Friday, 18 May 2012
Food Addiction Vs. Compulsive Eating: The Meaning Of Overeating:
The statement I often hear that overweight people surely must be “addicted to food” is contentious and offensive.
In 2004 and subsequently in 2006, two separate NICE guidance processes, one on eating disorders and one on obesity attempted to make sense of what psychologists describe as dysregulated and disinhibited eating. Whether this eating results in weight gain depends on the restraint that a person exerts in between episodes of overeating, or the use of compensatory behaviours such as purging which accompany overeating.
Sufferers speak about irresistible drives to eat any food or certain food types such as chocolate - in the context of cravings, low mood states, excitement and a sense that their behaviour is somehow wrong / abnormal. It seems apt to apply the label “addiction” to the behaviour and its motivations because there are many shared features between substance abuse and overeating. These shared features include ways in which “using food or drugs” brings about mood relief, tolerance, withdrawal symptoms, and the activation of similar neural networks, particularly in reward centres in the brain.
Sufferers also describe their experience in the language of addiction such as “I can’t get on with things unless I have my fix”. Or, “It’s like I’m addicted to food, I wish I could just take it or leave it, but it’s never enough.”
The reason why terms such as food addiction, chocolate addiction, binge eating disorder, comfort eating and compulsive eating are used inconsistently in scientific literature are because they are not diagnostic categories. They are simply our attempts to put labels on a rich diversity in human experience and behaviour, which have different meanings to different people (1). They are useful labels because they legitimize the individual’s search for treatment for eating behaviour which they consider at least, uncomfortable and at worse, insane.
For this reason, it is dangerous and incorrect to label the uninhibited eater simply as an “addict”. There is evidence for example, (based on pre load studies with ice cream), that the eating patterns of so-called addicts is motivated more by beliefs about what they have eaten rather than the foods themselves (2). Moreover, the label “addict” is often disempowering, suggesting that you are emotionally sick, with the ever-present danger of relapse. While it is true that there is a poor record of weight loss maintenance in anyone irrespective of where they start from, there are evidence based psychological treatments of “compulsive eating” which have a good and enduring outcome (3). These treatments don’t necessarily lead to losing weight.
Ignoring for the moment the question “what is a binge?”, evidence supports the view that among obese binge eaters there is a greater than average risk of the following; history of trauma, psychiatric illness, mood disorders, history of alcohol abuse, avoidant, dependent and borderline personality disorder (4). But don’t assume that this is true for all obese binge eaters, many of who just got into bad habits, enabled in part by the people who live with them. Or alternatively there are sufferers who have not learned how to manage stress.
So this is why labelling overeaters or even compulsive eaters as “addicts” is nonsense. Careful assessment will pick out factors that may interfere with treatment for weight control. Then, using techniques such as cognitive therapy to deal with the obesity mindset, emotional resilience training, mindfulness work, trauma counselling for some people and nutritional rehabilitation, we can package together a treatment which will help even the most disinhibited of overeaters – often quickly. They will stop bingeing and they will be able to eat their forbidden foods without danger of relapse.
Personally speaking, I have found it helpful to say to my clients “I refuse to call you an addict – you simply have some things to learn which will help you to manage your life differently.”
I would only start thinking about addiction if my overeater also has existing substance abuse problems or a history of them. For sure, there are aspects of 12 step programmes which are useful for anyone with a mental health problem to help with things like self worth and forgiveness, getting help from others and taking an inventory of all ones difficulties. But first and foremost I would turn to cognitive –emotional behaviour therapy for my overeaters(5).
Do we not owe it to our clients to “label” them as potentially normal as the rest of us?
HERE ARE SOME REFERENCES FOR STUDENTS
1 Fitzgibbon and Kirschenbaum (1999). Heterogeneity of clinical presentation among obese individuals seeking treatment. Addictive Behaviours 15, 291-295
2 Wilson T. (1993). Binge Eating And Addictive Disorders, in Binge Eating, Nature Assessment and Treatment. Eds Fairburn, C. and Wilson, T. Guildford Press.
3 Gladis, Wadden et al. (1998). Behavioural treatment of obese binge eaters, do they need different care? Journal of Psychosomatic Research 44 375-384.
4 Yanovski, Nelson, Dubbert & Spitzer (1993). Association of Binge Eating Disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry December (12):1910
5 Smith, Marcus & Kaye (1992). Cognitive behavioural treatment of obese binge eaters. International Journal of Eating Disorders 12, 257-262