Q&A Session On Binge Eating Disorder, Addictions-The Yale University Conference

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Session On Binge Eating Disorder, Addictions- The
Yale University Conference
QA
Ashley Gearhardt, PhD
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Can you describe organization rationale and
outcomes of the historic yale conference?

• The Yale Conference on Food Addiction was the
  first gathering of experts across the fields of
  addiction, obesity, and feeding behavior to focus
  on the question of whether certain foods can be
  addictive. The presentations and conferences that
  took place over the course of that meeting
  influenced much of the foundational thought about
  how addictive processes may be contributing to
  overeating and supported the emergence of this
  new area of study.

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How do you describe food addiction in 10 words or
less? How is it different than sugar addiction?

• Compulsive overeating triggered by repeated
  exposure to highly rewarding food. While I see
  (added) sugars as one of the most relevant
  ingredients to addictive-like eating, other
  ingredients also appear to be implicated. For
  example, potato chips and French fries are
  commonly eaten in an addictive-like way, but they
  have a low sugar content. They do have a higher
  starch content (which is converted to sugar in
  the body) and fat content. The food addiction
  term broadens the scope of focus beyond sugar.

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Can you describe the genesis, evolution and
validation of yale food addiction scale (YFAS)?
Are some foods most addicting, more addicting and
non-addicting?

• At the time that we first started doing this
  work, there was no scale to measure food
  addiction. Researchers were using obesity as a
  proxy, which we had some concerns about. Obesity
  can be caused by so many factors (e.g.,
  medication side effects, genetic conditions,
  physical inactivity), using it as a marker of an
  addiction to food is not super precise. We also
  saw that some people who had body weights in the
  normal range were reporting addictive-like
  eating, but this was not reflected in their
  weight because of dieting practices, physical
  activity or a fast metabolism.

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• Other approaches out there were the use of
  self-identification (ex. are you a chocoholic?),
  but it was hard to know what this might be
  capturing. So, we decided to use the diagnostic
  criteria for substance dependence (and now
  substance use disorders based on the DSM 5) and
  translate it to apply to the consumption of
  highly rewarding foods (e.g., chocolate, salty
  snacks). This allowed us to use the same criteria
  that we would use to diagnose any other substance
  use disorder to measure addictive-like eating.

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• It was also important for us to specify the types
  of foods that were most likely implicated in food
  addiction. We all have to eat, but the type of
  eating behavior associated with food addiction is
  driven not by a need for sustenance, but to
  experience pleasure or to fulfill a craving. Our
  future work has further borne out that this is
  not an addiction to the act of eating, but more
  specifically to the intake of foods that have
  artificially high levels of rewarding ingredients
  (like refined carbohydrates and fat). As time
  goes on and more research comes out, I think one
  of the next steps will be revising the term of
  food addiction to more accurately reflect the
  types of food that are capable of triggering an
  addictive process. Perhaps, highly processed food
  addiction?

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Should all psychiatrists evaluating disordered
eating include the yfas and add yfas to anorexia
nervosa, bulimia nervosa and binge eating
disorders? Which clinicians should use the yfas?

• For clinicians evaluating disordered eating, it
  would be useful to assess for food addiction by
  including some version of the YFAS. We have
  developed and validated brief versions of the
  scale (see the modified Yale Food Addiction Scale
  2.0) that can be used to quickly screen for an
  addictive-like phenotype. Food addiction and
  eating disorders appear to be overlapping, but
  distinct constructs with about half of
  individuals with an eating disorder meeting for
  food addiction. Individuals with both eating
  disorders and food addiction appear to have a
  more severe variant of the disorder.

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• For example, in binge eating disorder, those with
  food addiction exhibit more frequent binge eating
  episodes, more emotion dysregulation, and greater
  impulsivity. In bulimia nervosa, higher levels of
  food addiction symptoms at baseline predict worse
  treatment outcomes in response to a brief
  psychosocial treatment. Thus, knowing if an
  eating disorder patient has also high YFAS scores
  may inform clinical care. It is also important to
  note that about half of people with food
  addiction do not meet the requirements for an
  existing eating disorder. So, the use of the YFAS
  may also help understand the eating problems of
  people who do not clearly fit into traditional
  eating disorder categories. We also see that
  rates of food addiction are elevated for
  individuals with depression and post traumatic
  stress disorder, so it may also be important to
  assess in more general mental health clinics.

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What are the shared characteristics between binge
eating disorder and food addiction, and what are
the unique?

• The overlap between binge eating disorder and
  food addiction really is not that surprising when
  we step back and look at these conditions from a
  mechanistic level. Both binge eating disorder and
  addiction perspectives theorize that dysfunction
  in reward processes, craving, emotion
  dysregulation, and inhibitory control
  difficulties contribute to overconsumption of
  food and addictive substances, respectively.
  There are some unique aspects to both
  perspectives to consider as well.

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What are the shared characteristics between binge
eating disorder and food addiction, and what are
the unique?

• From a traditional eating disorder perspective,
  the role of shape and weight concern and attempts
  at dietary restriction are thought to be causal.
  From an addiction perspective, these aspects
  could still be considered important, but would
  not be as central. In contrast, the nature of the
  food itself would be extremely important from an
  addiction perspective. From a traditional eating
  disorder perspective, the role of the food itself
  is minimized. However, from an addiction
  perspective, certain foods (likely highly
  processed foods) may be so rewarding that they
  are capable of triggering addictive changes in
  reward and motivational circuitry.

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What are the relationships between overeating ,
obesity, parental food addiction and feeding
practices? Please explain. What are common
comorbidities you have found for YFAS?

• Research on how food addiction runs in families
  is only starting to emerge. In a recent study, we
  found that parents with higher food addiction
  scores also have children with higher food
  addiction scores. There are a number of factors
  that could contribute to this, including
  genetics, parenting practices, and the home food
  environment.

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What are the relationships between overeating ,
obesity, parental food addiction and feeding
practices? Please explain. What are common
comorbidities you have found for YFAS?

• We definitely need more research on this topic!
  And we need to provide parents with tools on how
  to optimally feed a child who has an
  addictive-like drive for highly processed foods.
  Right now there is very little guidance out there
  for parents, but definitely lots of blame. As
  researchers and clinicians, we need to do a
  better job equipping parents with empirically
  supported practices that is sensitive to the
  individual needs of their child. It is highly
  unlikely that a one-size fits all approach to
  feeding is going to be successful for all
  children, especially those at risk for food
  addiction.

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What are the relationships between overeating ,
obesity, parental food addiction and feeding
practices? Please explain. What are common
comorbidities you have found for YFAS?

• We do see that the YFAS is associated with a
  number of important co-morbidities, including
  obesity, diet-related disease and eating
  disorders. It is also associated with depression,
  PTSD, and gambling. My instinct is that
  transdiagnostic treatment approaches that focus
  on shared mechanisms across disorders (e.g.,
  emotion regulation, inhibitory control) are going
  to be important for addressing these
  comorbidities.

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Craving, Liking, and Wanting research is critical
to our understanding of addiction but what about
in food addiction?

• Craving is also essential in the context of food
  addiction. I think one of the misconceptions
  about addiction is that people who struggle are
  individuals who just like the drug more, but
  research hasnt really born that out. Instead, it
  seems to be that people who experience greater
  wanting and motivational drive for the substance
  (regardless of how much pleasure they get when
  they actually consume it) are at the greatest
  risk.

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Craving, Liking, and Wanting research is critical
to our understanding of addiction but what about
in food addiction?

• This enhanced motivational drive can express
  itself in the form of conscious cravings or
  sometimes automatic approach tendencies that can
  occur outside of the persons awareness. I think
  that equipping patients with a greater
  understanding of what triggers this enhanced
  motivational drive for them (e.g., cues in the
  environment, emotional states) is essential in
  giving them back control of their eating behavior.

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Can you describe the FAST Lab, what you have done
in this lab and what you hope to do going forward?

• At Yale, one of my mentors was Dr. William Corbin
  and he has a simulated bar lab. I got to see
  firsthand how important it was to investigate
  addictive behaviors in naturalistic, cue-rich
  environments. The experience of drinking a beer
  in a sterile, clinical room is so different than
  the typical experience of consuming alcohol. If
  we do research only in sterile, hyper-controlled
  environments, we dont see the craving,
  expectancies and behavior that are really key to
  problem drinking. Using Wills work as an
  inspiration,

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Can you describe the FAST Lab, what you have done
in this lab and what you hope to do going forward?

• I created the Food Addiction Science and
  Treatment lab to create a naturalistic, cue-rich
  food environment that resembles a fast food
  restaurant. It has furniture and menu boards to
  resemble a fast food restaurant, all our research
  assistants wear a uniform that resembles a fast
  food worker and it smells like French fries when
  the participants walk in. We have been using this
  lab to identify what are the mechanisms through
  which people are prone to overeat (craving being
  a big one!) and now we are investigating how
  neural responses to food advertisements might
  predict eating behavior in our fast food
  restaurant lab.

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What types of studies are being conducted to
evaluate the relationship between weight loss
surgery and addiction?

• There is interesting work suggesting that
  individuals who have weight loss surgery are at
  greater risk for the development of substance use
  disorders. Although there are many factors that
  likely contribute to this (e.g., different rates
  of absorption of drugs, increased access to pain
  killers after surgery), one hypothesis is that
  there is an addiction transfer from highly
  processed foods to drugs of abuse post-surgery.
  Dr. Gold was one of the first researchers to
  publish work on how individuals who are
  attempting to quit drugs of abuse are at greater
  risk for weight gain and overeating. The research
  on weight loss surgery suggests this increased
  risk might also go the other direction too.

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What are the 3-5 future directions?

• It is an exciting time to be doing research in
  this field and there are definitely more
  questions than answers. Some big future
  directions that come to mind for me are 1)
  identifying why certain foods are more capable of
  triggering an addictive process than others, 2)
  the development of new treatments that take into
  account the potentially addictive nature of
  highly processed foods, 3) investigating how
  addictive-like eating may emerge in children and
  teenagers, and 4) conducting more detailed
  research on the withdrawal syndrome that may
  result from cutting back on potentially addictive
  foods.

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