Robert Rymowicz, DO, was scheduled to present a session on food addiction at this year’s American Psychiatric Association (APA) Annual Meeting. In this video, he discusses the clinical importance of the topic, how highly processed foods affect the brain, and treatment strategies for the condition.
Dr. Rymowicz is a chief resident in psychiatry at the Rutgers New Jersey Medical School in Newark. He studied medicine at Western University of Health Science in Pomona, California. As a resident, Dr. Rymowicz was selected as a 2016 Ruth Fox Scholar by the American Society of Addiction Medicine, as a 2019-2021 American Psychiatric Association (APA) Foundation Leadership Fellow, where he serves on the Council on Addiction Psychiatry, and as a trainee representative to the board of directors of the American Academy of Addiction Psychiatry (AAAP) for 2020-2022. Following residency, he will begin fellowship training in addiction psychiatry at the University of California, Los Angeles (UCLA), where he hopes to focus on food addiction and gambling.
Read the transcript:
Hello, I'm Robert Rymowicz. I'm the chief resident in psychiatry at Rutgers New Jersey Medical School in Newark, New Jersey. In July, I'll be beginning addiction psychiatry fellowship training at UCLA.
We chose to discuss food addiction because it's a topic that ought to be of tremendous interest to psychiatrists, yet it's seldom discussed. Research has increased significantly over the past 2 decades. Our goal was to introduce this concept to the community at large in the hopes of promoting a wider conversation.
Food can be a source of tremendous pleasure but also tremendous distress. The modern world is an obesogenic environment. Historically speaking, obesity hasn't been that much of an issue nor has overeating, in large part because foods were either too scarce or not sufficiently palatable.
Nutrient deficiencies are now rare, but healthy eating requires people to exert some conscious effort with regards to their food choices and quantity selection. The average restaurant meal or the average portion size for take‑home foods can tend to be far more than what we need for our less than active lifestyles.
It's common knowledge that overly eating leads to an increase in body fat. Most dieting is motivated by distress or dysphoria or just displeasure over body image. The weight loss industry is said to be worth more than $70 billion a year.
Addressing body image issues alone won't address the fact that there's really no doubt that it may be beneficial for certain individuals to maintain certain body types for societal reasons, including employment opportunities and partner selection, or the fact that a loss of control with regards to foods and eating is a real problem.
It's also true that there are real health benefits to following a healthy diet, with obesity being the second leading cause of death in America. An appreciation of food addiction will help psychiatrists to recognize this very common problem and ideally help their patients lead more fulfilling lives.
How is food addiction different from eating addiction?
This isn't necessarily a distinction between food addiction and eating addiction as the 2 terms are used interchangeably. Both refer to a disorder characterized by frequent episodes of eating accompanied by a loss of control.
But our presentation had hoped to distinguish between the 2 by defining food addiction as a substance use disorder while allowing eating addiction to refer to a behavioral or process‑based disorder.
The DSM‑5 diagnosis of binge eating disorder likely captures the concept of eating addiction fairly well, describing a disorder in which an individual experiences a lack of control over eating and consumes large quantities of food. These eating episodes will allow for a temporary escape from psychological stress, but ultimately lead to distress and sometimes lead to a cycle of unhealthy eating behaviors.
Food addiction's an important concept because it allows us to examine certain foods as addictive substances. Hyperpalatable foods tend to highly processed and high in sugars and fats. Indeed, binge eating disorder is typically associated with such foods. Consumers of these foods are more likely to report cravings, psychological dependence, and withdrawal.
This doesn't seem to be unique to humans. Our pets seem to have much the same problem.
Some people seem to have a very significant problem in controlling their intake of hyperpalatable foods despite repeated and significant efforts, often but not always leading to obesity. Obesity is largely a side effect of the fact that these hyperpalatable foods tend to be energy‑dense.
Although there's no shortage in interventions available to address obesity, from the endless approaches available to diet and exercise, few address what may actually be the root cause, addiction to food.
If the addiction were to be to behaviors like eating alone, perhaps it could possible to transfer to eating unpalatable, low‑energy, or healthy foods or even indigestible substances. But this doesn't seem to be the case.
A better understanding of the effects hyperpalatable foods have on the brain may help eaters guide their food choices and may help producers design and create healthier alternatives.
How do highly processed foods affect the brain?
Hyperpalatable and highly processed foods affect the brain in a number of ways. Feeding behavior is mediated by a network of interacting neural circuits which regulate both homeostatic food intake, to replete energy stores, and hedonic food intake, as motivated by reward.
Leptin, made predominantly by adipose cells and enterocytes in the small intestine, and ghrelin, produced by the interior endocrine cells of the GI tract, are the primary regulators of both homeostatic and hedonic food intake and appear to influence dopamine activity.
These hormones, as well as GLP-1 and insulin among others, control not only hunger and appetite, but may also modulate the senses of taste and smell, increasing the value of certain cues.
The consumption of highly processed foods promotes dopamine release in the nucleus accumbens, which is central to reward‑ and addiction‑related behavior. In food addiction, dopamine seems to be related to food‑seeking behavior. It's worth noting that laboratory mice with highly impaired dopamine signaling will tend to die of starvation.
Food addiction shows altered striatal dopamine signaling similar to that seen in opioid and stimulant use disorders. The pleasurable reward from consuming highly palatable foods may be related to endogenous opioids. An increase in new opioid receptors is seen in both food addiction and opioid use disorder.
It's worth noting, however, that these effects are not attributable to any one particular macronutrient in foods despite some evidence that simple sugars could play a significant role.
What strategies do you recommend for the treatment of food addiction?
A number of support groups have been created, including GreySheeters Anonymous, Food Addicts Anonymous, Overeaters Anonymous, and Food Addicts In Recovery Anonymous, which generally follow a 12‑step approach similar to that pioneered by Alcoholics Anonymous.
Food Addicts Anonymous posits that some people are addicted to highly processed foods and must abstain from them in order to optimize their wellness. There's certainly evidence to suggest that some people may experience a loss of control with regards to certain foods and are better off avoiding them altogether.
Of note, Food Addicts Anonymous calls for abstinence from artificial sweeteners as well, but further research is needed to determine whether artificial sweeteners are beneficial or harmful to dieters and under what circumstances.
Glucose administered directly to the GI tract or hepatic portal vein has been shown to prompt dopamine release in the nucleus accumbens, but it's not clear that an artificial sweetener would have this same effect, though some people may be vulnerable to gustatory sweetness cues.
Therapy may be beneficial, including cognitive behavior therapy to help patients identify new coping mechanisms for their food addiction triggers and solution‑focused therapy may be helpful by examining lifestyle choices.
A number of psychopharmacological interventions may be appropriate to address appetite and hunger, cravings, or salience, or dysfunction at the level of dopamine signaling or the endogenous opioid system. In individuals with depression or anxiety, pharmacological interventions could also be focused on addressing those conditions.
Novel therapies, including transcranial magnetic stimulation, may be of some benefit with some studies showing a decrease in cravings for highly palatable foods following stimulation to the dorsolateral prefrontal cortex. Of course, nutritional and dietary counseling may be of benefit to some patients.
What further research do you feel is needed on this topic?
Further research is necessary to learn more about the neurobiology of this disorder, which foods or which components of those foods are at highest risk of contributing to this disorder, and which treatments are most effective in addressing this disorder.
The Psychiatry and Behavioral Health Learning Network is providing readers coverage of content that was scheduled to be presented at the APA’s 2020 Annual Meeting, which did not take place because of the COVID-19 pandemic.