Food, Eating Disorders, and Addiction
This is a critique of research commonly used to equate eating disorders with addictions, particularly food and/or sugar addiction.
Eating disorders are not addictions. While this statement is supported by many in the eating disorder (ED) community, it seems like a fairly fringe idea to assert for those outside the ED community. In this essay, I will provide a critique of research commonly used to equate eating disorders with addictions, particularly food and/or sugar addiction. What many people who research food addiction and those who support the food addiction model actually are referring to is the effect of semi-starvation and starvation on the body, not food addiction. Once semi-starvation and starvation stop, rehabituation can occur and what is seen as cravings and an eating disorder can stop. The main components of an addiction that will be discussed are chronic disease of motivation, memory and related circuitry, the pathological pursuit of reward and/or relief, the inability to abstain due to cravings, abstinence as treatment, and intoxication as well as tolerance.
Addiction is typically defined as a chronic disease that creates a cycle of reward, motivation, memory and circuitry in the brain.(1) To classify eating disorders as an addiction the behavior or food would have to create this ongoing cycle. It would be quite easy to argue that starvation, binging and purging, and binge eating create these cycles. Highly palatable foods, including sugar, have been found to activate dopaminergic pathways.(2) These are the same pathways that light up for heroin, cocaine and alcohol. The problem with using this logic is that these are the pleasure pathways, and music, humor, winning a prize, a mother recognizing her child and smiling faces all activate the same exact pathways.(2) None of these things are pathologized in nearly the same way that food or eating behaviors are. We cannot say that because a certain substance light up the same areas of the brain that it is addictive.
A ground breaking study conducted by Ancel Keys in 1944 which became known as the Minnesota Starvation Experiment gives a very clear understanding of the effects of semi-starvation on humans that had never experienced it prior. “But when it came to eating, the men agreed they were not "back to normal." Many ate "more or less continuously" and a subgroup of the subjects continued bingeing to the point of sickness, even eight months later.”(3) After having their caloric intake cut in half from approximately 3,000 to 1,500 calories, the men were not able to go right back to eating normally. Their behavior mimicked what many would call addiction with constant eating or binging behavior. The brain circuitry wasn’t operating out of addiction, but out of the need for food as a result of semi-starvation.
To be able to fairly look at eating disorders, we must be aware of the effects on the men who had never restricted their dietary intake before. So, we must ask the question – are the people suffering from orthorexia, bulimia nervosa (BN) and binge eating disorder (BED) suffering the effects of starvation and semi-starvation? Do people with a history of BED, also have a history of dieting? Dieting is semi-starvation where most people limit their food to 1,200 calories and sometimes less, which is below what these men were allowed.
The effect of diet cycling and eating disorders create the same symptoms the men in this experiment experienced including the pathological pursuit of reward and/or relief.(1) The men did not have an addiction or any other motivation to lose weight, besides the desire to help with research for prisoners of war who experience starvation. Human beings are highly complex and designed to survive. The need for food after semi-starvation and starvation is a biological function of survival.(4) The body is signaling the brain in all the ways it can to get energy needed for survival. This includes the need for food that is the easiest to digest to get energy in the fastest way possible. Yes, this can be interpreted as a pathological pursuit, but it is actually the body doing its best to survive.
The food addiction (FA) model asserts that the pathological pursuit of reward and/or relief is what leads food addicts to relapse. Relapse for food addicts would be the inability to abstain due to cravings.(1) The main problem with this argument is that food, including the macronutrient glucose, is a required substance to live. Although refined sugars and highly palatable foods may not be necessary to live, they do contain easily digestible nutrients that are essential to survival. Not to mention that the act of nourishment itself is necessary as well. A person cannot abstain from the act of eating (or liquid food by way of a tube) for an extended period of time without effects on one’s health. Abstinence in this regard is the very problem for patients with AN. This brings us back to the Minnesota Starvation Experiment results.(5) When a person restricts their food intake whether through dieting, lifestyle change, AN, BN, or BED, a period of what appears to be uncontrolled eating or binging is inevitable. What looks like relapse is actually a function of biological need to survive and is in no way a relapse, moral failing or lack of willpower to abstain from eating substances or behaviors.
In addition to relapse, intoxication and intolerance are used to diagnose substance use disorders.(6) While there are a lot of personal accounts of foods causing a “high” and increasing tolerance to amounts of food, research is not available to support this concept. Some personal accounts of patients with AN report euphoria from feeling control over their food, but not from food.(7) There is certainly no body of evidence to support intoxication and intolerance in regards to food or eating behaviors.
The most commonly accepted treatment from addiction is abstinence from the behavior or substance. This is not the answer to eating disorders even in people with BED, unlike substance use disorders.(8) (I do find problems with the addiction model of abstinence, but that will have to wait for another day!) In food addiction, abstinence is often synonymous with restriction in the form of dieting and/or weight loss, and it is detrimental to eating disorder recovery. The most useful method for long-term recovery for eating disorders is rehabituation to foods that have been restricted. The authors of Intuitive Eating write, “During this phase, the bulk of your eating may be foods that are heavier in fat and sugar than you’ve been accustomed to—although you may have been eating large quantities of these foods secretly or with guilt. The way you eat during this time will not be the pattern that you will establish or want for a lifetime.”(9) Neutralizing food, not abstinence, as a part of eating disorder recovery is essential. There isn’t a set time period for how long it might take an individual to recover from the guilt, shame, and stigma associated with food and weight. Abstinence will only contribute more to the restriction mindset which doesn’t create lasting recovery from eating disorders. Eating disorders cannot be treated as addictions even in formal treatment.
In conclusion, treating eating disorders as an addiction is problematic at best. It places blame on the food and dopaminergic pathways, and not on the biological response to semi-starvation or starvation. It is easy to explain eating disorder behavior as an addiction, except this doesn’t mean it is true. We see this particularly in the case of how many different activities light up the same pathways as alcohol and other drugs. If we try to treat it as an addiction, we will continue to perpetuate the idea that the substance is to blame and not treat the core of the issue. We must then look at the effects of restriction on the human body. Only then will we be able to assist patients to find true and lasting healing from their eating disorders.
1. American Society of Addiction Medicine. ASAM Definition of Addiction. https://www.asam.org/quality-practice/definition-of-addiction. Accessed July 18, 2017.
2. Robison J. A Little Nutrition Sanity – Sugar: The Other White Powder ... https://www.bing.com/crIG=55AC3E46EC364D42A58A6B2D15AD7D00&CID=3EF68B6A9351643F060881A992576584&rd=1&h=kwIVll8vcV3kUY7dDSKgEad407qK9n5ChyZZnDYI-gE&v=1&r=https%3a%2f%2fwww.linkedin.com%2fpulse%2flittle-nutrition-sanity-sugar-other-white-powder-rhetoric-jon-robison&p=DevEx,5062.1. Published August 2015. Accessed July 18, 2017.
3. Miller K, Minnesota Starvation Experiment - Starving Effects, Diet & Nutrition • Health • Sex & Relationships • The Anti-Diet Project, Photo: Wallace Kirkland/The LIFE Picture Collection/Getty Images. The Starvation Study You Need To Read. Minnesota Starvation Experiment - Starving Effects. http://www.refinery29.com/minnesota-starvation-experiment. Accessed July 18, 2017.
4. The Biology of Binge-Eating. Isabel Foxen Duke. http://isabelfoxenduke.com/the-biology-of-the-diet-binge-cycle/. Published January 29, 2016. Accessed July 18, 2017.
5. Monitor on Psychology. Monitor on Psychology. http://www.apa.org/monitor/2013/10/hunger.aspx. Accessed July 18, 2017.
6. What is Addiction? Psychiatry. https://www.psychiatry.org/patients-families/addiction/what-is-addiction. Published January 2017. Accessed July 18, 2017.
7. Binge Eating Recovery Process. BEDA Online. https://bedaonline.com/understanding-binge-eating-disorder/recovery-process/. Accessed July 18, 2017.
8. Dignon A, Beardsmore A, Spain S, Kuan A. 'Why I won't eat': patient testimony from 15 anorexics concerning the causes of their disorder. Journal of health psychology. https://www.ncbi.nlm.nih.gov/pubmed/17035265. Published November 2006. Accessed July 18, 2017.
9. Tribole E, Resch E. Intuitive eating: a revolutionary program that works. New York: St. Martins Griffin; 2012.