Refined food addiction: A classic substance use disorder☆
Introduction
Overeating in industrial societies is a significant problem that has been linked to an increasing incidence of overweight and obesity with their resultant adverse health consequences, including insulin resistance and diabetes mellitus, hypertension, and cardiac disease. Overeating has been attributed to the ready availability of food [1], [2], sedentary lifestyle [3], [4], [5], [6], [7], [8], and economic considerations [9], [10], [11]. While some or all of these ideas may have some degree of explanatory power, none of them address a critical question; namely, why do people in industrial societies persistently overeat despite considerable and repeated efforts not to do so?
We advance the hypothesis that a possible explanation is that processed foods with high concentrations of sugar or other refined sweeteners, other refined carbohydrates (such as flours), fat, salt, and caffeine are addictive substances, and, therefore, many people lose control over their ability to regulate their consumption of such foods. The addictive loss of control over these foods could account for the ever-increasing global epidemic of obesity and other metabolic disorders. Further, if it is shown to be valid, this hypothesis would have major implications for potential interventions to help reverse these trends.
The model of an addiction focused on processed foods containing high concentrations of refined sweeteners, flours, fats, salt, and/or caffeine is a biologically plausible explanation for this over consumption.
A growing body of research has found a correlation between the frequent consumption of fast food and soft drinks and obesity [12], [13], [14], [15], [16], [17], [18], [19]. The relationship between sweetened drinks, obesity, and diabetes has also been established [20]. Indeed, per capita consumption of refined carbohydrates has progressed significantly over the last 40 years, parallel to the increased incidence of the metabolic syndrome, which includes insulin resistance, overweight, hypertension, dyslipidemia [12], [21]. Table 1 shows the increased per capita consumption of hypothesized addictive foods in the United States for each year listed.
If the addiction hypothesis were true, then the overall US statistics would show a steady and dramatic increase in the consumption of refined foods corresponding to the steady and dramatic rise in overweight and obesity [12]. As seen in Table 1, this, in fact, is the case between 1970 and 1997 in the US.
High fructose corn syrup and flour show the most dramatic increase in consumption, with 61.9 lbs and 50.8 lbs, respectively, between 1970 and 1997. Although many other factors besides a potential addiction mechanism contributed to the observed increases, these data are consistent with the hypothesis of a clinical disorder of addiction to refined foods. Similar increases were seen in the use of tobacco when coupled with reduced prices and heavy advertising. Between 1880 and 1920, cigarette consumption increased from 50 cigarettes per adult to 500 [22].
Comparisons between overeating behavior and addictive drug behavior have been made. However, the comparison was difficult because it was presumed that the compulsive element associated with eating stems from appetite mechanisms while the compulsive element of drug use is derived initially from pleasure seeking and the powerful reinforcing properties of drugs of abuse in later stages of addictive disease [23]. Separating the elements of a healthy appetite from harmful addiction is further challenged by findings in rat studies that the neuropathways of appetite and addiction (pleasure and reward) extensively overlap [24]. Kalra and Kalra have identified a number of neuropeptide elements that are active in both reward and appetite pathways including neuropeptide Y (NPY), Y1 receptors, leptin, endocannabinoids CB1, anandamide 2-arachidonoyl glycerol, orexigenic (ORX) signaling, and endogenous opioid peptides (EOP) [24]. Numerous review articles have also established a connection between the neuropathways activated in the consumption of palatable food and the key reward pathways activated in drug and alcohol use [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36].
Under the framework that we are proposing in this article, the hypothesis could be that the very same mechanisms—pleasure seeking followed by mindless behavioral reinforcement—that are operative in the loss of control over drug use are also operative in the loss of control over certain foods.
Our hypothesis of addiction to refined foods is based on a fundamental distinction between two general categories of food: refined vs. unrefined. The first category includes ingredients that are refined by an industrial process, such as sugar, other sweeteners, flour, salt, caffeine, and certain fats. The second category comprises foods found in nature, such as meat, poultry, fish, beans, grains, vegetables, and fruit. In our model, we hypothesize that humans can become addicted to foods in the refined category, but not to foods in the unrefined category, however prepared. Although, there is not yet sufficient evidence to assert that any of the refined ingredients may act as psychoactive drugs, our observations strongly suggest that foods containing these ingredients, or composed entirely from them, are consumed in a manner consistent with generally understood concepts of addictive behavior found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [37].
Like drugs of abuse, sugars and flours are substances found in nature, where they exist in much smaller concentrations than in food and in combination with fiber, water, vitamins, and minerals. We propose that, like drugs, they are not addictive until extracted and concentrated by modern industrial processes. Examples from the world of drugs include cocaine extracted from cocoa leaves, opium extracted from poppies, ethanol distilled from grains, fruits, and potatoes or nicotine smoked from dried tobacco. Importantly, there is good evidence that carbohydrate preference (and likely fat preference and salt preference) is ‘hard-wired’ into humans because it plays a crucial role in attracting people to eat safe and nutritious foods such as fruits. Whereas small concentrations of these substances contained in natural foods also have significant amounts of fiber, vitamins, and trace minerals that serve the useful purpose of directing us to eat such foods, large concentrations of these substances contained in refined foods may subvert this adaptation and lead some people to compulsively seek and consume refined foods.
In addition, a factor in the development of refined food addiction is the practice in industrial cultures of combining these substances with each other in ways which are entirely unnatural but which may enhance their potentially addictive force. Examples of these artificial combinations include soft drinks, which contain sugar and caffeine; doughnuts, which contain refined flours, sugar, salt, fat and sometimes caffeine from chocolate; and French fries, which contain fat, salt, and, often, dextrose. The combinations are in concentrations much larger than those found in nature, and are dissociated from foods with nutritional value such as meats and fruits.
The DSM-IV defines substance dependence as three or more of the following seven symptoms occurring within 1 year: tolerance, withdrawal symptoms, substance taken in larger amounts or for a longer duration than intended, attempts to cut back, excessive time spent pursuing, using or recovering from use, reduction or discontinuation of important activities because of use, and continued use despite adverse consequences.
Our hypothesis is that overeating can be described as an addiction to refined foods that conforms to the DSM-IV criteria for substance use disorders. The DSM-IV criteria have been validated extensively across substances and cultures [38], [39], [40], [41], [42], [43], [44]. The DSM-IV criteria have been established through an arduous process of consensus building among experts and are considered the best operational definition of addiction (substance abuse and dependence) currently available. Further, if our hypothesis is true, we expect that individuals with the disorder would meet the DSM-IV criteria for a substance use disorder.
The hypothesis evolved in the context of our lay experience with self-identified refined food addicts, and our critical reading of the literature on obesity, eating behavior, and addiction to drugs. In this paper, we will discuss how these observational and scientific data support our hypothesis. For organizational and heuristic purposes, the body of the paper will be structured according to the 7 DSM-IV substance dependence criteria. We will present qualitative data from our observations under each criterion, followed by a discussion of the literature relevant to the criteria.
Ms. Joan Ifland, a lay educator, developed observations over 12 years of experience working with self-identified food addicts. She attracted students from her popular writings and workshops. She also made generic observations in a recovery group.
In addition, the specific illustrations described in this article, which are illustrative of the shared experience of hundreds of others with whom our lay educator has interacted, were collected from students at an adult education class on the ill effects of sugars and flours held on May 6, 2008 in Houston, Texas. Most of the respondents were overweight or obese, middle-aged, middle class women. Half of the respondents were of white, non-Hispanic race, 33% were African–American, and the remaining 17% was comprised of members of other races. The students were given the survey questions shown below, which were adapted from the Structured Clinical Interview for the DSM-IV. After a discussion period, students were invited to write down their own experiences. They signed a statement at the bottom of the form giving the researcher permission to use the quotes without attribution. Twelve forms were collected; one form from a minor was deleted.
The comments pertain to products containing sugars, caffeine, fat, and salt such as soft drinks, sweetened coffee, cake, cookies, hard candy, mints, chocolates, ice cream, pasta, bread, cornbread, crackers, and pie. In the discussion of loss of control, students did not reference problem behavior with unrefined fruits, vegetables, starches, or proteins.
The literature review took place over 3 years in the course of a doctoral program in the development a new interdisciplinary field, addictive nutrition. Searches were conducted using key words food addiction, addictive properties, neurophysiology, obesity, weight loss, pharmaceuticals, diabetes, food addiction, and validation.
Articles retrieved and reviewed included studies of the addictive properties of individual foods, cross over studies where food is substituted for drugs, brain imaging studies in the obese, studies describing the overlap of CNS pathways between appetite and reward, animal studies of addictive behavior in the use of refined foods, addiction assessment studies, and epidemiological studies of the spread of obesity. Relevant chapters from standard nutrition and addiction textbooks were also included. The literature was re-evaluated and re-interpreted in light of the DSM-IV criteria for substance dependence. In this article, we highlight those studies that provide empirical support for specific criteria as discussed under each DSM-IV substance dependence criterion.
Section snippets
DSM-IV language
(1) Tolerance, as defined by either of the following:
- (a)
A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
- (b)
Markedly diminished effect with continued use of the same amount of the substance [37].
Observations from interactions with self-identified refined food addicts
The compulsive need to consume larger quantities of particular foods in order to obtain the desired effect was a recurrent theme among almost all people that comprise the observed population. The desired effects reported are similar to other drugs of abuse,
Applying DSM-IV substance dependence criteria to refined foods: literature review
We note that there is much missing scientific data supporting the food addiction hypothesis, particularly empirical research in humans. That would be expected at the early stage of new disease identification. That is why the observational data is so critical at this stage of hypothesis generation. Nonetheless, if the hypothesis proves to be correct, it would be expected that researchers engaged in the study of obesity and addiction would have generated evidence for the disease of refined food
Intoxication, abuse, and relapse
In addition to the seven diagnostic criteria for dependence, the DSM-IV contains criteria for intoxication and abuse. Regarding intoxication, the DSM-IV states that, “The most common changes involve disturbances of perception, wakefulness, attention, thinking, judgment, psychomotor behavior, and interpersonal behavior” [37]. In the illustrations listed above, the prevalence of sleepiness would seem to create evidence for the criteria of wakefulness, attention, thinking, and judgment, and
Discussion
The intent of this paper has been to present evidence for the hypothesis that certain refined food consumption behaviors meet the criteria of the DSM-IV for substance use disorders. The observations of a lay educator in the field of sugar and flour addiction led to the creation of the hypothesis. The paper offers illustrations of the DSM-IV behaviors as applied to eating and as described by adults attracted to a class on the topic of the ill effects of sugars and flours. The paper also
Conclusion
The epidemic of illness related to overweight and obesity is a public health problem of great significance. Unfortunately, patients’ attempts to reduce weight have been disturbingly resistant to known treatment approaches. In this paper, we advanced the hypothesis that a fundamental reason for this failure is that many people suffer from an addiction to refined foods. The observational and empirical data in support of this hypothesis were discussed in the framework of the DSM-IV criteria for
References (77)
- et al.
School vending machine use and fast-food restaurant use are associated with sugar-sweetened beverage intake in youth
J Am Diet Assoc
(2006) - et al.
Relationship of mother and child food purchases as a function of price. a pilot study
Appetite
(2006) - et al.
Price and maternal obesity influence purchasing of low- and high-energy-dense foods
Am J Clin Nutr
(2007) - et al.
Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity
Am J Clin Nutr
(2004) - et al.
Regular sugar-sweetened beverage consumption between meals increases risk of overweight among preschool-aged children
J Am Diet Assoc
(2007) - et al.
Differential associations of fast food and restaurant food consumption with 3-y change in body mass index: the Coronary Artery Risk Development in Young Adults Study
Am J Clin Nutr
(2007) - et al.
Food craving and food “addiction”: a critical review of the evidence from a biopsychosocial perspective
Pharmacol Biochem Behav
(2000) - et al.
Evidence for sugar addiction: behavioral and neurochemical effects of intermittent, excessive sugar intake
Neurosci Biobehav Rev
(2008) - et al.
Neural and psychological mechanisms underlying appetitive learning: links to drug addiction
Current Opin Neurobiol
(2004) - et al.
Too much of a good thing: neurobiology of non-homeostatic eating and drug abuse
Physiol Behav
(2005)
Neural systems recruited by drug- and food-related cues: studies of gene activation in corticolimbic regions
Physiol Behav
Addiction and its reward process through polymorphisms of the D2 dopamine receptor gene: a review
Eur Psychiat
Of human bondage: food craving, obsession, compulsion, and addiction
Physiol Behav
NIH symposium series: ingestive mechanisms in obesity, substance abuse and mental disorders
Physiol Behav
The obesity epidemic: is glycemic index the key to unlocking a hidden addiction?
Med Hypotheses
Neural mechanisms underlying obesity and drug addiction
Physiol Behav
Convergent validity of DSM-III-R and DSM-IV alcohol dependence. results from the National Longitudinal Alcohol Epidemiologic Survey
J Substan Ab
DSM-IV alcohol dependence and abuse: further evidence of validity in the general population
Drug Alcohol Depend
Substance Dependence Severity Scale (SDSS): reliability and validity of a clinician-administered interview for DSM-IV substance use disorders
Drug Alcohol Depend
Stimulation of 5-HT1B receptors decreases cocaine- and sucrose-seeking behavior
Pharmacol Biochem Behav
Salt addiction: a different kind of drug addiction
Med Hypothes
Caffeine withdrawal in normal school-age children
J Am Acad Child Adoles Psychiat
Caffeine dependence in teenagers
Drug Alcohol Depend
Childhood obesity stigma: association with television, videogame, and magazine exposure
Body Image
Diet composition, energy intake, and exercise in relation to body fat in men and women
Am J Clin Nutr
Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults
Eating Behav
Compliance of insulin-dependent diabetics with a low-fat diet
J Am Diet Assoc
Body mass index gain, fast food, and physical activity: effects of shared environments over time
Obesity (Silver Spring Md)
Activity, dietary intake, and weight changes in a longitudinal study of preadolescent and adolescent boys and girls
Pediatrics
Impact of television viewing patterns on fruit and vegetable consumption among adolescents
Pediatrics
The determinants of overweight and obesity among 10- to 15-year-old schoolchildren in the North West Province, South Africa – the THUSA BANA (Transition and Health during Urbanisation of South Africans; BANA, children) study
Public Health Nutr
Increasing prevalence of overweight, obesity and physical inactivity: two population-based studies 1986 and 1994
Europ J Public Health
Activity, inactivity, and screen time in relation to weight and fatness over adolescence in girls
Obesity (Silver Spring Md)
Diet, physical activity, and sedentary behaviors as risk factors for overweight in adolescence
Arch Pediat Adoles Med
Comparison of price change and health message interventions in promoting healthy food choices
Health Psychol
Shifts in patterns and consumption of beverages between 1965 and 2002
Obesity (Silver Spring Md)
The role of sugar-sweetened beverage consumption in adolescent obesity: a review of the literature
J Sch Nurs
Salt intake is related to soft drink consumption in children and adolescents: a link to obesity?
Hypertension
Cited by (248)
Psychological, behavioural, and ethical considerations
2023, Ketogenic: The Science of Therapeutic Carbohydrate Restriction in Human HealthConverging vulnerability factors for compulsive food and drug use
2021, NeuropharmacologyCitation Excerpt :Consistent with the negative reinforcement perspective, people high in YFAS scores more often reported using food to self-soothe (Berenson et al., 2015; Brewerton, 2017; Burmeister et al., 2013; Burrows et al., 2017a,b, 2018; Ceccarini et al., 2015; Chao et al., 2017; Davis et al., 2011; de Vries and Meule, 2016; Gearhardt et al., 2012; Granero et al., 2014; Koball et al., 2016; Masheb et al., 2018; Meule et al., 2014, 2015) and anticipated less positive reinforcement from eating (Meule and Kübler, 2012). Individuals who self-identify as having food addiction also reported using food to self-medicate their feelings of being tired, anxious, depressed or irritable (Ifland et al., 2009). The Palatable Eating Motives Scale documents that eating palatable food to “cope” with problems, worries and negative feelings is a primary motive for why people eat palatable food (Burgess et al., 2014; Boggiano, 2016; Boggiano et al., 2015b).
Combatting chronic metabolic disorders and delaying aging by improving glucose-insulin metabolism and fat accumulation in nondiabetics: Emphasizing dietary links
2021, Nutrition and Functional Foods in Boosting Digestion, Metabolism and Immune Health
- ☆
This work was not supported by grant funding.