Bridging the Gap Between Food Addiction and Eating Disorder Treatment

 

What happens when food addiction frameworks meet eating disorder care and treatment? 

In this 5th and final installment of this food addiction series, I take a closer look at what we know, what we don’t, with some thoughts on where we go from here.

If you haven’t already, I encourage you to start from the beginning and work your way through.

Part 1 – What is Food Addiction and How is it Diagnosed?
Part 2 – Linking Dietary Restriction and Food Addiction
Part 3 – Evolutions in the Food Addiction Research Landscape: Then and Now
Part 4 – Rethinking Food Addiction Research: Critiques, Concerns & Questions

First, I want to say thank you for all of the feedback. I’ve heard from so many of you, sharing your own thoughts alongside your appreciation for this deep dive. It honestly felt daunting to try to organize and communicate all of the information alongside my own interpretations on food addiction, particularly knowing I couldn’t possibly include everything. Truth be told, I put this series off for several months because it felt so overwhelming. So this is me, tolerating the discomfort I feel with doing something quite imperfectly. 

As someone who follows my work, you know that my whole professional world is eating disorders (EDs). It is this lens that I bring to the topic of food addiction. So, to round out this conversation, I’d like to share some questions and concerns that I have regarding the application of the ultra-processed food addiction model for individuals with EDs.

But before naming some of my concerns, I want to say that I believe that most nutrition professionals who work with individuals with EDs have far more in common than what is different. 

What is shared is easily lost because describing the nuance, context, and process that occurs between provider and client over time is exceedingly difficult to convey! 

• I think most of us strive to partner with our clients, honor their experience and autonomy, and work towards greater peace with food and body. 
• I think most of us utilize nuance, experimentation, and sensitivity to support those we work with.
• I think this is particularly true of outpatient providers because we operate with far more latitude and the luxury of time that is typically not afforded our higher level of care colleagues. 

And even when I disagree with my colleagues, I am ultimately glad I live in a world where differences of opinion and approaches exist. My beliefs, convictions, values, and approach are not for everyone, nor should they be.

So, on to a few of my concerns for the EDs community.

Higher weight individuals with restrictive eating disorders

Nowhere (to my knowledge) in the food addiction literature is Atypical Anorexia Nervosa (AAN) mentioned. It is beyond the scope of this post to write in length about AAN, but it’s important to note that it is no different from Anorexia Nervosa except it occurs in individuals of average or higher weight. I believe this diagnostic distinction based on BMI alone is driven by weight stigma rather than scientific rigor or logic. Yet, due to anti-fat bias, individuals with AAN experience serious mistreatment and neglect, even in ED-specific treatment. It takes significantly longer, on average, to receive an accurate ED diagnosis, and these individuals access treatment far less often than their lower-weight counterparts. They are more likely to be misdiagnosed as having Binge Eating Disorder. Their symptoms are often much more severe when they finally do access treatment (Harrop et al., 2021; Harrop 2023; Kennedy et al., 2017; Lebow et al., 2015; Nagata et al., 2018; Walsh, 2023). This is an extremely vulnerable group of people who typically have a long history of being told to restrict their food as a means to control their bodies. This occurs at ED treatment centers and by ED treatment providers.

Due to weight stigma, I worry that even the most well-intended providers will be more inclined to suggest a restrictive dietary plan for higher weight individuals (aligning with their AN), when working towards a more inclusive nutrition approach is needed. This already occurs in ED treatment, and the “food addiction” approach has the potential for real misuse with this population where restriction in the absence of low weight is all too often dismissed, encouraged, or applauded. 

Issues of accessibility, sustainability, desirability 

For many people, highly processed foods are the most financially and logistically feasible foods for them. Typical of how we do things in the US, it’s tempting to center individual responsibility to mitigate the massive harms of systemic problems. Many of the issues we face with our food systems, as well as food access and affordability, simply cannot be remedied by individuals who are often overworked, overstressed, and under-resourced. Neurodivergence, illness, disability, finances, social norms, family culture, and much more make the reduction and especially the elimination of highly processed foods a solution with pretty significant limitations (Laurent, et al. 2022).

More questions than answers

There remains a vast array of questions that have yet to be answered or even explored via research. This is particularly true regarding how to treat “addictive like eating” among those with active EDs. As has been discussed, the YFAS is the only validated tool to assess for the presence of a “food addiction,” yet by design, it cannot provide the context for “addictive-like” eating or discriminate accurately between a “food addiction” or an ED. Current models of treatment point to the need for a high degree of meaningful training in order to discern what mechanisms are most likely to be perpetuating “addictive-like” eating behavior. I’m concerned about the application of a model that holds particular risk for folks with EDs, given that dietary restriction is a preferred strategy of the illness. 

There are a number of questions I have regarding the application of the “food addiction” model to the treatment of eating disorders:

• Given the high degree of diagnostic overlap between UPFA and EDs, is something distinct being captured among those who meet criteria for both (according to the YFAS and DSM) (Schulte et al., 2016; Gearhardt & Schulte, 2021)? How do we know?
• Is it possible to distinguish a “food addiction” from an ED via a comprehensive clinical assessment? Is it possible to discern this difference when a client is actively utilizing ED behaviors, engaging in dietary restraint, and/or malnourished (regardless of body size) (LaFata et al., 2024; Wiss & Brewerton, 2020)?
• What are the risks and benefits for legitimizing “food addiction” for people with active EDs? How might this diagnosis affect internalized stigma, feelings of self-efficacy, capacity to enact change, and heal disordered eating? I can imagine risks and benefits looking very different from person to person (Cassin et al 2021; Wiss & Avena,  2021).
• How does treatment for a “food addiction” align or depart from more traditional ED treatment? I’m curious about the granular level similarities and differences, particularly with the nutrition plan (Dennis et al., 2024; O’Hea et al., 2024). 
• Can an addiction model of treatment improve outcomes for a subset of individuals who have not responded well to more traditional models of ED treatment (Camacho-Barcia et al., 2022; di Giacomo et al., 2022; Jiménez-Murcia et al., 2019; Munguía et al., 2022; Wiss & LaFata, 2024)? 
• Given the fact that some people’s “food addiction” scores significantly diminish over the course of eating disorders treatment, how is this explained if the addictive component is the food ingredients (Hilker, et al., 2016; Mungia et al., 2022)?

I am particularly interested in harm reduction models of care that reduce exposure to certain foods at certain times or contexts. 

Modifying certain foods (e.g. dose, context, timing) while engaging in other healing aspects of treatment (e.g. emotion regulation, trauma, community support, pursuing meaningful hobbies/interests, etc.) makes tremendous sense for some people. I have utilized these approaches in my work with clients over the years. I’ve just never framed it as treating a “food addiction.” I’m not convinced it was or is. 

I have additional thoughts on how we can work with individuals who experience high degrees of salience and physiological responses to certain foods. I think this might be best captured in a case study. Post a comment below to let me know if you think this would be valuable for you. If yes, I will write it up for a future post.

In my experience, many people find a degree of healing and peace with food they never thought possible. Many start their recovery process, convinced they are addicted to food. 

And through treatment, they are astounded to find these feelings diminish and ultimately resolve. I appreciate and am sensitive to the fact that this is not the case for everyone. The path that gets clients to a better place is always uniquely theirs and rarely reflected by the steps outlined in cookie-cutter manualized treatments. 

I don’t believe there is a singular path to healing. 

People recover from their EDs without formal treatment. Others engage in years of intensive treatment before that magical “something” makes all the difference. 

There are some common threads to what I have observed to be effective:

• A non-hierarchical relationship between clinician and client that is rooted in mutual respect, non-judgment, and attunement. The client’s perspective and experience is of equal or greater value to the clinician’s experience and clinical training. The healing happens in working together.
• A willingness to try things on with plenty of opportunities to notice how something lands, not just psychologically but also from an embodied experience.
• Access to healing across multiple dimensions: nutritional, physiological, psychological, emotional, spiritual, relational, and environmental. The integration of these aspects is critical, which is why there is such tremendous value in teamwork and community-based contributions.

As I close this out, I would love to hear from you:

1. Would you like to see me write a piece on utilizing creative approaches to working with high food salience? After reflection, I think this closely mirrors what “food addiction” proponents call harm reduction. 
2. What lingering questions, concerns, or hopes do you have regarding the application of the “ultra-processed food addiction” model to ED treatment?

Send me a message on Instagram and let me know.

Wow, this was a long one. Thank you for being here. Even if I don’t know you, I appreciate that you are in this with me.

Be sure to check out the other articles in this 5-part series on Food Addiction:

• Part 1 – What is Food Addiction and How is it Diagnosed?
• Part 2 – Linking Dietary Restriction and Food Addiction
• Part 3 – Evolutions in the Food Addiction Research Landscape: Then and Now
• Part 4 – Rethinking Food Addiction Research: Critiques, Concerns & Questions

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If you’re a clinician supporting clients navigating food struggles – including those tied to body image, you don’t have to navigate this alone. Fiona Sutherland and I have created a new 3-part workshop series called Body Image in Focus to help clinicians feel more confident and equipped to have these conversations with care. Registration is now live, and the first session of 3 is on July 23rd.

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If you are a client looking for resources to help you, I’ve got you covered too. Here is a page with several free resources that can help you on your path, whatever that may be.

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Citations:

– Camacho-Barcia, L., Munguía, L., Gaspar-Pérez, A., Jiménez‐Murcia, S., & Fernández‐Aranda, F. (2022). Impact of Food Addiction in Therapy Response in Obesity and Eating Disorders. Current Addiction Reports, 9(4), 268–274. https://doi.org/10.1007/s40429-022-00421-y

– Cassin, S. E., & Sockalingam, S. (2021). Advances and Future Directions in the Clinical Utility of Food Addiction. Nutrients, 13(2), 708. https://doi.org/10.3390/nu13020708

– Dennis, K., Barrera, S., Bishop, N., Nguyen, C., & Brewerton, T. D. (2024). Food Addiction Screening, Diagnosis and Treatment: A Protocol for Residential Treatment of Eating Disorders, Substance Use Disorders and Trauma-Related Psychiatric Comorbidity. Nutrients, 16(13), 2019–2019. https://doi.org/10.3390/nu16132019

– di Giacomo, E., Aliberti, F., Pescatore, F., Santorelli, M., Pessina, R., Placenti, V., Colmegna, F., & Clerici, M. (2022). Disentangling binge eating disorder and food addiction: a systematic review and meta-analysis. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 27(6). https://doi.org/10.1007/s40519-021-01354-7

– Gearhardt, A. N., & Schulte, E. M. (2021). Is Food Addictive? A Review of the Science. Annual Review of Nutrition, 41(1), 387–410. https://doi.org/10.1146/annurev-nutr-110420-111710

– Harrop, E. N., Mensinger, J. L., Moore, M., & Lindhorst, T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. The International Journal of Eating Disorders, 54(8), 1328–1357. https://doi.org/10.1002/eat.23519

– Harrop E. N. (2023). A lived experience perspective on the classification of atypical anorexia nervosa. The International Journal of Eating Disorders, 56(4), 844–845. https://doi.org/10.1002/eat.23884

– Hilker I, Sánchez I, Steward T, Jiménez-Murcia S, Granero R, Gearhardt AN, Rodríguez-Muñoz RC, Dieguez C, Crujeiras AB, Tolosa-Sola I, Casanueva FF, Menchón JM, Fernández-Aranda F. Food Addiction in Bulimia Nervosa: Clinical Correlates and Association with Response to a Brief Psychoeducational Intervention. Eur Eat Disord Rev. 2016 Nov;24(6):482-488. doi: 10.1002/erv.2473. Epub 2016 Sep 4. PMID: 27593963.

– Jiménez-Murcia, S., Agüera, Z., Paslakis, G., Munguia, L., Granero, R., Sánchez-González, J., Sánchez, I., Riesco, N., Gearhardt, A. N., Dieguez, C., Fazia, G., Segura-García, C., Baenas, I., Menchón, J. M., & Fernández-Aranda, F. (2019). Food Addiction in Eating Disorders and Obesity: Analysis of Clusters and Implications for Treatment. Nutrients, 11(11), 2633. https://doi.org/10.3390/nu11112633

– Kennedy, G. A., Forman, S. F., Woods, E. R., Hergenroeder, A. C., Mammel, K. A., Fisher, M. M., Ornstein, R. M., Callahan, S. T., Golden, N. H., Kapphahn, C. J., Garber, A. K., Rome, E. S., & Richmond, T. K. (2017). History of Overweight/Obesity as Predictor of Care Received at 1-year Follow-Up in Adolescents With Anorexia Nervosa or Atypical Anorexia Nervosa. The Journal of Adolescent Health: official publication of the Society for Adolescent Medicine, 60(6), 674–679. https://doi.org/10.1016/j.jadohealth.2017.01.001

– LaFata, E. M., Worwag, K., Derrigo, K., Hessler, C., Allison, K. C., Juarascio, A. S., & Gearhardt, A. N. (2024). Development of the Food Addiction Symptom Inventory: The first clinical interview to assess ultra-processed food addiction. Psychological Assessment, 36(11). https://doi.org/10.1037/pas0001340

– Laurent, J., Martin, A. R., & Tompkins, C. L. (2022). Persistent and Unsuccessful Attempts to Cut Down on Ultra-Processed Foods and the Associated Challenges for Dietary Adherence. Current Addiction Reports, 9(4), 275–281. https://doi.org/10.1007/s40429-022-00418-7

– Lebow, J., Sim, L. A.,& Kransdorf, L. N. 2015). Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders. Journal of Adolescent Health, 56(1), 19-24. https://doi.org/10.1016/j.jadohealth.2014.06.005

– Munguía, L., Gaspar-Pérez, A., Jiménez-Murcia, S., Granero, R., Sánchez, I., Vintró-Alcaraz, C., Diéguez, C., Gearhardt, A. N., & Fernández-Aranda, F. (2022). Food Addiction in Eating Disorders: A Cluster Analysis Approach and Treatment Outcome. Nutrients, 14(5), 1084. https://doi.org/10.3390/nu14051084

– Nagata, J. M., Garber, A. K., Tabler, J. L., Murray, S. B., & Bibbins-Domingo, K. (2018). Prevalence and correlates of disordered eating behaviors among young adults with overweight or obesity. Journal of General Internal Medicine, 33(8). 1337-1343. https://doi.org/10.1007/s11606-018-4465-z

– O’Hea, E. L., Edwards-Hampton, S. A., Beall, D. L., Sonneville, K. R., Ziedonis, D. M., & Gearhardt, A. N. (2024). The Food Addiction Clinical Treatment (FACT) Manual: A Harm Reduction Treatment Approach. Behavioral Sciences, 14(7), 557–557. https://doi.org/10.3390/bs14070557

– Schulte, E. M., Grilo, C. M., & Gearhardt, A. N. (2016). Shared and unique mechanisms underlying binge eating disorder and addictive disorders. Clinical Psychology Review, 44, 125–139. https://doi.org/10.1016/j.cpr.2016.02.001

– Walsh, B. T., Hagan, K. E., & Lockwood, C. (2023). A systematic review comparing atypical anorexia nervosa and anorexia nervosa. International Journal of Eating Disorders, 56(4). 798-820. https://doi.org/10.1002/eat.23856

– Wiss, D. A., Avena, N., & Gold, M. (2020). Food Addiction and Psychosocial Adversity: Biological Embedding, Contextual Factors, and Public Health Implications. Nutrients, 12(11), 3521. https://doi.org/10.3390/nu12113521

– Wiss, D., & Brewerton, T. (2020). Separating the Signal from the Noise: How Psychiatric Diagnoses Can Help Discern Food Addiction from Dietary Restraint. Nutrients, 12(10), 2937. https://doi.org/10.3390/nu12102937

– Wiss, D. A., & LaFata, E. M. (2024). Ultra-Processed Foods and Mental Health: Where Do Eating Disorders Fit into the Puzzle? Nutrients, 16(12), 1955–1955. https://doi.org/10.3390/nu16121955[/vc_column_text][/vc_column][/vc_row]