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Food for Thought: A Necessary Paradigm Shift

A significant segment of the American population can, and does, consume all different types of foods with seemingly little in the way of adverse consequences. Another segment of the population carries a sensitivity to certain types of foods, typically highly processed, calorie-dense, hyper-palatable foods. Many people who identify as food addicts experience loss of control when eating foods with high amounts of refined sugar, white flour, salt and/or fat. The analogy from the world of addiction is that the majority of people can drink alcohol and be satisfied with just one drink. Alcoholics, who have a biological reaction to alcohol that renders them unable to stop represent a minority. Ongoing research has been quite useful in debunking the myth that you can’t be addicted to food. However, the eating disorder field is lagging behind the rest of medicine when it comes to the reality that addiction for some individuals can involve food substances (like refined sugar)  just as it can involve alcohol, cocaine or opiates for others. In fact, people with co-morbid ED and substance use disorders (the so-called “double winners”) are more likely to have  food addiction (FA) as part of their eating disorders.

FA, along with addiction involving other processes, such as compulsive internet use, compulsive work behavior, compulsive shopping, compulsive sexual behaviors, is not yet included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). As such, many treatment professionals remain steadfast in the belief that FA is not legitimate, despite emerging neurobiologic as well as clinical evidence to the contrary. Much research has demonstrated behavioral and neurobiological evidence supporting the construct of food addiction involving refined sugar in rodents. Several studies using functional imaging in humans also support the existence of food addiction,  showing that food-addicted people experience the same alterations in the reward and behavioral control areas of the brain as those of persons with addiction involving drugs and alcohol.

Why does this matter? Because untold numbers of people with FA remain unidentified and untreated in their disease; even worse, people with eating disorders who have FA are routinely treated by ED professionals who reiterate the “all foods fit” edict that drives nutritional therapy for anorexia nervosa, bulimia and binge eating disorder.  That dictate works very well treating patients with eating disorders who do not have food addiction. But this same dictate along with “all foods in moderation” is potentially deadly to  those with FA, who need to abstain from certain food substances in order to experience freedom from compulsive food behaviors. Further, for the brain circuits that govern their behaviors to heal from the disease of addiction, people with FA need abstinence from the substances which trigger large dopamine spikes in the reward center (a hallmark of the brain disease of addiction). The types and amounts of food substances that do that are highly individualized.

Keeping this in mind, consider the two clinical scenarios below. Would a respected treatment provider encourage a patient recovering from ED with a peanut allergy to consume a handful of peanut butter cups on occasion because all food must fit? Of course not.  Would that same professional instruct a person recovering from alcoholism to have a cocktail at happy hour once a certain level of treatment progress has been made, because having a cocktail with friends is normal? Of course not.

Treatments designed to help a person with restricting anorexia reach recovery may be detrimental to a person with FA that manifests as compulsive bingeing and purging. Conversely, treatments designed to help a person with FA would be detrimental to a person with anorexia struggling with compulsive self starvation, rigid eating and fear of gaining weight.

The difficult work we have as professionals is identifying who within the broad eating disorder diagnostic buckets has FA and who does not, and then tailoring treatment approaches designed specifically to help that individual heal. Many ED professionals think that treating FA using an abstinence model is incompatible with having a flexible, abundant and variety-rich meal plan. There is ample room for flexibility and variety in nutritional plans and therapy approaches for those with FA. Treatment of FA is also compatible with Health at Every Size and intuitive eating, as respected and well-established treatment philosophies for many in ED recovery. With that said, we must advance as a field and grow in our overall understanding of the many types of eating disorders within each diagnostic label, grow in our capacity to adequately identify who has which disease types, and finally treat people accordingly.  As we do at SunCloud, FA must be acknowledged by those in the ED community including dietitians, nutritionists, therapists and physicians. Until this paradigm shift occurs more broadly, treatment as it stands will remain inadequate, stigmatizing to those who don’t fit into the standard model and most importantly, potentially dangerous for those with ED’s that involve FA.


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