originally published by https://www.psychologytoday.com/us/blog/food-body-love  June18, 2019

Never has food and weight evoked such emotion and been such a moral issue. As part of the “war on obesity” some have blamed food addiction as the cause of increasing weight of Americans—and sugar is being compared to Big Tobacco. There are even grumblings of a class action suit against food industry giants who include this “addictive” substance in their products. Meanwhile, the focus on obesity perpetuates bias against larger bodies which—combined with messaging that certain foods are dangerous and addictive—fuels food phobia that contributes to increasing rates of eating disorders.

But is sugar—or any food for that matter—truly addictive? And, is treating eating issues such as binge eating disorder as an “addiction” helpful or harmful? Those are two of the most important questions for clinicians who treat eating disorders such as binge eating disorder to answer now. And here’s why: Using a classic addiction model of abstinence from “addictive” foods doesn’t work—in fact, such restriction actually induces binge eating.

Problems with the Addiction Model

The reward system in the brain is very powerful. We certainly are pleasure seekers, and certain types of food entice more cravings than others—those foods that are highly palatable, those that contain sugar, refined flour and fat (a cookie) can light up the midbrain dopamine receptors. In early food addiction brain imaging studies, many researchers argued that the brain “on sugar” looks just like the brain on cocaine.

The key here is pleasure. Take the same scans of a brain on an awe-inspiring vista in nature or a mother seeing her child for the first time—yep, it lights up like fireworks. Pleasure has profound reinforcing qualities, and singling out any one category of foods is problematic given that we need food to survive. We can avoid drug substances, but how far do we go with sugars and other carbohydrates? Ask someone with orthorexia (a term for health-food obsession gone bad) who reads labels so closely that they know every single different word for “sugar. Ask someone from the Keto Diet camp: Is fruit from a tree or a “below ground” root vegetable acceptable? ”

A recent study shows that the addictive qualities of cheese may be more powerful than those of sugar. Do we now avoid all dairy? There go two food groups! It’s this type of black and white thinking that fuels the 65-billion-dollar diet industry.

Many a person enters my office and says, “Doctor, I need help, I’m addicted to food!”  After nearly 30 years as an eating behavior specialist, I must keep in mind what really works. Or rather, what doesn’t work. An addiction model of abstinence doesn’t work, in fact, we now know that restriction induces binge eating. Forbidden foods are the foods that my client’s binge on.

The Case for Behavioral Addiction (not “Food” Addiction)

It’s been eight years since my doctoral research regarding the treatment of binge eating disorder. At that time, prior to the distribution of the DSM-5 in May 2013, there was debate as to the inclusion of Binge Eating Disorder as a stand-alone eating disorder. Some believed binge eating should be considered as an addiction spectrum disorder.

In many ways binge eating has the behavioral characteristics of substance addiction: Loss of control, increasing amounts of food to get the same reward effects, unsuccessful attempts to cut back as seen in yo-yo dieting, continuing to binge eat despite severe health consequences, increased social isolation due to stigma, and behaviors that are accompanied by a feeling of shame and self-loathing.

When you compare criteria from the DSM-5 for Binge Eating Disorder to the Yale Food Addiction Scale (YFAS) they look very similar. Although, in one study, only 57 percent of those with BED also qualify for Food Addiction on the YFAS. So it’s not a slam dunk. Although the aforementioned behavioral criteria for addiction can be met, physiological dependence is where we fall short. So, rather than a substance addiction, binge eating may be a behavioral addiction like problem gambling, involving disinhibition of eating in general. If so, the disorder might be more aptly described using the term “eating addiction.”

An overview of the food addiction research suggests that it may not be the actual food that is addictive, but rather a restriction/binge pattern of consumption. Increased dietary restraint and avoidance of forbidden foods do increase binge incidence—and it is this intermittent gorging that appears to create the addiction like process.

Because of this, treatment of binge eating disorder has taken a moderate, “all foods fit” approach that focuses more on making peace with food and the body dissatisfaction that drives the binge-and-restrict behavior. Treatment focuses on addressing the emotional dysregulation and avoidant behaviors such as bingeing to escape their present reality. Becoming weight-neutral rather than using weight loss as a measure of treatment “success” helps those struggling to focus on intrinsic factors driving the behavior rather than the size of their bodies.

The Role of Cravings in Binge Eating Disorder

The struggle is real: Some people who have had prolonged exposure to high-sugar and high-fat foods have decreased dopamine receptors making them more vulnerable to pleasurable stimuli. This heightened sense of anticipation for reward increases their risk for using food for self-medication whether conscious or subconscious.

When explaining this to my clients, I use the metaphor of a fighter plane such as in the movie Top Gun that has technology that “locks in” the target for a missile launch. By the time your brain “locks in” on food, you’re toast unless you use some very skilled flying to change your trajectory. Once triggered, these types of cravings activate reward-seeking behaviors. Behavior is influenced by stress. Food exposure combined with stressful stimuli, including prolonged food deprivation may activate this painful pull. Someone in substance use recovery might use the term “jonesing.”

For those with binge eating disorder, unfortunately the wanting is more powerful than the liking of the actual food or experience. There is evidence of dissociative processes during a binge that interestingly makes it hard to fully enjoy the “reward” the person was seeking.

There is also now evidence that it’s not just the mid-brain that creates cravings. Some cravings might belong to our “second brain” in our gut. There are 10 trillion bacteria in the gut, producing chemicals that talk to each other and communicate to our brain through our Vagus nerve, the long cranial nerve that wanders through all our bodily organs from the brain to the gut. New research suggests that certain gut bacteria may pull us toward highly palatable foods—and after we eat them, release sugars and fatty acids, lifting our spirits considerably. Other organs also get involved in the craving process, like the pancreas, which makes insulin. Over time, one might develop a cellular resistance to insulin, creating high levels of circulating insulin in the body. High levels of circulating insulin trigger more craving and hunger.

Given this emerging science, how can we begin to use this gut brain and endocrine system knowledge to help those caught in the struggle? There is evidence that we can change our gut bacteria to decrease cravings by cutting back on high sugar and high-fat foods. In the event of a stomach bypass, we know that a completely different microbiota forms and creates completely different cravings. Which also means patients can change it back based on the diet that they adopt post-surgery, bringing light to the fact that even altering our plumbing isn’t a permanent solution. Some feel that we should alter food environments for those recovering from binge eating disorders. A disordered eating food addiction nutrition guide, DEFANG, introduced by Wiss & Brewerton, focuses on reducing exposure to highly palatable foods which play havoc on our craving brain and body. They believe that not all foods fit for some, arguing that just because our food industry produces a food, that doesn’t mean we have to include it in our lives.

Harm Reduction in Binge Eating

We know that a full abstinence model doesn’t work in the long run since restrict-binge cycles are a primary factor in eating disorders as well as subclinical yo-yo dieting. Although controversial in substance use, a harm reduction model may fit here. In working with my clients using a mindful eating framework, I’ve found that it is important to first address emotional and biological food insecurity— fear of not getting enough food—as a priority. This means untangling the diet rules mentality and allowing for all foods fitting.

One must instill the truth that all foods are permissible before suggesting that some foods might not be beneficial. Choice and self-determination are the driving forces of making this work.

The steps my clients take include:
• Creating structure and training hunger with regular meals, much like getting yourself on a good sleep schedule, is important in taming cravings.
• Allowing for favorite foods in a safe, supportive and mindful environment. (Reducing exposure to highly palatable foods in this way could be compared to recommending that an alcoholic not keep booze in the cupboards at home.)
• Learning mindfulness skills aimed at keeping one in their “right mind” and implementing a self-care focus for decreasing stress may lead toward intrinsically led choices—choices where the goal is for feeling good, rather than being good or looking good.
• Adding fiber-rich whole plant foods and lean proteins to balance blood sugar and “feed” healthy microbiota which in turn will turn down cravings.
• Understanding that eating foods for pleasure and socialization, not just fueling their bodies, are important for long term recovery!
• Knowing when to say “when.” I tell clients that when they start to notice an obsessional, singular focus on the dessert table and that awful panic starts to rise up they can learn to do some fancy flying of their own fighter jet and dodge the missile by getting the heck out of there.

originally published by https://www.psychologytoday.com/us/blog/food-body-love  June18, 2019

References

Corwin & Grigson (2009).  Symposium Overview. Food Addiction: Fact or Fiction. The Journal of Nutrition. 139: 617-619.

Smith & Robbins (2013). The Neurobiological underpinnings of obesity and Binge Eating: A rationale for adopting the food addiction model. Biological Psychiatry.  73: 804-810

Gearhardt, Corbin and Brownell. (2009) Yale Food Addiction Scale (YFAS) use to determine whether the 2009 diagnostic criteria for substance dependence were presenting eating problems. Appetite. 52: 430-436

Wiss & Brewerton. (2017). DEFANG, The disordered eating food addiction nutrition guide.  Eating and Weight disorders 22 (1): 49-59