FOOD ADDICTION: FACTS, FICTION, CHALLENGES - PowerPoint Presentation

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FOOD ADDICTION: FACTS, FICTION, CHALLENGES

Jeremy

Clorfene, Ph.D.

Head

Psychologist Advocate Weight

Management

Program (Chicago Area)

565

Lakeview Parkway, Suite 102

Vernon

Hills, IL 60061

o

847-990-5770

c

847-877-1331

www.jeremyclorfenephd.comSlide2

Advocate Weight Management

What do we do and what is our program’s mission?

…

to provide a comprehensive weight management program that treats obesity through medical and behavioral intervention by teaching the tools needed to lose weight and maintain the weight loss for a lifetimeSlide3

How

?

Organization, structure, programming (one-on-one with MD, Behavior, RD, Exercise, Clinician + groups)

Alter

food choices, food quantity, aid in improving physical activity, and medication/health management.

that

is…more nutritious foods, less carbs/sugar, more physical activity, and improve medical/health

profile.Slide4

Current Cause of Obesity

?

1

.

Disproportionate

food intake of carbohydrate and simple

sugars (in volume)

2

. Subsequent decrease in other foods such as protein, fats,

and

fiber (poor nutrition).

3

. Diminished physical activity

4

. Diminished sleep

5

.

Medications / Medical Issues

6.

Convenience

,

cheap sugar

7

. Genetics (only explains 1/3 variance for obesity and does not account for morbid obesity

)Slide5

Is

Obesity:

Is it Food Addiction?

Is

it compulsive overeating?

Is

it Binge Eating Disorder?

Is

obesity the result of being “fat”?

Is

obesity a pathology?

Is

it normal human response to environment with dire consequences?

Is it a dieting

disorder?

Is it a stress

disorder?

Is it a body

image problem?

Is it a sign

of a deeper emotional problem?Slide6

Obesity HistorySlide7
Slide8

Why The Trend? History

(Graph

):

1

. 1970’s “Fat Free

Fallacy”–Med. Community (lipids bad)

2

. Food Pyramid (

grains

grains

grains)

3

. Agribusiness Policy (Earl “Rusty”

Butz

, sect. of

agric

) “Get Big

or Get Out” – lots and

cheap! Slide9

Obstacles we are up against? (our culture)

1. Sophisticated organized

system

to make

carbs, high sugar, high calorie foods

ubiquitously available, cheap, and tasty (e.g.,

soda,

bread, sweets, cereal, fast

fried food)

2. Longer work hours, longer

commutes (especially

women)

3

. Lots and lots of

pleasure

eating habits

(

always pressing the yummy

button – not easy to change)

4

. And … YOU GOT TO EAT! Slide10

Old School Food Market

New School

Food MarketSlide11

In Essence…

We

are

all the

antidote

(treatment) to

the

venom (poison) to what Kelly Brownell

(2004) has described

a culture as a “

Toxic Food Environment”

which is

responsible for the

rapid

increase obesity

rates.

What do we do?

Control

food, educate, build skills, create positive

experiences

, accountability, support, validate,

motivate

, attempt to transform

our patients

from ___________(?)

to

the __________(?)Slide12

REAL TIME PROBLEM

In

practice

we see powerful repeated behavioral patterns.

Identify the patterns, it then guides interventions and improves outcomes (transformation)!

Common pattern:

Can’t “stop

” eating forbidden foods (and quantity

)…

weight increases…emotional

distress

ensues…

adding

to negative belief

system…which

fuels more eating.

NOT IN CONTROL

. Slide13

In many cases it

feels like,

looks

like, and acts

like…

ADDICTION

.

But is it?Slide14

Is obesity (morbid obesity) really a “Food Addiction”?

Does “Food Addiction” best explain why people can’t stop eating and making poor choices?

Does “Food Addiction” best explain why people lose weight and regain it all back and more?

Do we want to label obese people as “addicts”?

If addiction explains some, then which ones?

The

idea that a person can be addicted to

food

(or certain foods) has recently received

attention from

science, but being addicted to a “necessity”

(

i.e., oxygen, water, or food) must be evaluated thoroughly and its clinical implications handled responsibly.Slide15

Addiction looks like?Slide16

ADDICTION DEFINED

Classic hallmarks of addiction include

:

impaired control over substances/behavior,

(CAN’T STOP EVEN WHEN TRY)

preoccupation with substance/behavior,

continued “seeking”

continued use despite negative consequences (impact on social, professional, financial, health), and often denial

immediate gratification (short-term reward)

coupled with delayed deleterious effects (long-term costs)

mood/thought altering (YOU GET HIGH)!Slide17

Addiction

Defined cont

.

Physiological dependence occurs when the body has to adjust to the substance by incorporating he substance into its ‘normal’ functioning

Creating condition of

tolerance

and

withdrawal

Tolerance

: body requires increasingly larger amounts to achieve the original effects.

Withdrawal

: the negative physical and psychological symptoms when reducing or discontinuing a substance

Symptoms

:

anxiety, irritability, intense cravings, nausea, hallucinations, headaches, cold sweats, tremors, possible seizures

DSM-IV, 2013 Slide18

Common Addictions are:

Alcohol (most common)

Weed

Nicotine

Heroine

Cocaine

Morphine (Vicodin)

Benzodiazepines (Xanax)

Ritalin

Gambling

Sex (porn)

Internet? Slide19

The Debate…the Evidence:

What about Food Addiction?

Is it real? Slide20

Press/Media Diagnosis/Treatment

Peer reviewed journals / research

Public

Science

Clinical

Food Addiction / “You are an Addict”?

Finlayson, Web 2013Slide21

I. Public

perception of food addition

…

Does it exist? Slide22

“Of course it exists!”

“Currently I’ve been binge eating everyday now for almost the past month. At first it only a couple days a week but now it’s daily. Eating until I feel like I’m going to die. For me it’s my coping mechanism for things in life. I believe it’s a slow for of suicide and the same goes for alcoholics and drug addicts. I just choose food as my drug.”

Anna B, 55. www.foodaddictsanonymous.orgSlide23
Slide24

Self-help literature and Support groupsSlide25

“I

eat properly in front of other people and

then eat tons when

I get home and no one can see me

.”

“I

am fine for a while then I say just one bit of chocolate won’t hurt then it’s like I’ve blown it so who cares and I will start again tomorrow

.”

“I

eat in the car before I get home stuffing my face and if people knew what I

was

doing I couldn’t bear it

.”“I

get this craving in my head

for “it” and

I cant relax until I have had it

.”

“Once I start I can’t stop.”Slide26

Public perception of Food Addiction

…

Food addiction is real and foods can be addictive

Resonates with personal experience and relationships with food and eating – popular explanation for obesity

“Addiction” has entered into common usage but often mean any activity done to excess

E.G., TV, shopping, cell phone use, work, plastic surgery…

Metaphor vs. real medical condition

View is reinforced by reporting of Food Addiction in the media

1000-2000 new articles per month containing the term “Food Addiction.”

Chocolateaholic

!

Frequently reported with references to “junk food”, general obesity and illegal drug use

Lee

et al. 2013

PLOS

One

Slide27

II. Clinical

perspectives on

Food Addiction…

Does it exist? Slide28

Clinical says…

kinda

but not technically

Which addictions are “real” and which are

not, is extremely

important

for all clinicians: Psychiatrists, PCP’s, Psychologists, Counselors, Nurses,

RD’s

, Policy makers

,

Regulatory

bodies,

Pharmaceutical

and Insurance

Industries

•

APA’s

Diagnostic and Statistical Manual “Bible of Psychiatry

” (DSM) is most influential

point of reference for diagnosis of

addiction

• It evolves and changes: diagnosis validity can be questioned

DSM-I (1952, 130 pages, 106 mental disorders)…

Homosexuality was categorized as sociopathic personality disturbance

DSM-V (2013, 900 pages, 300 disorders) Slide29
Slide30

No

mention of “addiction

”

“

Substance-Related Disorders” (1.Substance- abuse and 2.Substance- dependence

)

10

categories of

substance

Dependence

= 3+ symptoms (max 7) with significant impairment or

distress

With

or without physiological dependence (tolerance/withdrawal

)

Binge

Eating Disorder noted as requiring further

research

Food

Addiction NOT included

•

•

2000

-

2013

DSM-IV

TRSlide31

Substance-Related

and Addictive

Disorders

Continuum

of severity:

number of symptoms

Mild

= 2, Moderate = 4, Severe = 6

(

max 11

)

“

Dependence” seen as normal bodily response to a

substance

Gambling

disorder included as sole

behavioral addiction

BED recognized

as Feeding and Eating

Disorder

Internet

use disorder noted as requiring further

research

Food

addiction still NOT

included

May 2013

DSM-5Slide32

DIAGNOSIS: Substance

use disorders span a wide variety of problems arising from substance use, and cover 11 different

criteria (DSM-V):

1. Taking

the substance in larger amounts or for longer than the you meant to

2. Wanting

to cut down or stop using the substance but not managing to

3. Spending

a lot of time getting, using, or recovering from use of the

substance

4. Cravings

and urges to use the substance

5. Not

managing to do what you should at work, home or school, because of

substance

use

6. Continuing

to use, even when it causes problems in relationships

7. Giving

up important social, occupational or recreational activities because

of

substance use

8. Using

substances again and again, even when it puts the you in danger

9. Continuing

to use, even when the you know you have a physical or

psychological

problem that could have been caused or made worse

by

the substance

10. Needing

more of the substance to get the effect you want (tolerance)

11. Development

of withdrawal symptoms, which can be relieved by taking

more

of the substance.Slide33

“DSM…The

strength of the DSM has been “reliability” – to ensure clinicians use the same terms in the same way. The weakness is its lack of validity –common symptoms may have different causes and treatments. For research purposes, we need new/better ways of classifying mental disorders based on dimensions of

observable

behavior and neurobiological measures

.”

NIMH

Dir. Thomas

Insel

,

MDSlide34

Is

Food Addiction

a type of Binge Eating Disorder

?

Slide35

Binge Eating Disorder (BED):

finally

got its due in the DSM-V!

Binge eating disorder will now have its own category as an eating disorder. In the DSM-IV, binge-eating disorder was not recognized as its own disorder but rather was diagnosable under the category

Eating

Disorder Not Otherwise Specified (

EDNOS

).Slide36

DSM-V (Binge Eating Disorder)

Recurrent

episodes of binge eating. An episode of binge eating is characterized by both of the following:

eating, in a discrete period of time (for example, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

a sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating)

The binge-eating episodes are associated with three (or more) of the following:

eating much more rapidly than normal

eating until feeling uncomfortably full 

eating large amounts of food when not feeling physically hungry 

eating alone because of feeling embarrassed by how much one is eating

feeling disgusted with oneself, depressed, or very guilty afterwards

Marked distress regarding binge eating is present

.

The binge eating occurs, on average, at least once a week for three months.

The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (for example, purging) and does not occur exclusively during the course Anorexia Nervosa, Bulimia Nervosa, or Avoidant/Restrictive Food Intake Disorder.Slide37

This revision is intended to increase awareness of the significant differences between BED and overeating. 

According

to the American Psychological Association, “recurrent binge eating is much less common, far more severe, and is associated with significant

physical

and psychological problems.”Slide38

Food Addiction

may only be relevant to Binge Eating Disorder and not

necessarily relevant

to all

(most) individuals dealing

with

obesity

Truth is…we don’t know (limited evidence)

And…Food Addiction

may be the result obesity rather than a

cause

Gary

Taubes

(2010)…”People are fat not cause they eat too much, rather they eat too much because they are fat.”Slide39

III. Science perspectives

on

Food Addiction

…

Does

it exist? Slide40

Science says maybe…

been looking at this issue for sometime

Most

evidence for food’s

“addictive”

properties lies in the biological realm. Food and drugs of abuse exploit similar pathways in the

brain:

D

opamine

and

Opiate

systems

(

pleasure centers

).Slide41

Science cont

.

More

rewarding the food or drug is evaluated to be, the greater the release of extracellular dopamine, conversely when you block dopamine receptors reduce the reward value of sugar and drugs

PET

scans on

Subst. Abuse and

Obese pts show lower dopamine receptor levels…need more to get reward

Inverse

relationship between overeating and illicit drug use

Wang et al., 2004Slide42

The Rats…

Rats

more often choose water with sugar…when remove the sugar, withdrawal symptoms emerge.

But rat studies have clear limitations

Major

factors beyond palatability are …

availability

, visual appeal, economics, incentives,

alternative

reinforcement,

advertisements, and carbs are fun!Slide43

Drug

treatments for

Substance Abuse

and Obesity

?

Same

drugs used for SA could they be effective for Obesity?

Drugs

that improve dopamine functioning such as Naltrexone

Naltrexone blocks opiate rec that regulate release of dopamine has modest / inconsistent effects on alcohol dependence

Naltrexone with BED and Obesity early research

are scant.

Most drugs for Obesity is to impact appetite, urges, calorie absorption, moodSlide44

Sept, 2014.

Contrave

is a combination of two existing generic drugs in an extended-release formulation. One is naltrexone, which is used to treat alcohol and opioid dependence. The other is bupropion, which was approved under the name Wellbutrin to treat depression and under the name

Zyban

to help people quit smoking.Slide45

Comparison: Substance Abuse (SA),

Binge Eating Disorder (BED), and Obesity (FA?).

Great description of Addiction is that it’s a

“

Chronic

Relapsing

Disorder

”

Temporal course of relapse patterns is different

(

but measuring slightly different factors)

The

disorders have uniform but strikingly different patterns of relapse over time.

Wilson,

G.T

. (2010) Slide46

Temporal Course:

Substance Abuse

Nicotine

, Heroin, and Alcohol relapsed early post-treatment, and thereafter, relapse rates decelerated dramatically. The amount of accumulated time abstinent may be the transcending variable.

That

is, “abstinence begets abstinence.” Slide47

Temporal Course:

Binge Eating Disorder:

Binge

Eating Disorder is somewhat in the middle in that you get a significant reduction in binging early in treatment with mixed long-term results. However, no change in weight.

Striegel

-Moore, et al., 2010Slide48

Temporal Course:

Obesity

:

Obesity

initial weight loss is rapid and then slowly declines. Weight regain then begins and continues gradually until weight stabilizes somewhat below baseline levels. This temporal pattern is fairly independent of initial weight loss. Efforts to prevent relapse in the treatment of obesity via aggressive maintenance strategies have been able to slow the rate of regain over time but have failed to alter the basic accelerating function of the relapse curve.Slide49

Clear Issue in attempting to compare and establish validity is how we measure

these constructs:

Different

patterns will emerge for

sure

What are we measuring

?

Substance Abuse = drug relapse

BED = binge relapse

Obesity/FA = weight change and/or carb, sugar relapse?

What

do we need to

measure and treat if

we are to be

successful treating Food Addiction?

Slide50

Gearhardt

,

A.N

. et al., 2011Slide51

• One difference compared to BED is significant impairment

or

distress.

One difference regarding substances is the desire to get “high” from food/carbs/sugar?

Is it plausible that “DSM-V Substance Abuse criteria apply to food as a substance? Slide52

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different

criteria (DSM-V):

1. Taking

the substance in larger amounts or for longer than the you meant to

2. Wanting

to cut down or stop using the substance but not managing to

3. Spending

a lot of time getting, using, or recovering from use of the

substance

4. Cravings

and urges to use the substance

5. Not

managing to do what you should at work, home or school, because of

substance

use

6. Continuing

to use, even when it causes problems in relationships

7. Giving

up important social, occupational or recreational activities because

of

substance use

8. Using

substances again and again, even when it puts the you in danger

9. Continuing

to use, even when the you know you have a physical or

psychological

problem that could have been caused or made worse

by

the substance

10. Needing

more of the substance to get the effect you want (tolerance)

11. Development

of withdrawal symptoms, which can be relieved by taking

more

of the substance.Slide53

Psychometric measurement of “Food Addiction”

Development

of Yale Food Addiction

Scale (

YFAS

)

The

YFAS

is a measure that has been developed to

identify

those who are most likely to be exhibiting

markers and symptoms of substance

dependence

(criteria in DSM-IV-R) by the consumption

of high fat/high sugar foods

.

(larger amounts, can’t quit, time spent, impacts other areas of life, use despite

neg

consequences, tolerance, withdrawal, impairment)

Persistent

desire or un-successful effort to cut down endorsed by 71% sample

High

internal reliability:

α=.75

Convergent

validity with Eating Disorder and Binge Eating Scales

Discriminant

validity from Problem Alcohol Use

Scales

Gearhardt

,

A.N

. et al.,

2009Slide54
Slide55
Slide56

Challenges with

psychometric assessment of

“

Food Addiction” for

research

Assumption

that addiction is a stable, measurable concept

•

Assumption that Food Addiction exists to be

quantified

• No

clear threshold for ‘addictive’ versus ‘normative’ eating

behavior

•

Overlap with existing scales for severity of Binge Eating,

Disinhibition

, Emotional Eating, Food Craving, etc

.

•

Does it give any additional information

?

•

Is it necessary or helpful to ‘

medicalise

’ common

behaviors with

diagnostic labels? Slide57

More Challenges…

Problems

with food as “drug

”

Validity

of food addiction, misuse or abuse requires

new

categories of food –

(again it is essential

for

survival)

e

.g

.

“junk

”,

“hyper-palatable”, “high-sugar

” versus

“healthy

”,

“natural

”, “Wholesome

”

No

objective threshold for addictive potential of

foods (e.g., blood alcohol levels)

Bread

was found to be food “most difficult to control eating” in sample of obese “Food Addicts

”

Gearhardt

(2012) Yahoo Health

Slide58

If Food Addiction is cause of obesity it is

not following

other subst. addiction rates (stable/flat over time), thus calling into

question

Food Addiction’s

validity

and/or may

have to be evaluated and categorized

differently.

Alcohol

Statistics Teen Drug Use

Adweek

, 2015

www.monitoringthefuture.org

, 2014Slide59

RECAP

So…Does Food Addiction exist?

Yes it does!

How do we know? Cause we see it everyday, but it is not clean!

FA is unlikely to be the dominant (only) causal pathway to explain obesity, which is heterogeneous syndrome and profoundly environmental (“toxic food environment”).

Is

100% relapse prevention the goal

? Prevention of what?

Maintenance

strategies can slow but seldom prevent relapse.

Moreover

, the expenditure of time and money required to implement resource-intensive maintenance strategies renders them impractical for any large-scale, community-based intervention (Brownell, 2010).

Future Research –

YFAS

is key, and ask pts “yes or no” as FA.Slide60

Treatment Implications

Can

we market our program as a

Food Addiction treatment

program?

NOPE!...why?

Can

we call our patients food addicts?

(Isn’t

that a bit offensive

?)

NOPE!...why?Slide61

So, if Food Addiction does exist how to best treat?

Begs the question:

What is the key to treating addictions?

A. Abstinence

Or

B: Teach our patients how to eat and control their trigger, self-proclaimed addicted foods?

 Slide62

Key

themes

for

treating Obesity/FA

:

Abstinence

Build history of alternative foods

Environment (home, work, drive-thru)

Build Control

Skills (impulses, emotional

)

Build a system/language about FASlide63

Treatment keys

:

1. Abstinence, Abstinence, Abstinence!

(abstinence for all addictions is key treatment goal*)

a.

pt

identifies self as a food addict

b. identify the “can’t control food”

c. minimum one year sobriety from that food (2yrs ideally)

d. track it, reward abstinence, make it public

*

National Institute on Drug Abuse, 2015Slide64

Treatment keys

:

2. Build

history of alternative

foods

a. changing biochemical nature of the body and brain

b. nutrition goes up cravings go down

c.

lowers valence of the “addiction food”Slide65

Treatment keys

:

3. Environment

(home

,

drive-thru

)

a. Environment is the true cause, then must be significant part of the solution!

b. The girl-scout cookie effect

c. kid’s

gotta

have it – no the don’t

d. Get it out of the house!

e. Eating out = weight gain

Slide66

Treatment keys

:

4. Build Control and More Control

a

.

positive self-talk

b

.

reinforce success

c

. get

back on plan if get off planSlide67

Treatment keys

:

5

. Skills, skills, skills

(impulses, emotional)

a

.

stress management

b

.

emotional eating

c

.

delay impulses

d. manage relationshipsSlide68

Treatment keys

:

6. Build

a

system

about

Food Addiction

a

.

review food addiction model

b

.

review abstinence

c

.

entire team on same page

d

.

not powerlessSlide69

Questions…?

Thank you