Co-written by Kim Dennis, MD, CEDS and Shale Marks, LCSW, CADC
There is longstanding debate in the eating disorder field about whether the use of an addiction model and encouraging patients to engage in eating disorder specific 12-step mutual support groups is clinically useful for ANY treatment seeking patients with ED.
We recently attended yet another webinar promoted by an eating disorder “primary” treatment center that espoused the opinion that such an approach is detrimental to ALL patients with eating disorders, and further that such a model wouldn’t be appropriate to treat co-occurring addiction in these patients.
Much of the argument centered around the word’s “addiction” and “abstinence.” Most eating disorder clinicians remain highly resistant to the idea that eating, and body related behavioral syndromes can be conceptualized within the clinical and neurobiological framework of addiction, even though more and more research studies validate the reality of shared brain circuitry dysfunction involved with reward and habitual behavior in both disorders (as well as similarities with OCD). Food addiction is another hotly debated area, largely denied among eating disorder professionals whose training and clinical framework often stems from the perspective of treating restricting anorexia nervosa. Other medical professionals and addiction professionals tend to be open to assimilating the emergence of data supporting eating disorders as reward dependent syndromes, even studies looking at restricting behavior itself being an immediately rewarding phenomenon in patients with AN-restricting type.
Food Addiction
Addiction is a primary disease of the brain; one relevant factor in the development of addiction is genetic loading, and another relevant factor is exposure to substances or behaviors which activate the brain circuitry that is characteristic of this disease of addiction. Which substances or behaviors will prove triggering to one person’s brain versus another’s is highly individualized, especially when we consider the many faceted experience of taste, eating, exercise and experience of the body. Addiction as a phenotype emerges when a susceptible brain is exposed to substances, behaviors, adverse life experiences, cultural and social contexts that promote the development of the disease.
In substance use disorder (SUD) we often see alcohol, nicotine, marijuana, heroin, cocaine, or opiates as the drug of “choice” (more accurately, drug of “no choice” or drug of imprisonment). Although the societal perception of these drugs is one of negativity, toxicity, badness, etc., none of these substances is inherently bad. We can attach no moral judgement to any of these; indeed, many derivatives of these drugs have been used for years in the service of sound medical practice. At the end of the day, they are no better or worse than aspirin, insulin, or digitalis. These drugs become hazardous when ingested by a person who has the disease of addiction or risk factors for addiction. Similarly, peanuts are a fine food for most people to eat. Those with the body, genes, physiology of having a peanut allergy cannot safely ingest peanuts—not because peanuts are bad or they are bad, but because of the interaction of peanuts with their specific biology.
In FA the substance triggering the aberrant reward circuitry in the brain is food, typically hyperpalatable, high-refined sugar, calorie-dense foods. Not unlike cocaine or heroin, candy, cake, broccoli, or donuts have no innate moral value. These foods are neither good nor bad. Toxic or healthy. These foods are usually identifiable and triggering; they can profoundly excite the reward center of the brain for certain individuals, which can lead to addictive behaviors triggered by specific foods. This subpopulation of patients with eating disorders must be screened for antecedent restrictive behaviors (which can promote binging behavior that IS NOT food addiction). Typically, patients with food addiction have strong family history of addiction, personal history of substance addiction, and early developmental trauma histories.
Standard eating disorder treatment utilizes (and rightly so) the “all foods fit” nutritional philosophy. Standard eating disorder treatment also stigmatizes any nutritional philosophy that supports a patient in utilizing a meal plan that includes low exposure to specific food substances (low refined sugar meal plan for example). Not only is the nutritional philosophy stigmatized in the eating disorder professional world but recovered food addicts are stigmatized in the larger eating disorder recovery community. This rigid adherence to a one size fits all nutrition philosophy among most eating disorder treatment professionals persists; even though in medicine we routinely support people in avoiding certain substances if their bodies cannot metabolize them without harm. We would never support a person with a peanut allergy in eating a snickers bar or a person with biopsy-proven celiac disease in consuming wheat gluten. We support our patients with type 1 diabetes mellitus in having the amount and types of sugars their specific bodies can metabolize with the treatments that we provide. We support our patients with severe alcoholism in continuing to hydrate themselves while abstaining from drinking fluids containing alcohol. We believe it’s long overdue for the eating disorder field to acknowledge that within our diagnostic buckets we have a wide array of different disease types, with different underlying brain and genetic underpinnings, not to mention the infinite complexity that comes with complex co-occurring disorders. Our hope is that the field will adopt a more inclusive and, in our opinion, more accurate nutritional philosophy: “All foods fit, but not all foods fit all the time for all persons.”
LISTEN: Dr. Kim on Molly Carmel’s podcast!
Why There’s No One Single Solution with Dr. Kim Dennis
Dr. Kim and Molly explore why there’s no one solution for everyone and why self-judgment simply isn’t helpful. It’s a rare interview with Dr. Kim discussing the SunCloud Health treatment model, her lived experiences and more.
https://mollycarmel.com/podcast/why-theres-no-one-single-solution-with-dr-kim-dennis/
Listen on Apple: https://podcasts.apple.com/us/podcast/what-youre-craving/id1553369318?i=1000528109619
Listen on Spotify: https://open.spotify.com/episode/14EIi9dr3fRObJEQSnLczX
Preview from the interview,
I am just glad someone is talking about this. It is the one format that has helped me and I was in the typical ED treatment for years. Now that I’m in a state where only the “all foods fit” model is offered, I’ve gone from residential support to none. Thanks for doing this work and I hope more providers catch on. One size DOES NOT fit all and it’s so frustrating trying to explain this to people in the ED field.