WHAT IS FOOD ADDICTION?
By H. Theresa Wright, MS, RD, LDN and Joan Ifland, PhD
Originally published by the Academy of Nutrition and Dietetics (Dietetic Practice Group, Behavioral Health Nutrition).
Sixty-five percent of Americans are overweight or obese, and obesity causes or contributes to increased risk of numerous chronic diseases such as diabetes, obesity, hypertension and cardiovascular disease. This paper offers potential insight into the problem by describing a new approach to understanding it, i.e. that some overeating is an addiction.
The phrase ‘food addiction’ is coming into popular use. However, no paper has attempted to define food addiction in classic drug addiction terms according to current addiction diagnostic criteria. The goal of this paper is to fill that gap by defining food addiction through the behaviors described in current American Psychiatric Association (APA) addiction diagnostic criteria, as well as addictive brain dysfunctions found in overeaters.
In addition to describing a definition of food addiction, the paper briefly discusses the specific foods used addictively based on research and clinical observations. The Conclusion covers the implications of food addiction as an explanation for the overeating epidemic, and the need for understanding addiction in managing obesity and some eating disorders
The limitations of this paper are several. This paper does not cover assessment of the severity of food addiction, treatment, causes of food addiction, vulnerable populations, genetics, scope of the field of research nor research techniques. Nor does the paper offer evidence that food addiction exists as that has been done elsewhere. Readers can also find an extensive description of consequences elsewhere.
Before the advent of brain imaging research techniques, definitions of addiction were made through descriptions of patterns of behaviors. Starting in the 1950’s, the APA played a key role in the development of definitions of addictive behaviors through publication of addiction diagnostic criteria in its Diagnostic and Statistical Manual of Mental Disorders (DSM). The drug and alcohol addiction diagnostic criteria are developed by committees of experts in lengthy discussions over years. The criteria are periodically revised. 
Can some food use fit these drug addiction criteria? Let’s look at the DSM V, and its criteria for substance dependence. In 2013, the DSM V revised the criteria for substance use disorders; there are now eleven symptoms. This paper uses the DSM-V criteria to define food addiction as they are considered to be the ‘gold standard’ for diagnosing addictions.
Brain imaging technology introduced in the 1990’s gave insight into the origins of addictive behaviors. With scanning technology such as Magnetic Resonance Imaging (MRI) and Positron Emission Topography (PET), addictions could be defined as the presence of specific dysfunctions in the brain. These dysfunctions suggest that over-activation of cravings pathways in concert with deactivation of inhibition and decision-making centers could explain irrational addictive and overeating behavior that is otherwise difficult to understand.
By combining the APA’s work in developing addiction diagnostic criteria and with the neuro-researchers’ work in exposing the underlying brain dysfunctions; we now have a good understanding of the ‘how and why’ of addictions . These large bodies of research make it possible for us to describe food addiction with confidence. As seen below, findings developed to describe addictions apply readily to overeating.
Although a thorough discussion of addictive foods is beyond the scope of this paper, a short description of these foods helps to orient the reader to the below discussion. Addictive foods are identified by the presence of psychotropic ingredients, by neuro-responses in brain imaging research, by clinical and 12 Step observations of loss of control in use of these foods, and by animal studies showing addictive behavior in use of these foods.
The addictive properties of sugar are perhaps the most studied. Rats will choose sugar, high fructose corn syrup, and saccharine over cocaine and heroin. Rats have shown a withdrawal syndrome similar to that of morphine . Sugar activates the dopamine pathway.  Food addiction recovery groups often recommend abstinence from sugar and sweeteners. 
Gluten and flour made from gluten-grains contains a gluteomorphine that appears to activate the opiate pathways . Recovery groups often recommend eliminating wheat and flour. Salt has been observed to be used by morphine addicts in withdrawal, presumably as a replacement for morphine.  Processed fat appears to activate the opiate pathways in the brain.  Dairy contains a casomorphine which has been shown to create a numbing effect in rats.  Caffeine has intoxication and withdrawal diagnoses in the DSM-V.  These would all be classified as addictive or “trigger foods.”
Further, the Overeaters Anonymous pamphlet, Dignity of Choice, defines trigger foods in this way:
“Trigger” or “binge” foods are foods that we eat in large quantities or to the exclusion of other foods; foods that we hoard or hide from others; foods that we eat secretly; foods that we turn to in times of celebration, sorrow, or boredom; or foods that are high in calories and low in nutritional value. In addition, we look to see whether there are any common ingredients among those foods – like sugar or fat – that might exist in other foods we haven’t listed.
Each of us may have problems with different foods or ingredients. If a food has been a binge food in the past, or if it contains ingredients that have been binge foods for us, we remove it from our plan…. Extra servings of a non-trigger food might create cravings. If we are unsure whether or not a food causes problems for us, we leave it out at first. Later, with abstinence, the correct answer becomes clear.” 
Thus we see that there are similarities between the foods avoided in 12 Step eating recovery groups and those found to have addictive properties in the research literature. Abstinence from these foods has been seen to reduce cravings and help establish control over eating.
THE DSM-V ADDICTION DIAGNOSTIC CRITERIA AS APPLIED TO OVEREATING
In 2013, the APA published 11 addiction diagnostic criteria in its DSM-V. A person needs to meet two to three criteria for a diagnosis of mild addiction; four to five for moderately addicted; and six or more for severely addicted. For the purposes of this article, the words, ‘processed food’ are used as the addictive substance. Citations are provided to support clinical observations by referring to research that describes the behaviors in overweight populations.
Here are examples of how these diagnostic criteria are described in paraphrased quotes from overeating clients.
- “Processed food is often taken in larger amounts or over a longer period than was intended.” This criteria is reported in studies as the tendency to regain lost weight, presumably in a pattern of unintended overeating. 
I started by promising myself I’d only have three cookies, but before I knew it, I had eaten the whole bag.
I always feel like I have to have more no matter what I’ve promised myself!
- “There is a persistent desire or unsuccessful efforts to cut down or control processed food use.” This behavior is seen in studies as an inability to lose weight. 
I have tried every diet out there – Atkins, Medifast, Jenny Craig, you name it. I do good for a while and then I just can’t stand it and go back to my old ways.
I know I need to change my eating and eat less junk food, but some days I just can’t stop!
- “A great deal of time is spent in activities necessary to obtain processed food, use processed food, or recover from its effects.” Food addicts report spending time too tired to exercise or do anything but watch television. This behavior is found in the overweight research. 
I plan my day so there is plenty of time to stop at a number of fast food outlets on the way home. Then I eat dinner, too. Then I’m too tired to do anything.
I have food hidden everywhere; I am constantly watching to make sure I have enough.
- “Craving, or a strong desire or urge to use processed food.” Research shows a relationship between cravings responses and BMI. 
I spent the whole day just thinking about the doughnuts. I couldn’t focus on my work. I finally decided to go eat them just to get them out of my head.
As soon as I finish one meal, I start thinking about the next. I think about food all the time.
I was so angry with my spouse, but oddly, all I could think of was potato chips.
- “Recurrent processed food use resulting in a failure to fulfill major role obligations at work, school, or home.” Lower productivity among the obese is established in the research literature. 
I am too tired from eating processed foods to play with my kids in the evening.
I miss a lot of work going to doctor’s appointments. I wish I could just clean up my diet and improve my health but I always fail.
My performance at work is declining. I spend all day going back and forth to the break-room and vending machines. I never get anything accomplished.
- “Continued processed food use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of processed food.” Weight gain is documented in non-supportive marriages. 
My husband wants me to get the fattening foods out of the house and away from our overweight kids. He wants me to lose weight. We fight about it but I love sweets and bread and I love giving them to our kids. It may cost me my marriage.
- “Important social, occupational, or recreational activities are given up or reduced because of processed food use.” Isolation has been documented in the obese.  and human resource managers are seen to discriminate against the obese. 
I’ve given up applying for promotions. I’m too depressed. I would feel better if I could improve my diet but I can’t give up my ‘comfort’ foods.
I don’t like to eat out with friends and family anymore because I’m afraid I’ll lose control and start eating too much. I know I’m isolating but I don’t care.
The only friends I have are characters on TV. They don’t bug me about my weight. Outside of work, I’m spending my life lying on the couch, eating and watching TV.
I don’t exercise because I don’t want to put on the tight workout clothes. I’m so ashamed of myself.
- “Recurrent processed food use in situations in which it is physically hazardous.” Eating is the most common distraction while driving. 
I got pulled over for missing a stop sign! I was eating the pizza on the way home and I did not notice the stop sign or the police car behind me. I’m oblivious when I’m eating in the car.
Drive-thru fast food means I pull out onto the street driving with no hands because I’m frantically digging out the fries and catsup.
- “Processed food use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by processed food.” Research shows non-compliance with diet in diabetics, for example. 
My doctor just diagnosed me with diabetes. He says I need to lose weight and start taking care of myself. I know this, but I just can’t seem to do it.
My blood pressure and cholesterol are really high. They wanted me to lower them with diet, but I keep falling off the wagon.
- “Tolerance, as defined by either of the following:
A need for markedly increased amounts of processed food to achieve intoxication or desired effect.” The evidence for this phenomenon in overeaters comes from brain imaging research that shows the down-regulation of dopamine receptor fields characteristic of tolerance. 
Once I start with ice cream, I cannot stop! It never feels like enough! I used to be satisfied with a few spoonfuls!
From one bag of chips and dip to a jar of peanuts, a bag of pretzels, and then a few bars of chocolate… I can’t stop till I’m so stuffed I can’t move! I never used to do this.
Or, “A markedly diminished effect with continued use of the same amount of processed food.”
With my coffee drinks, I never know what will be enough anymore – sometimes it’s only a little; sometimes it takes a lot.
One soda used to be enough to get me through the afternoon. Now I’m crashing before the afternoon is over.
- “Withdrawal, as manifested by either of the following:” A morphine-like withdrawal from sugar has been observed in rats  and caffeine withdrawal is described in the DSM-V 
“The characteristic withdrawal syndrome for the processed food.”
When I’m trying to cut-back on junk food, the cravings seem to intensify.
After I binge, I wake up groggy and miserable, so the next day is ruined, too.
“Processed food is taken to relieve or avoid withdrawal symptoms.”
If I stop eating sweets and bread for a few days, I am anxious and irritable, and sometimes I even feel like I have the shakes. I start eating sweets again to feel better.
It got so when I tried to diet, I would become lightheaded, forgetful, restless, and unable to concentrate. I would fall off the diet because I was so miserable.
As these quotes and citations show, there are observations and studies of loss of control over processed foods that meet the DSM-V criteria for the diagnosis of an addiction. Although processed foods are quite different from drugs and alcohol as they are perceived and used in our culture, nonetheless the eating patterns that result from their use are similar to addictive behavior.
ADDICTIVE NEURO-DYSFUNCTION AS SEEN IN OVEREATERS
Scientists have noticed for several decades that the brains of overeaters show altered functioning similar to the brains of drug addicts. [26, 27] These observations are based on a growing body of research literature generated from brain imagining studies designed to understand addictions as well as overeating. This research is important because it supports the definition of overeating as an addiction.
The addiction-like changes found in the brains of overeaters are as follows:
- Over-active addictive pathways. These pathways are also known as the pleasure or craving pathways and include serotonin, dopamine, opiate, endorphin, and endocannabinoid. In overeaters, these pathways over-secrete craving neurotransmitters.  This ‘flooding’ of addictive neurotransmitters appears to produce intense cravings that are associated with loss of control.
- Sensitivity to triggers. In overeaters, very slight stimulation can trigger the overproduction of craving neurotransmitters. Researchers have seen that just thinking about a processed food product can produce the flooding of neurotransmitters. 
- Conditioned, learned, or Pavlovian responses. The craving response of overeaters, like those of addicts, can be subject to conditioning.  Just as Pavlov conditioned the saliva glands of dogs to activate at the ringing of a bell without the presence of food, addictive neuro-pathways can also be conditioned to activate even when processed foods are not present. This means that a place, person, thing, event or time associated with consumption of processed foods can trigger cravings without the presence of processed food.
- Non-functioning cognitive centers. During a flooding of addictive craving neurotransmitters, the decision-making, memory and learning centers in the brain cease to function.  This may ‘explain’ many of the behaviors seen in the APA’s addiction diagnostic criteria. At the moment of flooding, people are not able to remember consequences nor make good decisions.
- Non-functioning inhibition center. The flooding has also been observed to coincide with ‘shut-down’ of the inhibition center.  This is interpreted as a loss of control, and may contribute to the unintended use described in the APA’s addiction diagnostic criteria.
- Down-regulated receptor fields. In order for the pleasure neurotransmitter to complete its circuit, it must ‘hit’ or ‘dock on’ a transmitter receptor. In addicts and overeaters, these receptor fields are down-regulated or ‘shut-down.’ The theory is that as over-use and overexposure to stimulation bombard these receptors, they down-regulate. The person then increases consumption in an attempt to reestablish the level of pleasurable feeling they once had when the receptors were open. This may explain the phenomenon of tolerance.
- Activation by stress. The addictive pathways are activated by stress in overeaters. 
This body of research is important evidence for overeating as an addiction to processed foods.
WHAT FOOD ADDICTION IS NOT
Food addiction is not binge eating just as binge drinking is not alcoholism. However, binge eating may be present in food addiction. Food addiction is not emotional eating just as alcoholism is not emotional drinking; rather, it is a substance-based addiction. Even ‘food addiction’ is not well-named. It should be ‘Processed Food Addiction’ as there is little evidence for addiction to non-processed foods.
A very important distinction must be made between a substance-based addiction and a behavioral addiction. Food addiction has been discussed as a behavioral syndrome. However, this is not consistent with neuro-imaging research nor clinical observations of the role of specific processed foods in addictive eating behavior. Approaching food addiction as a problem of behavior leads to a confusing dead end in terms of treatment, because we can’t become abstinent from the behavior of eating.
However, framing overeating as loss of control over specific foods opens the door to treatment success because, while we have to eat, we don’t have to eat the foods that trigger the addiction. We are now in the familiar territory of recovery from alcoholism. Yes, we have to drink, but we don’t have to drink alcohol. The ‘substance’ approach is well-supported by both research and clinical experience. Under this approach, food addiction is being defined as a syndrome of addiction to substances in the same category as alcohol and drug addiction; and not as a behavioral addiction such as shopping, sex or gambling.
Understanding addiction to certain foods may be helpful in managing the obesity epidemic. If overeating is, in fact, an addiction to processed foods, that could explain why weight-loss treatment approaches that involve continued use of addictive foods have sometimes been unsuccessful. Although extensive 12 Step Groups use abstinence protocols on a lay basis, health professionals need to become comfortable with assessing and treating food addiction through similar abstinence protocols. Given the dire nature of the obesity epidemic, such commitment would seem warrented.
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