Natalia Lee and Adrian Carter, from the Neuroethics group at the University of Queensland Centre for Clinical Research, Australia and Members of the International Neuroethics Society
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Many of us enjoy foods that are high in sugar, fat, salt, or a combination of the three; take savoury biscuits for example. Dr. David Kessler’s The End of Overeating explores in detail the art and science behind the creation of highly palatable foods. Despite their appeal, most of us are able to exhibit adequate control when consuming or over consuming these foods. However, there is a subset of the population for whom control over these foods becomes problematic and can result in unhealthy weight gain or obesity. For these individuals, consumption can become life threatening. Why is it that some who wish to reduce their intake of these foods are not able to do so?
While some may point to weak willpower or misplaced motivation, prominent neuroscientists have suggested that the failure to regulate eating behaviours is symptomatic of a food addiction. Dr. Nora Volkow, the effervescent director of the National Institute on Drug Abuse and one of the most vocal advocates of the brain disease model of addiction, has argued that some forms of obesity should be included as a mental disorder in the latest iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The case for food addiction is based on several lines of evidence. Animal and human neuroimaging studies have shown that some foods, particularly those high in sugar, fat and/or salt, can produce changes in the brain similar to those produced by addictive drugs, such as cocaine and heroin. This is unsurprising given that drugs of addiction were originally shown to act on the neural pathways that mediated everyday rewarding activities, such as eating (see here for a thoughtful exposition). There also appears to be a common genetic risk for vulnerability to drug addiction and obesity. Patterns of eating in obese individuals, in particular those with binge eating disorder, also closely resemble key behaviours exhibited by drug abusers.
Leaving aside concerns regarding the strength of the evidence presented in favour of food addiction and an addiction model of obesity (see Ziauddeen et al. and Epstein et al. for informative reviews), what would be the social and clinical implications of labelling overeating and certain subsets of obesity as an addiction?
It has been argued that food addiction could improve our understanding of obesity and the development of more effective treatments and policy measures to reduce over consumption. Its effect on stigma is less certain. Obese individuals may come to view their weight and eating as something outside of their control; they are not just suffering from urges that encourage weight gain but are suffering from a ‘brain disease’ that causes them to overeat. Research is needed to understand what implications an addiction model of obesity will have upon individuals struggling to reduce their weight and to control their eating.
Dr. Robert Lustig and colleagues, among others, have argued that neuroscientific research on the addictive properties of certain foods provides compelling evidence for policies that reduce their consumption across the population, such as taxes and regulations on the sale and promotion of sugar. There is already strong epidemiological evidence for the efficacy of population-based policies, as well as practical evidence from those used to regulate tobacco. Neuroscience may in fact be used to promote a high-risk approach focussing primarily on individuals with or at risk of food addiction. This would be counterproductive as excess weight is a global public health concern whereby a shift away from processed energy-dense foods to those that promote health would be beneficial to most, not simply those deemed to be suffering from a food addiction. Historical behaviour of the alcohol, tobacco and gambling industries suggests that the food industry is likely to exploit this view. Our research (forthcoming) suggests that the public, while supporting the view that certain foods can be addictive, does not support commonly advocated population-based policies, such as advertising restrictions and food taxes, to improve levels of obesity. The reasons behind this warrant further investigation.
While the current enthusiasm of research into animal and human neuroimaging studies on overeating warrants thoughtful consideration, scientists and researchers should also consider the potential social and policy implications of their findings. The clinical impact of food addiction diagnoses on the ability to reduce overeating and weight also needs to be examined further. Contrary to popular accounts, an addition model of obesity may actually reduce obese individuals’ ability to control their eating and weight.
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I strongly disagree that an addiction model will make obese feel more powerless. Indeed, I think that a broad-based understanding of it as an addiction will a) make it more likely that insurance companies will help pay for treatment, b) make the medical profession take the problem of obesity as a medical one rather than a guilt trip, c) make the obese themselves more likely to look for specific help.
An obese person already feels powerless, as I know from more than 50 years of personal experience. A name for what is going on and a society that takes the problem as serious but treatable can only increase the feeling of optimism. Quoting Lustig, Volkow and Keller lends credibility to the neuroscience, but you haven’t taken into account how alcoholism and drug addiction are treated (and they, too, were once considered a matter of will power), or at the science on recovery as reported by Pam Peeke, MD, in The Hunger Fix.
From a purely U.S. perspective: As for government regulation of advertising, taxation, etc.: well, I still smoke. I’m more conscious of how much I smoke but I do it anyway. The expense makes it much less likely that I’ll throw away a half-smoked cigarette. Instead, I’ll snuff it out and finish it later.
And the statistics regarding who in the U.S. smokes are not good. It is the poor who tend to be active smokers, the very people least likely to eat well, have regular medical check-ups or have insurance.
And the tobacco industry was not shut down. It now sells its products in Asia. The same could happen with hyperpalatables except that a) South American & European chocolate is so much better than ours, b) much of our junk food is based on idiosyncratic American tastes — ranch style in China? I don’t think so.
But the food industry has already expanded into those markets and will find ways to do so. As long as American corporations, that pay few taxes, can find a willing market, the less likely they are to switch their manufacturing and the less likely Washington is going to be to subsidize, say, broccoli crops rather than corn.
Thank you for your response Frances and for your insights. We too had anticipated that an addiction model of obesity would help encourage a broader understanding of obesity and would alter its current method of treatment. As mentioned above, providing an alternative explanation to some forms of obesity has been projected to lessen weight-based stigma and improve treatments for excess weight. The results of our study instead showed minimal public support for apparent changes to the current obesogenic environment, such as lack of support for health insurance coverage for treatment. Since this study is the first to examine the public’s attitudes toward an addiction model of obesity, additional studies may help shed some light on some of this study’s findings.
Two years ago, I had a lightbulb moment about my behavioral habits, ingrained since childhood, that took me to see a psychiatrist who specializes in diagnosing and treating ADHD – in children and adults. I am in my forties and have struggled since I was a toddler with controlling food intake, particularly sugary, stimulating things. I carry around a lot of extra weight as a side effect of my sugar “addiction”, which has caused a lot of distress over the years, to me and to those who care about me. The key adjective here is “stimulating”. As someone, it turns out, who was born with ADHD – poor functioning of the dopamine system in the prefrontal cortex that causes individuals to instinctively seek various ways to stimulate themselves to stay focused and alert (little boys bounce off walls and can’t sit still at school) – my totally instinctive impulse was to seek sugar, and I faithfully listened to that impulse. It’s probably that very thing which kept me focused enough to do well at school rather than suffering some of the troubling academic problems a lot of ADHD kids contend with. And why does my self-medicating coping mechanism actually make a lot of sense? Because dopamine production and function is regulated by … wait for it … glucose metabolism. Without anyone knowing it, I was constantly trying to supply, even at age 5 when all I knew how to do was make a bowl of sugary cereal for myself (and then another one), the very thing my misfiring neurotransmitters were craving. Today, I haven’t lost tons of weight since diagnosis and the beginning of treatment with meds, but I do know that I have a relationship with food that looks a lot more like my “normal” eater friends. I no longer have to stop and buy something when I pass a bakery window, but most importantly, I no longer feel the debilitating shame I carried around for decades, more toxic than any fat on my body, caused by a profound conviction, readily supported by the popular culture, that those who can’t control themselves around sugar are morally inadequate and have a deep, unforgivable character flaw. Western society has managed to become compassionate and knowledgeable enough to acknowledge that depression, for instance, is a flaw in chemistry, not character. I long for the day when people are equally well informed about all sorts of addiction, including the addiction to sugar. It keeps me awake at night, wondering now many self loathing people are showing up at 12 step meetings, having lost control of their lives and belief in themselves because of their struggles with all sorts of substances, including food, when really what is going on has to do with neurobiology and chemistry, not weakness or unworthiness. Imagine the healing if we could give them all the kind of medical expertise I had access to? But the healing is not even remotely about the fat – it’s a healing of the spirit. We should NEVER underestimate the value and power of that to add quality, wellbeing and value to a life.
Despite common beliefs about the causes of obesity, many people share your views. And as you probably know, myopic views about the causes of obesity are helpful to no one. If the general public accepts the concept of food addiction, it will be interesting to see how it actually affects obesity. One can only hope that it will have a positive impact.
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