Food addiction: 'An area of ongoing scientific investigation'

Key takeaways

• A recent poll found that 13% of adults aged 50 to 80 years showed signs of addiction to highly processed foods.
• One expert said it is important to recognize and treat food addiction. Another said that the idea stems from a lack of understanding how the brain regulates weight.

Addiction to highly processed foods can lead to adverse health outcomes, but little is understood about why some patients show a higher propensity for these foods and how to manage the condition in a primary care setting.

Recently, a survey conducted by the University of Michigan National Poll on Healthy Aging showed that 13% of U.S. adults aged 50 to 80 years met criteria of addiction to highly processed foods over the past year.

Researchers additionally found that even more — 44% — had at least one symptom of food addiction and that mental health seemed to be a factor; those who rated their mental health as fair or poor were three times more likely to meet food addiction criteria than those who rated their mental health as good, very good or excellent.

The most common symptoms were intense cravings at least once a week, which 24% of participants reported, an inability to cut down on intake despite a desire to do so at least two to three times a week, which 19% reported, and signs of withdrawal at least once a week, which 17% reported.

Jeffrey T. Kullgren, MD, MS, MPH, director of the National Poll on Healthy Aging and associate professor of internal medicine at the University of Michigan, told Healio that food addiction is an important and increasingly recognized issue because of the possible adverse health outcomes it can cause.

“We know that higher levels of consumption of highly processed foods can lead to a host of downstream health problems,” he said. “This is why we wanted to study just how common it was for older adults to have difficulty with moderating or constraining their consumption of highly processed foods, so that we can see how common that problem is and identify solutions to help them with this issue.”

However, the concept of food addiction is not universally accepted.

Fatima Cody Stanford, MD, MPH, MPA, MBA, FAAP, FACP, FAHA, FAMWA, FTOS, an obesity medicine physician and associate professor of medicine and pediatrics at Harvard Medical School and director of Diversity & Inclusion of the Nutrition Obesity Research Center at Harvard, said she is “not a huge fan of this concept of food addiction.”

“I believe that this idea ... comes from our lack of understanding of the pathophysiology of how the brain regulates weight and desires for food,” she said. “While we have organizations dedicated to food addiction, much like we have for opioid or alcohol use disorder, food is something unlike those things in that ... we all have to eat.”

Stanford acknowledged that some people have a higher propensity for consuming highly processed food and experience problems with a sense of fullness, but she believes these things are “part of the biology, as opposed to food addiction in and of itself.”

The science

Food addiction is being increasingly studied, and there are arguments for and against its validity. The diagnosis of food addiction is not formally recognized in the DSM-5, but research has suggested that the criteria for substance use disorders could be transferred to food addiction.

A 2019 study published in Nutrients found evidence indicating some similarities between addictive characteristics of food and illicit drugs, including control and reward pathways in the brain and behaviors like craving and impulsivity. The researchers reported that there are differences but “many parallels that should not be ignored.”

A more recent systematic literature review published in Appetite revealed evidence connecting symptoms of food addiction to hormones and blood biomarkers related to stress, feeding and addiction. The researchers of this study noted significant findings for cholecystokinin (CCK), cortisol, ghrelin, leptin, insulin and glucose, oxytocin and more.

Both studies called for more research and noted that food addiction is likely to remain a hot topic of debate until more conclusive evidence is found.

Kullgren said it seems that some people might be more susceptible to food addiction; he cited findings from the National Poll on Healthy Aging that showed differences in the prevalence of food addiction around age, physical health status, gender, mental health status and more.

The science behind food addiction “is an area of ongoing scientific investigation,” but it is likely that there is some overlap between the mechanisms that underlie addiction to other substances and those for addiction to highly processed foods, he said.

“We know that addiction to a range of substances — whether we're talking about alcohol or tobacco, or, in this case, sugar-sweetened beverages or highly processed foods — addiction to any particular substance shares some common pathways in the brain,” he said. “There’s ongoing research to better delineate some of these pathways and to identify ways in which they are similar ... and areas in which the pathways may differ somewhat.”

Kullgren also noted that a better understanding of the pathways for addiction to highly processed food “will hopefully allow us to, in the future, develop new treatments for this issue.”

Stanford said that hormones could affect hunger and the tendency to consume highly processed and palatable foods. If a patient has high levels of ghrelin, for example, they will be hungry constantly, she said. If patients have high levels of CCK, on the other hand, they will be full very quickly.

At the touch of a button, she added, she can order anything to be delivered to her doorstep or walk outside and find a fast-food restaurant, “but something about my brain doesn’t tell me that that’s desirable.” A lot of that, she said, “has to do with how my brain signals and what my body desires and what it does not desire.”

“When I'm treating patients who come in and tell me, ‘I have a food addiction,’ and I treat them with a therapy that changes their brain’s regulation, then they no longer have a food addiction,” Stanford said. “It's because I'm treating the biology that’s causing them to think that this is part of their issue, as opposed to recognizing that it’s part of their biology influenced by the environment that we live in.”

Screening

Kullgren said he hopes to be able to adapt some of the measures used in the survey to help primary care providers identify patients who might be more affected by food addiction, like the Yale Food Addiction Scale, a validated scale that researchers have been using and refining over time.

The scale uses several questions related to urges to consume highly processed food, trying and failing to cut down on highly processed foods, other disruptions to one’s life from consumption of highly processed foods and more.

“This is a scale that is used for research purposes to identify addiction to highly processed foods and can also be adapted for primary care settings so as to identify patients who may be wrestling with this problem, and hopefully directing them to resources that can help them with behavioral change,” Kullgren said.

In terms of who should be screened and how often, Kullgren said “that is a really important area for future research,” but there is no good answer to that question yet.

Stanford said that she screens patients by asking how hungry patients are between meals and how much it takes for them to feel full.

“[Patients will] tell you ... ‘I get a small plate out, and then I go for a second and third of that,’” Stanford said. “By the time they’ve done all that, they’ve already gotten to a large plus plate, but they needed that to feel full. Then I know that whatever I'm doing isn’t working enough and I need to do something else to help them.”

Management

When it comes to managing food addiction, Kullgren said that “it’s important to recognize from our study some of the patient populations that were more likely to be affected by food addiction.”

“We found food addiction to be more prevalent among certain patient subgroups, and that's an area that I think is especially relevant for primary care physicians to understand who might be most affected by this issue so that certain patient populations could be prioritized for improving, for example, mental health or trying to improve physical health so as to hopefully make it easier for those patients to then also work on their food addiction in parallel,” he said.

However, he also noted that behavioral health professionals can help engage patients in behavior changes.

“Often, trained behavioral health professionals can help identify what might be some of the drivers of health behavior challenges that patients are facing and can work longitudinally with patients to develop and then refine plans that will help patients successfully engage in behavior change,” Kullgren said. “I think addiction to highly processed food is likely to be an area where behavioral health professionals may be able to provide effective services to support patients and behavior change.”

When asked if food addiction could be managed in a primary care setting, Stanford said “yes and no,” depending on if the provider sought additional education on obesity.

“There is no standardization regarding teaching about obesity,” she said. “It’s the biggest chronic disease in human history, but it’s not required education. I would love for this to be in the hands of primary care, but very few have been exposed to any education to share this and treat their patients.”

As an obesity medicine physician, Stanford said that, in targeting obesity, she could subsequently treat multiple chronic diseases, especially if she sees a patient sooner rather than later.

“If you've labeled yourself as ‘a food addict,’ it's probably that you just haven’t gotten the right level of care, and there are those of us who are willing and able to help,” she said.

Stanford said that “there are different buckets of treatment” for what may be labelled as food addiction: lifestyle modifications, pharmacology and surgical interventions.

“It’s very complex,” she said. “It makes my work with patients not an easy job, but it also makes it very rewarding when I’m able to help them succeed.”

Lifestyle interventions may focus on sleep management, exercise — including strengthening activities, cardio, mindfulness and flexibility activities — or nutrition. Specifically, Stanford said she asks patients to eat lean protein, whole grains, fruits and vegetables. She also said that some medications could influence different brain pathways and their chemistry — inhibiting norepinephrine reuptake, for example — and can help mitigate obesity.

“Often, you — the person who has had this label — has assumed it’s all on you, something you have to do to help yourself be better,” she said. “I would say, why not share that responsibility with those of us who treat individuals who struggle? I think that that’s going to be the best strategy to take for the longest-term success.”

References:

• Adams RC, et al. Nutrients. 2019;doi:10.3390/nu11092086.
• Addiction to highly processed food among older adults. https://www.healthyagingpoll.org/reports-more/report/addiction-highly-processed-food-among-older-adults. Published Jan. 30, 2023. Accessed Jan. 30, 2023.
• Romer SS, et al. Appetite. 2023;doi:10.1016/j.appet.2023.106475.