Compulsive Eating Behavior and Food Addiction: Emerging Pathological Constructs

By George F. Koob

Compulsive Eating Behavior and Food Addiction: Emerging Pathological Constructs is the first book of its kind to emphasize food addiction as an addictive disorder. This book focuses on the preclinical aspects of food addiction research, shifting the focus towards a more complex behavioral expression of pathological feeding and combining it with current research on neurobiological substrates. This book will become an invaluable reference for researchers in food addiction and compulsive eating constructs.

Compulsive eating behavior is a pathological form of feeding that phenotypically and neurobiologically resembles the compulsive-like behaviors associated with both drug abuse and behavioral addictions. Compulsive eating behavior, including Binge Eating Disorder (BED), certain forms of obesity, and ‘food addiction’ affect an estimated 70 million individuals worldwide.

• Synthesizes clinical and preclinical perspectives on addictive eating behavior
• Identifies how food addiction is similar and/or different from other addictions
• Focuses on the underlying neurobiological mechanisms
• Provides information on therapeutic interventions for patients with food addiction

• Language: English
• Publisher: Academic Press
• Release date: Jul 24, 2019
• ISBN: 9780128163832

Book preview

Compulsive Eating Behavior and Food Addiction

Emerging Pathological Constructs

Editors

Pietro Cottone

Boston University School of Medicine, Boston, MA, USA

Valentina Sabino

Boston University School of Medicine, Boston, MA, USA

Catherine F. Moore

Boston University School of Medicine, Boston, MA, USA

George F. Koob

National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA

Table of Contents

Cover image

Title page

Copyright

Contributors

Preface

Chapter 1. A history of food addiction

Introduction

References to addiction in relation to food in the 19th century

A description of eating disorders in 1932

Food addiction in the 1950s

Varying themes in the second half of the 20th century

Increased popularity in the 21st century

Current developments

Conclusions

Chapter 2. Food addiction prevalence: Development and validation of diagnostic tools

Early approaches to identifying food addiction

Yale Food Addiction Scale

Modified original YFAS

Children's Yale Food Addiction Scale

Yale Food Addiction Scale 2.0

Modified YFAS 2.0

YFAS 2.0 for children

Alternative model: eating addiction

Next steps in the assessment of food addiction

Chapter 3. Dissecting compulsive eating behavior into three elements

Introduction

The prevalence and significance of compulsive eating

Food addiction as a disorder of compulsive eating

Dissecting compulsive eating behavior into three elements

Habitual overeating

Overeating to relieve a negative emotional state

Overeating despite aversive consequences

Discussion

Summary

Chapter 4. Habitual overeating

Introduction

Overview of habit formation

Compulsive eating driven by habit

Palatable food cues facilitate habitual behavior

Neurobiological habit systems

Potential interactions of habit with other elements of compulsive eating

Summary and conclusions

Chapter 5. Reward deficits in compulsive eating

Food and brain reward systems

Overeating and diet-induced obesity in rodents: the cafeteria diet

Assessing brain reward function: intracranial self-stimulation thresholds

Effects of cocaine on brain reward function

Effects of heroin on brain reward function

Effects of hunger on brain reward function

Effects of weight gain on brain reward function

Brain circuitries that regulate hedonic eating

Striatal D2 dopamine receptor signaling and brain reward deficits in obesity

Striatal D2 dopamine receptor signaling and compulsive eating despite negative consequences in obesity

Summary

Chapter 6. The dark side of compulsive eating and food addiction: Affective dysregulation, negative reinforcement, and negative urgency

Introduction

Yale Food Addiction Scale definition

Opponent-process, negative reinforcement model of compulsive substance use

Conceptual extension to compulsive eating

Evidence for the dark side from human studies

Conclusion

Chapter 7. Food addiction and self-regulation

Brief introduction to food addiction

Definitions of impulsivity and self-regulation

Empirical research on self-regulation and food addiction

Summary and conclusions

Chapter 8. Reward processing in food addiction and overeating

Introduction

Reward processing in eating behavior

Conditions associated with overeating or compulsive behavior toward food

Reward processing in food addiction

Reward processing in overweight and obesity

Reward processing in BED

Reward processing in Prader–Willi syndrome

Comorbidities and addiction transfer

General discussion

Chapter 9. Interactions of hedonic and homeostatic systems in compulsive overeating

Introduction

Homeostatic regulation of food intake

Food palatability and motivation

Conditioned learning and habit formation

Stress and negative emotional state

Binge eating and impaired executive functions

How homeostatic and hedonic regulations of feeding may concur to drive maladaptive pattern of food intake

Compulsive overeating and substance-use disorders

Conclusion

Chapter 10. Genetics and epigenetics of food addiction

Introduction

Family and twin studies

Candidate gene studies

Genome-wide association studies

Gene–gene and gene–environment interactions

Epigenetics

Summary and conclusions

Chapter 11. Neuroimaging of compulsive disorders: Similarities of food addiction with drug addiction

The role of dopaminergic and opioid pathways in drug and food reward

Effects of drugs of abuse and food intake on opioid release

Acute effects of drugs of abuse and palatable food on dopamine signaling and neural activation in the mesolimbic circuitry

Effects of chronic substance misuse and overconsumption of high-calorie food intake on changes in the brain's reward circuitry

Foods associated with addictive-like eating

Interaction between substance and behavioral indicators of addiction

Neural vulnerability factors that increase risk for substance abuse and addictive-like eating

Differences between addictive disorders and addictive-like eating

Conclusions and future directions

Chapter 12. Modeling and testing compulsive eating behaviors in animals

Introduction

Compulsive eating in preclinical research

Chapter 13. Sex and gender differences in compulsive overeating

Obesity

Overeating

Disordered eating

Grazing

Nocturnal eating

Emotional eating

Food addiction

Bulimia nervosa

Binge eating

Sex differences in the BED diagnostic criteria

Sex differences in psychological comorbidities

Sex differences in biopsychosocial/sociocultural factors

Genetics

Influences of gonadal hormones

Animal models

Human studies

Treatment outcome

Summary and conclusions

Chapter 14. Addressing controversies surrounding food addiction

Introduction

Food addiction controversies

Conclusions

Chapter 15. Food addiction and its associations to trauma, severity of illness, and comorbidity

The concept of food addiction

Food addiction and its links to eating disorder and obesity severity

Food addiction and its links to trauma and posttraumatic stress disorder

Food addiction and its links to trauma and obesity

Food addiction and psychiatric comorbidity

Food addiction, obesity, and medical morbidity and mortality

Implications for treatment

Summary

Index

Copyright

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Contributors

Iris M. Balodis,     Peter Boris Centre for Addictions Research, Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada

Revi Bonder,     York University, Toronto, ON, Canada

Benjamin Boutrel

Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Switzerland

Division of Adolescent and Child Psychiatry, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Switzerland

Timothy D. Brewerton,     Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States

Jonathan E. Cheng,     Laboratory of Addictive Disorders, Departments of Pharmacology and Psychiatry, Boston University School of Medicine, Boston, MA, United States

Pietro Cottone,     Laboratory of Addictive Disorders, Departments of Pharmacology and Psychiatry, Boston University School of Medicine, Boston, MA, United States

Caroline Davis,     York University, Toronto, ON, Canada

Fernando Fernández-Aranda

Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain

Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain

Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain

Ashley N. Gearhardt,     Department of Psychology, University of Michigan, Ann Arbor, MI, United States

Kirstie M. Herb,     Eastern Michigan University, Department of Psychology, Ypsilanti, MI, United States

Susana Jiménez-Murcia

Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain

Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain

Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain

Paul J. Kenny,     Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States

George F. Koob

National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, United States

Neurobiology of Addiction Section, Intramural Research Program, National Institute on Drug Abuse, Baltimore, MD, United States

James MacKillop,     Peter Boris Centre for Addictions Research, McMaster University/St. Joseph's Healthcare Hamilton, Hamilton, ON, United States

Gemma Mestre-Bach

Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain

Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain

Adrian Meule,     Department of Psychology, University of Salzburg, Salzburg, Austria

Catherine F. Moore

Laboratory of Addictive Disorders, Departments of Pharmacology and Psychiatry, Boston University School of Medicine, Boston, MA, United States

Graduate Program for Neuroscience, Boston University School of Medicine, Boston, MA, United States

Cara M. Murphy,     Center for Alcohol and Addiction Studies, Brown University, Providence, RI, United States

Katherine R. Naish,     Peter Boris Centre for Addictions Research, Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada

Marc N. Potenza

Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States

Connecticut Council on Problem Gambling, Wethersfield, CT, United States

Connecticut Mental Health Center, New Haven, CT, United States

Department of Neuroscience and Child Study Center, Yale School of Medicine, New Haven, CT, United States

Clara Rossetti

Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Switzerland

Division of Adolescent and Child Psychiatry, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Switzerland

Valentina Sabino,     Laboratory of Addictive Disorders, Departments of Pharmacology and Psychiatry, Boston University School of Medicine, Boston, MA, United States

Karen K. Saules,     Eastern Michigan University, Department of Psychology, Ypsilanti, MI, United States

Emma T. Schiestl,     Department of Psychology, University of Michigan, Ann Arbor, MI, United States

Erica M. Schulte,     Department of Psychology, University of Michigan, Ann Arbor, MI, United States

Eric Stice,     Oregon Research Institute, Eugene, Oregon, United States

Sonja Yokum,     Oregon Research Institute, Eugene, Oregon, United States

Eric P. Zorrilla,     Department of Neuroscience, The Scripps Research Institute, La Jolla, CA, United States

Preface

With the sharp increase in rates of obesity and eating disorders in Western countries, a focus on the potential addicting properties of food has become a point of emphasis for researchers attempting to explain behaviors and neurobiological processes that may contribute to this growing epidemic. Drawing from analogous concepts in the addiction literature, compulsive eating behavior has emerged as a transdiagnostic construct, consisting of a pathological form of feeding that phenotypically, neurobiologically, and conceptually resembles compulsive-like behavior associated with both substance/alcohol-use disorders and behavioral addictions.

Recently, the scientific community has begun to embrace and evaluate the concept of addictive and compulsive eating behavior. A Web of Science search reveals a persistent, steady increase in compulsive eating research over time, coupled with a recent explosion of food addiction studies following the creation and validation of new diagnostic tools in 2009 (Fig. 1). While the scientific discussion on food addiction and compulsive eating behavior is in its nascent stage and the concepts are still somewhat controversial, this research holds enormous potential for improving treatment and prevention strategies for millions of people.

The book begins with "A History of Food Addiction to place this concept and the current state of research into a historical context. Furthermore, the term and diagnosis of food addiction is explained in great detail by the researchers key to its development in Food Addiction Prevalence, Development, and Validation of Diagnostic Tools. Following this, we, the editors, wrote a chapter detailing on what have been identified as the elements of compulsive eating behavior in Dissecting Compulsive Eating Behavior into Three Elements." This chapter describes the elements of (1) habitual overeating, (2) overeating to relieve a negative emotional state, and (3) overeating despite negative consequences and outlines their conception from the field of drug addiction after many behavioral and neurobiological overlaps were observed. A more in-depth breakdown of each element follows in Chapters 4–8. Chapter 4, "Habitual Overeating," overviews the ways in which eating behavior can become inflexible and rote in compulsive eating. "Reward Deficits in Compulsive Eating and The Dark Side of Compulsive Eating and Food Addiction describe the dual processes that make up the element of overeating to relieve a negative emotional state. In Food Addiction and Self-Regulation," the inhibitory control processes that underlie overeating despite negative consequences are discussed at length.

Figure 1  Number of scientific publications on food addiction and compulsive eating in recent decades. Values were obtained by a Web of Science search for each 5-year span using the search terms food addiction and compulsive eating.

Other chapters serve to illustrate the overlaps among the elements of compulsive eating behavior and between these elements and other biological mechanisms. "Reward Processing in Food Addiction and Overeating investigates the intersection of striatal reward processes with prefronto-cortical control circuits. In Interactions of Hedonic and Homeostatic Systems in Compulsive Eating," the elements of compulsive eating are discussed in the context of highly relevant homeostatic feeding mechanisms.

For updates into specific technical fields of research into compulsive eating behavior, chapters on genetics ("Genetics and Epigenetics of Food Addiction), neuroimaging (Neuroimaging of Compulsive Disorders: Similarities of Food Addiction with Drug Addiction), and animal models (Modeling and Testing Compulsive Eating Behavior in Animals") were included.

We have also included a chapter to address the highly relevant topic of "Sex and Gender Differences in Compulsive Overeating." This chapter not only does an excellent and thorough job detailing the current evidence in this area but also highlights an area of inquiry with much left to understand in terms of biological mechanistic sex and gender differences in compulsive eating.

Furthermore, as the concept of food addiction and the consideration of forms of pathological overeating as addictive behaviors have been fraught with debate, we have a chapter devoted to "Addressing Controversies Surrounding Food Addiction." While we have a clear bias as editors of this book, this chapter serves to clarify some of the most prominent arguments that continue to fuel discussion on this topic. We hope to continue the discourse, while also using this book to highlight the undeniable breakthroughs in knowledge and mechanisms that have come about from the food addiction concept.

In the final chapter, "Food Addiction and Its Associations to Trauma, Severity of Illness, and Comorbidity," the utility of, and implications for, studying food addiction within the context of overall mental and physical health is discussed.

Each chapter stands on its own, and together all the chapters form a comprehensive picture of what drives compulsive eating behavior, how the prevalence compulsive eating, and how future therapeutic strategies may look. We have intended that this book be a bridge between preclinical and clinical researchers and drives further excitement in this rich and continually developing field.

Some common definitions of terms used throughout the book:

1. Binge eating: Eating within a 2-hour period of time an amount of food larger than what most people would eat in a similar period of time under similar circumstances and a sense of lack of control over eating during the episode.

2. Binge eating disorder: Recurrent (i.e., >1x weekly for 3 months, on average) binge eating as defined above, coupled with marked distress regarding binge eating and three or more cognitive symptoms (e.g., eating alone out of embarrassment, feeling disgusted/guilty). Importantly, no compensatory behaviors (e.g., purging) are associated with binge eating.

3. Compulsivity: Repetitive behaviors in the face of adverse consequences as well as repetitive behaviors that are inappropriate to a particular situation. Compulsivity has historical roots in the symptoms related to obsessive compulsive disorder, impulse control disorders, and substance-use disorders and may involve engagement in compulsive behaviors to prevent or relieve distress, anxiety, or stress.

4. Compulsive eating: Broadly defined as an irresistible, uncontrollable urge to overeat despite efforts to control this behavior. Compulsive eating behavior manifests as one or more of its constituent elements: habitual overeating, overeating to alleviate a negative emotional state, or overeating despite negative consequences.

5. Food addiction: Eating-related problems assessed by a recently created psychometric measurement tool: the Yale Food Addiction Scale (YFAS). This scale was originally modified in 2009 from the substance-dependence criteria described by the Diagnostic and Statistical Manual (DSM, fourth ed.) and subsequently updated to reflect changes to the substance-use disorder diagnosis in the DSM-5. A diagnosis of food addiction is given when a patient displays clinically significant impairment or distress and meets criteria, such as eating much more than intended and experiencing problems in ability to function because of food. In the updated YFAS, a severity score is calculated based on number of symptoms endorsed (2–3=mild, 4–5=moderate, 6+=severe). Importantly, this emerging but not fully established condition is different from the already well-recognized feeding-related pathologies, and further validation is necessary.

6. Overeating: Consuming an excessive amount of food relative to energy expended.

7. Overweight/obesity: A body mass index ≥25 and ≥30 is considered overweight and obese, respectively, as defined by guidelines set forth by the World Health Organization. Overweight/obesity is neither necessary nor sufficient to characterize compulsive eating.

8. Dopamine: A key neurotransmitter in the basal ganglia, long implicated not only in Parkinson's disease but also in incentive salience. In driving, incentive salience dopamine conveys motivational properties to previously neutral stimuli perpetuating cue and context reward seeking. Dopamine is not a reward neurotransmitter per se. In fact, the midbrain dopamine system neurons decrease firing to repeated presentation of predicted rewards, but it is reactivated by unpredictable rewards. It is critical for the rewarding properties of psychostimulant drugs and through its incentive motivational actions promotes reward seeking in general.

9. Addiction: A chronically relapsing disorder characterized by compulsive drug seeking, loss of control over drug intake, and emergence of a negative emotional state when the drug is removed.

10. Brain reward system: The medial forebrain bundle and its connections historically forms the brain reward system. It supports brain stimulation reward with the lowest currents of all structures in the brain. It is composed of not only ascending monoamine pathways but also prominent descending pathways from the basal forebrain to the midbrain and brainstem. The mesocorticolimbic dopamine pathway projects from the ventral tegmental area and parts of the substantia nigra to the ventral striatum and prefrontal cortex. It is not the reward system per se but contributes to incentive salience (as described above).

About the Cover

On the cover is the painting ‘Cakes and Pies’ by artist Wayne Thiebaud. Wayne Thiebaud was born in 1920 in Mesa, Arizona, USA; shortly thereafter moving to California where he has lived for most of his life. He is widely known for his many colorful works from the 1950-60s—many depicting confections such as pies, ice cream cones, candy, and cakes.

Chapter 1

A history of food addiction

Adrian Meule     Department of Psychology, University of Salzburg, Salzburg, Austria

Abstract

It seems widely accepted that research on food addiction is a new field that emerged in the 21st century because of the obesity pandemic. This chapter will demonstrate that this concept is not new at all. Food was mentioned along with addiction as early as the 19th century. The term eating addiction to describe patients with binge eating was first used in the 1930s. The term food addiction was first used in the 1950s. Throughout the second half of the 20th century, different addiction perspectives on chocolate consumption, anorexia nervosa, bulimia nervosa, binge eating disorder, and obesity were lively discussed. Thus, research on food addiction encompasses a long history with recurring themes that receive renewed interest in recent years.

Keywords

Anorexia nervosa; Binge eating; Bulimia nervosa; Eating addiction; Food addiction; Obesity

A chocolate inebriate has appeared. His addiction has been for three years, and his general health is much impaired, principally the digestion. His only thought night and day is how to get chocolate.

The Quarterly Journal of Inebriety, Volume 12, Issue 4, October 1890 (p. 392)

Introduction

Concepts of diseases and mental disorders are not set in stone. References to drink madness can be found in ancient civilizations and terms such as drunkenness, intemperance, inebriety, dipsomania, or alcoholism were used in the 18th and 19th centuries to describe substance-related addictive disorders (White, 2000). While the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) distinguished between substance abuse and substance dependence (American Psychiatric Association, 1994), this distinction has been repealed in its fifth revision. The DSM-5 now lists several substance use disorders and, for the first time, a non–substance-related addiction: gambling disorder (American Psychiatric Association, 2013).

Similar dynamics can be found in the field of eating disorders. Anorexia nervosa was the first eating disorder included in DSM-I in 1952 and appeared along pica and rumination in DSM-II in 1968 (Dell’Osso et al., 2016). Bulimia nervosa was added to the DSM-III in 1980. The DSM-IV yet again involved some slight changes in the categorization of eating disorders and now—in addition to changes made to the diagnostic criteria for anorexia and bulimia nervosa—the DSM-5 lists pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified eating disorders (e.g., night eating syndrome).

In the light of high prevalence rates of obesity in the past decades, there is an increased interest if certain foods may have an addiction potential and if obese individuals—or at least a subgroup of them—can be considered food-addicted. In fact, it seems widely accepted that food addiction is a relatively new idea that was conceived in the past 20 years to explain the rising obesity prevalence (Davis, Edge, & Gold, 2014; Yau, Gottlieb, Krasna, & Potenza, 2014). Yet, is this alleged new disorder really a new concept in an attempt to explain why nowadays so many people are obese? This chapter will demonstrate that the concept of food addiction actually has a long history and did not arise from the obesity pandemic.

References to addiction in relation to food in the 19th century

In the scientific literature, references to addiction in relation to food have been made as early as the late 19th century. In the first journal of addiction medicine—the Journal of Inebriety (1876–1914)—food was routinely mentioned (Davis & Carter, 2014; Weiner & White, 2007). When describing diseased cravings, for example, Clouston (1890) referred to the stimulating effects of, craving for, and dependence on both food and alcohol (Table 1.1). Similarly, Crothers (1890a) cautions against some stimulating foods when describing how diseases in children with alcoholic ancestors should be treated (Table 1.1). Finally, a case of a chocolate inebriate is mentioned in the journal (Crothers, 1890b), describing his persistent craving for and preoccupation with chocolate as an addiction (Table 1.1).

A description of eating disorders in 1932

Mosche Wulff was a Soviet-Israeli physician and psychoanalyst who lived from 1878 to 1971. In 1932, he published an article in German in the International Journal of Psychoanalysis (Fig. 1.1), in which he describes case studies of five of his patients (Wulff, 1932). I refer interested readers to an article by Stunkard (1990) that provides a short biographical note on Moshe Wulff along with an English translation of some excerpts of his article. In a nutshell, Wulff's case studies include the description of binge eating, including precedent food craving and subsequent feelings of guilt as well as aspects of emotional eating (eating more in response to negative affect, eating less when in a positive mood) and restrained eating (periods of restriction between eating binges). Importantly, he calls the symptomatology of all five cases eating addiction (German: Esssucht) throughout the article and provides an explanation for using this term at the end (Table 1.1).

Food addiction in the 1950s

Following up on Wulff's observations, Hamburger (1951) noted the apparent parallels between recurrent binge eating episodes and gambling or drinking: it is this eating pattern that most readily invites the label ‘addictive’ (Table 1.1). The American physician Theron Randolph (1906–95) first used the term food addiction in the scientific literature in 1956 (Table 1.1). In contrast to modern views that associate addiction with the consumption of highly processed foods (Ifland et al., 2015; Schulte, Avena, & Gearhardt, 2015), however, he noted that most often involved are corn, wheat, coffee, milk, eggs, potatoes, and other frequently eaten foods (Randolph, 1956, p. 221). Although food addiction did not appear in other scientific articles around this time, famous psychiatrist Albert J. Stunkard (1922–2014) noted during a panel discussion in 1959 that the term food addiction was widely used back then (Table 1.1; Hinkle, Knowles, Fischer, & Stunkard, 1959).

Table 1.1

a  This quote is from an editorial for which authorship was not specified and, thus, the editor (T.D. Crothers) is indicated as author here.

b  This article is in German and the quotes have been translated by the author of this chapter. An English translation of some excerpts of this article can be found in Stunkard (1990).

Varying themes in the second half of the 20th century

In 1960, Overeaters Anonymous was founded. This self-help organization is based on the 12-step program of Alcoholics Anonymous and, accordingly, uses an addiction framework for overeating. For example, in contrast to cognitive behavioral therapy, which emphasizes flexible food choices with no forbidden foods (Wilson, 2010), Overeaters Anonymous advocates abstinence from certain foods (Russell-Mayhew, von Ranson, & Masson, 2010). Yet, the term food addiction was only occasionally mentioned in scientific articles in the 1960s and 1970s, primarily in the context of obesity (Table 1.1; Bell, 1960, 1965; Clemis, Shambaugh, & Derlacki, 1966; Swanson & Dinello, 1970; Thorner, 1970).

Figure 1.1 Excerpt from the title page of an article by Mosche Wulff. It reads International Journal of Psychoanalysis; Edited by Sigmund Freud; Volume 18; 1932; Issue 3; On an interesting oral symptom complex and its relationship to addiction; Lecture at the German Psychoanalytical Society, April 12th, 1932; By Mosche Wulff; Berlin.

Notably, however, some cases of bulimia nervosa or binge/purge-subtype anorexia nervosa were described as an addiction in these decades as well (Vandereycken, 1994). For example, Ziolko (1966) presents a case of hyperorexia, which he denotes—similar to Wulff (1932)—as eating addiction (i.e., Esssucht in German). In a report about an expert group discussion about overeating and vomiting, Garrow (1976) notes that one group of subjects with chronic anorexia nervosa exemplify many aspects of addiction; they habitually/constantly ingest and vomit food in large quantities (p. 407).

In the 1980s, the excessive food restriction displayed by individuals with anorexia nervosa was mentioned for the first time in the context of addiction (Scott, 1983). Similarly, Szmukler and Tantam (1984) described anorexia nervosa as an addiction—what they called starvation dependence. For example, they note that patients with anorexia nervosa are dependent on the psychological and possibly physiological effects of starvation. Increased weight loss results from tolerance to starvation necessitating greater restriction of food to obtain the desired effect, and the later development of unpleasant ‘withdrawal’ symptoms on eating. (p. 309). Finally, Marrazzi et al. (Marrazzi et al., 1990; Marrazzi & Luby, 1986) compared anorexic phenomenology with addictive states in their auto-addiction opioid model of chronic anorexia nervosa.

Another approach stemming from an addiction perspective on eating was the examination of addictive personality in individuals with anorexia nervosa, bulimia nervosa, or obesity (Davis & Claridge, 1998; Feldman & Eysenck, 1986; Kayloe, 1993; Leon, Eckert, Teed, & Buchwald, 1979). Several studies compared whether individuals with anorexia nervosa, bulimia nervosa, or obesity scored higher than healthy controls and similar to individuals with tobacco use, alcohol use, or gambling disorder on certain addiction personality questionnaires (de Silva & Eysenck, 1987; Hatsukami, Owen, Pyle, & Mitchell, 1982; Kagan & Albertson, 1986; Leon, Kolotkin, & Korgeski, 1979).

In the 1990s, a particular interest emerged on addiction-like consumption of chocolate. Characteristics of chocolate such as its macronutrient composition, sensory properties, and ingredients such as caffeine and theobromine were discussed as contributors to its addictive-like nature (Bruinsma & Taren, 1999; Patterson, 1993; Rozin, Levine, & Stoess, 1991). Some studies investigated self-identified chocolate addicts (Hetherington & Macdiarmid, 1993; Macdiarmid & Hetherington, 1995; Tuomisto et al., 1999) or examined associations between chocolate addiction and other addictive behaviors (Greenberg, Lewis, & Dodd, 1999; Rozin & Stoess, 1993).

Besides these themes, a variety of different topics were covered in one or few single articles in the 1980s and 1990s. These include discussions of the role of endorphins in terms of an addictive response in obesity (Gold & Sternbach, 1984; Wise, 1981), substance abuse as a metaphor in the treatment of bulimia nervosa (Slive & Young, 1986), a foodaholics group treatment program (Stoltz, 1984), and some unusual case studies of addiction-like carrot consumption ( Kaplan, 1996; Černý; Černý, 1992). Finally, the first critical reviews were published, which scrutinized adopting an addiction framework in the treatment of eating disorders (Bemis, 1985) and questioned the overall food addiction approach based on conceptual and physiological considerations (Rogers & Smit, 2000; Vandereycken, 1990; Wilson, 1991, 2000).

Increased popularity in the 21st century

Increased interest in food addiction in the early 2000s was largely driven by brain imaging studies in humans—particularly in individuals with obesity or binge eating disorder (Volkow, Wang, Fowler, & Telang, 2008)—and by animal models of addiction-like sugar intake (Avena, Rada, & Hoebel, 2008). Besides these lines of research, numerous review articles were published that discussed behavioral, cognitive, and neural parallels between obesity or binge eating disorder and substance dependence and examined whether the diagnostic criteria for substance dependence can be applied to food and eating (e.g., Barry, Clarke, & Petry, 2009; Corsica & Pelchat, 2010; Davis & Carter, 2009; Gearhardt, Corbin, & Brownell, 2009a; Ifland et al., 2009; Pelchat, 2009; Thornley, McRobbie, Eyles, Walker, & Simmons, 2008).

Correspondingly, several approaches were developed to measure addiction-like eating in humans based on translating substance dependence criteria to food and eating (Meule, 2011). For example, Cassin and von Ranson (2007) replaced references to substance by binge eating in the substance dependence module of the structured clinical interview for DSM-IV axis I disorders to diagnose addiction-like eating in individuals with binge eating disorder. Relatedly, Gearhardt, Corbin, and Brownell (2009b) developed the Yale Food Addiction Scale by adapting DSM-IV substance dependence criteria to food and eating. Scoring of this self-report questionnaire allows for a dichotomous classification of the presence or absence of food addiction. It may be because of this uniqueness that the scale turned out to be widely used in the years that followed (Meule & Gearhardt, 2014).

Current developments

In 2013, gambling disorder was the first behavioral addiction that was added as an addictive disorder in addition to substance use disorders in DSM-5. Reflecting this nosological change, researchers have proposed that framing addiction-like eating as a behavioral addiction may be more appropriate than framing it as a substance-related disorder (Hebebrand et al., 2014). This approach has intuitive appeal and, at first glance, seems to resolve some controversies that are inherent in the substance-based food addiction approach. Yet, the eating addiction approach may create more problems than it solves. For example, efforts have been made to develop self-report measures for capturing eating addiction (Ruddock, Christiansen, Halford, & Hardman, 2017). Yet, eating addiction may be in fact even harder to distinguish than food addiction from existing concepts such as binge eating–related disorders (Schulte, Potenza, & Gearhardt, 2018; Vainik & Meule, 2018).

The current state of affairs can be broken down into three different views:

(1) certain foods are regarded as addictive substance(s), and, thus, so-called food addiction represents a substance-related addictive disorder (Ifland et al., 2015; Schulte, Potenza, & Gearhardt, 2017),

(2) it is not possible to identify a specific substance in foods that is addictive (similar to nicotine in tobacco, ethanol in alcoholic beverages, tetrahydrocannabinol in cannabis, etc.), and, thus, so-called eating addiction represents a behavioral addictive disorder (Hebebrand et al., 2014; Ruddock et al., 2017),

(3) neither food addiction nor eating addiction represent valid concepts or—even if they are—they are not necessary (Finlayson, 2017; Rogers, 2017; Ziauddeen & Fletcher, 2013).

While most writings on this topic clearly take up one of these three positions, it has also been argued that the addiction perspective on eating requires a more nuanced view (Fletcher & Kenny, 2018). For example, Lacroix, Tavares, and von Ranson (2018) emphasize that alternative conceptualizations of addictive-like eating may be overlooked when the discussion is framed as a dichotomous debate between food and eating addiction models. Such alternative views include, for example, considering compulsivity as a transdiagnostic construct in both addiction and pathological overeating (Moore, Sabino, Koob, & Cottone, 2017).

Conclusions

Food addiction is not a new idea that emerged in the 21st century because of the obesity pandemic. Instead, researchers have discussed for many decades whether humans can be addicted to certain foods and whether certain eating behaviors represent an addictive behavior. The history of food addiction research involves different perspectives, which range from mentioning food in the context of addiction in the late 19th century, describing binge eating as eating addiction in the 1930s, establishing the term food addiction in the 1950s, acknowledging the addiction-like character of binge eating in individuals with bulimia and binge/purge-subtype anorexia nervosa in the 1960 and 1970s to characterizing the self-starvation of individuals with anorexia nervosa as an addiction in the 1980s, and many more. Thus, research on food addiction encompasses a long history with dynamically changing but recurring themes. These include the types of food involved (e.g., chocolate and other foods), discussions about the appropriateness of a food addiction versus eating addiction rationale, and which type of individuals are involved (e.g., individuals with anorexia nervosa, bulimia nervosa, binge eating disorder, and/or obesity).

In spite of its long history, the food addiction versus eating addiction versus not-an-addiction discussion has developed to a lively debate in recent years. To move the field forward, researchers need to generate—and agree upon—testable predictions, which may include neural mechanisms (Fletcher & Kenny, 2018) or whether the construct of addictive-like eating holds incremental clinical utility over and above existing eating disorder diagnoses (Lacroix et al., 2018). Furthermore, providing an addiction framework in the prevention and treatment of eating disorders and obesity will likely be helpful in some instances but may be unnecessary or even counterproductive in others (Meule, 2019). Therefore, future studies need to systematically examine under which circumstances and for whom an addiction perspective on eating is beneficial for normalizing food intake and reduce eating-related distress.

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Chapter 2

Food addiction prevalence

Development and validation of diagnostic tools

Ashley N. Gearhardt a , Erica M. Schulte, and Emma T. Schiestl     Department of Psychology, University of Michigan, Ann Arbor, MI, United States

Abstract

Food addiction has become a topic of growing scientific and public interest in the past two decades as rates of obesity have continued to rise globally. However, unlike existing substance-use disorders, the consumption of food is necessary for survival, and the highly processed foods that seem to be most associated with addictive-like eating are abundant in the environment without regulation. Thus, one of the central challenges in this line of research is to operationalize a behavioral phenotype of clinically significant addictive-like eating behavior. In the current chapter, we will (1) consider initial approaches to identifying addictive-like eating, (2) discuss the development of the most established measure of food addiction (i.e., Yale Food Addiction Scale) and the prevalence of its diagnostic threshold score, (3) consider an alternative framework for conceptualizing addictive-like eating, and (4) outline future research directions that may advance understanding of the clinical relevance of food addiction.

Keywords

Addiction; Eating disorders; Food addiction; Obesity; Substance-use disorders

There has been a steady increase in both public interest and scientific evaluation of the food addiction concept in the last 20   years (Davis, 2013; Meule, 2015). This has been driven by a number of factors, particularly the global pandemic of obesity that has accompanied the spread of highly rewarding, cheap, and accessible processed foods (e.g., fast food, pastries). Obesity is now a leading cause of preventable death, a major factor in reduced life expectancies, and a contributor to increasing burden on the medical system (Kelly, Yang, Chen, Reynolds, & He, 2008; Mokdad, Marks, Stroup, & Gerberding, 2004; Ng et al., 2014). As the public health consequences of excess body weight have become more apparent, basic science has identified striking parallels between the biopsychosocial mechanisms underpinning addictive disorders and excess food consumption (Ahmed, Guillem, & Vandaele, 2013; Avena, Rada, & Hoebel, 2008; Johnson & Kenny, 2010; Parylak, Koob, & Zorrilla, 2011), such as dysfunction in reward, motivation, stress, and inhibitory control systems. This has led to the hypothesis that an addictive process may be contributing to overeating, for at least a subset of individuals (Gold, Frost-Pineda, & Jacobs, 2003; Gold, Graham, Cocores, & Nixon, 2009). Given that food consumption is necessary for survival and eating past satiety is a relatively common occurrence, one of the challenges of this emerging research is how best to assess and determine the prevalence of clinically relevant food addiction. In the current chapter, we will (1) consider initial approaches to identifying addictive-like eating, (2) discuss the development of the most established measure of food addiction (i.e., Yale Food Addiction Scale (YFAS)) and the prevalence of its diagnostic threshold score, (3) consider an alternative framework for conceptualizing addictive-like eating, and (4) outline future research directions that may advance understanding of the clinical relevance of food addiction.

Early approaches to identifying food addiction

To survive in times of famine, humans have evolved to find certain tastes (e.g., sweetness associated with sugar) or mouthfeel (e.g., creaminess associated with fat content) that reflect high calorie content especially rewarding (Lieberman, 2006). For much of human history, these rewarding signals from food were confined to naturally occurring foods, such as fruits or nuts. Over time, human ingenuity allowed for the creation of new food products, such as chocolates and cakes, which contained artificially high levels of rewarding ingredients such as sugar and fat. The idea that these highly rewarding foods (e.g., chocolate) could be eaten in an addictive way has been present since the 1800s (Meule, 2015), but access to large quantities of highly rewarding foods was often restricted to affluent individuals, as ingredients such as sugar were expensive (Mintz, 1986). Over time, with changes in food science and economic policy, highly rewarding foods are no longer a rare treat but now dominate the modern food environment. Highly processed foods that have artificially high levels of refined carbohydrates (e.g., sugar, white flour) and fat (e.g., pizza, chocolate, chips) are easily accessible, inexpensive, and heavily marketed (Monteiro, Levy, Claro, de Castro, & Cannon, 2010). As these highly processed foods have become more integrated into the food environment around the globe, rates of obesity (particularly severe obesity), overeating, and diet-related disease have soon followed (Monteiro, Moubarac, Cannon, Ng, & Popkin, 2013).

Parallels between highly processed foods and drugs of abuse suggest that an addictive process may be contributing to the widespread overconsumption of these foods. The strongest evidence for this has been observed in basic science models, where exposure to highly processed foods has been related to both biological and behavioral indicators of addiction. Animals exposed to highly processed foods (e.g., cheesecake, Oreo cookies) have exhibited neurobiological (e.g., dysfunction in the mesolimbic dopamine system) and behavioral changes (e.g., binge behavior, heightened motivational drive) that are consistent with addiction (Avena et al., 2008; Johnson & Kenny, 2010; Oginsky, Goforth, Nobile, Lopez-Santiago, & Ferrario, 2016; Oswald, Murdaugh, King, & Boggiano, 2011; Parylak et al., 2011). Animal models have also demonstrated that the consumption of highly processed foods leads to changes indicative of the dark side of addiction by increasing the likelihood that these animals will experience negative affective states (e.g., anhedonia, anxiety) (Parylak et al., 2011). This enhances motivation to consume these foods in an effort to both reduce negative emotional states and avoid withdrawal-like states when access to these foods is limited (Parylak et al., 2011). Furthermore, a common ingredient in highly processed foods, sugar, appears to be such a powerful reinforcer that animals will overwhelmingly choose access to it over drugs of abuse (e.g., cocaine), even if they are exhibiting signs of dependence to the drug (Ahmed et al., 2013). Thus, in animals, these palatable, rewarding, and highly processed foods appear to have a notable addictive potential.

In humans, obesity has been associated with neural responses implicated in addiction. For example, obesity has been related to dysfunction in the mesolimbic dopamine systems, also observed in addiction (Volkow, Wang, Fowler, & Telang, 2008). Both obesity and addiction have also been associated with problems related to cue reactivity, habit learning, self-control, stress reactivity, and interoceptive awareness (Volkow, Wang, Tomasi, & Baler, 2013). However, there are concerns with using obesity as a proxy for addiction. Obesity is a medical condition that can result from a number of factors, including physical inactivity, medication side effects, and genetic conditions (Grundy, 1998). Although obesity can reflect elevated intake of highly caloric foods (Rosenheck, 2008), excess consumption is not necessarily indicative of addiction. For example, 40% of college students binge drink (O'Malley & Johnston, 2002), but only 6% meet criteria for alcohol dependence (Knight et al., 2002). Additionally, individuals who have an addictive-like relationship with food may be able to engage in behaviors (e.g., fasting, purging, excessive exercising) that may lead to a body mass index (BMI) in the normal range (Meule, 2012). Thus, the use of obesity as a proxy for food addiction may both over- and underidentify a phenotype consistent with an addictive response to highly processed foods. Furthermore, there have been other conceptualizations of addictive-like eating that have not relied on BMI but instead on self-identification as a chocoholic or carb craver (Spring et al., 2008; Tuomisto et al., 1999). However, these self-identified labels have not included an assessment of behavioral symptoms of addiction and thus may represent a strong desire for a certain food type rather than the construct of addiction as defined by the medical and scientific community.

Yale Food Addiction Scale

Given the lack of a standardized definition of food addiction, the original YFAS was developed in 2009 (Gearhardt, Corbin, & Brownell, 2009). The YFAS applied the Diagnostic and Statistical Manual of Mental Disorder (DSM) IV diagnostic criteria for substance dependence (e.g., loss of control, continued use despite negative consequences, withdrawal, tolerance) to the consumption of highly processed foods (e.g., chocolate, pizza) (see Table 2.1 for DSM-IV and DSM-5 diagnostic criteria) (American Psychiatric Association, 2000). The resulting 25-item measure has been found to be psychometrically sound demonstrating internal consistency, test–retest reliability, convergent, discriminant, incremental, and predictive utility (Meule & Gearhardt, 2014). The YFAS provides two scoring options: (1) a continuous symptom count that ranges from zero to seven symptoms met