The Dark Side of Food Addiction

great post from Emily Deans at Evolutionary Psychiatry

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.
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