ratcheting up of my weight with successive dieting.

    I did manage to lose weight on low fat, while eating all that low-fat sugary crap. Did it make full-fat pizza and ice cream more alluring on the week-end?

    I did a five day fast while low carbing--I became a binge eater for a few weeks. Not even vaguely pathological, it went away when my body got back up to where it wants to be.

  5. "In my experience there are two sorts of people. Those who can’t bear to be cut off from any particular foods and would rather count calories, and these folks love their fit bits and food scales and weight watchers apps. Then there are those who couldn’t be bothered, who find calorie counting a horrible nuisance, and prefer to avoid certain types of foods."

    This is a thoughtful and helpful observation Emily.

  6. It's probably not terribly surprising that binge-eaters don't take to intuitive/mindfulness eating. After all, it's not like it's the savouring of the actual flavour-profile of a plasticky chocolate thing per se that appeals, it's the pleasant sensations of having eaten 100 of them. That's (one reason) why a plate of completely plain pasta or other starch can be so rewarding- because it gives you a rush of sugar and other pleasant associated sensations- even though it doesn't taste of anything.

    There's a distinction that might be worth making explicit in the case of people who become miserable when tasty foods are withdrawn. Aside from the people who are literally addicted and feel bad precisely because the food has been withdrawn, there's probably an overlapping group who feel miserable antecedently and use tasty food to ameliorate that misery.

  7. LOL. "Dreaming about chocolates" sounds quite funny to me. Anyways, I agree with you on the most part. Addiction should not be there for anything. If you want to have a healthy life, eat healthy and eat correct quantity.

    Finn Felton
    Kopi Luwak

  8. Finn, your comment reveals that you just don't get it. People can "want" a healthy life and still not do what you do (if, indeed, you're one of the people you describe who eat healthy and eat correct quantity). Some want, and do. Others want, just as sincerely, but consistently stumble, the way a drinker who sees the considerable downsides of continuing to drink, decides to change, but "cant."

    The different is a biochemical sensitivity to substances that, once put into the body, creates cravings that overwhelm other "wants." The phenomenon is not new or complicated.

    What you and others have to understand is that a new set of substances have to be adding to the understanding of addicting substances — not just alcohol or cocaine or heroin, but refined food-like products, especially those crafted into complicated layerings of sugar, salt and fat.

  9. This post reminded me of the part of Gary Taube's book (Good Calories Bad Calories) that goes over the Minnesota Starvation Study. The participants obsessed about foods, cutting out recipes, cut out and saved recipes, always talked about what they're gonna eat after the study, and many of them went on to have careers in the culinary arts. When I went was on a portion control diet with a cheat day ("Body for Life" if you want to look it up) I had the exact same emotions towards food as described in the book. Now on a ketogenic diet I don't care about food nearly as much.

    To make a long story longer I personally believe food addictions are more of a hormonal imbalance then a psychiatric disorder. I wonder if other types of addiction (drugs, sex, video games, shopping, whatever) have more of a connection to hormonal imbalance than we think.

  10. This is one of the most important blogs that I have seen, keep it up!


Tired of receiving spam comments! Sorry, no new comments on the blog

Note: Only a member of this blog may post a comment.