food addictions aug 2008

Food Addiction, Eating Food Addiction, Eating Disorders and “Normal” Disorders and “Normal”

Overeating: Overeating:

What’s the Difference?What’s the Difference?

Presented by:Sandee Nebel, LMHCPresidentWhite Picket Fence Counseling Center, LLC

Stacy Seikel, MDBoard Certified Addiction MedicineBoard Certified Anesthesiology

Understand the difference between Understand the difference between “normal” overeating, eating disorders “normal” overeating, eating disorders and food addictionand food addiction

Review recent literature on food Review recent literature on food addictionaddiction

Understand treatment of food Understand treatment of food addictionaddiction

OBJECTIVES

The ProblemThe Problem The SolutionThe Solution What WorksWhat Works

OVERVIEWOVERVIEW“NORMAL” EATER (WITH OBESITY), “NORMAL” EATER (WITH OBESITY),

EATING DISORDERS, FOOD ADDICTIONEATING DISORDERS, FOOD ADDICTION

Philip Werdell, copyright, 2007

The The PROBLEMPROBLEM is is physical:physical:– WeightWeight

“NORMAL” OVEREATER (WITH OBESITY)

The The SOLUTIONSOLUTION is is physicalphysical::– Medically approved dietingMedically approved dieting– Moderate exerciseModerate exercise– Support for eating, exercise and Support for eating, exercise and

lifestyle changelifestyle change

“NORMAL” OVEREATER (WITH OBESITY)

What WorksWhat Works::– WillpowerWillpower– Bariatric SurgeryBariatric Surgery– DietsDiets

“NORMAL” OVEREATER (WITH OBESITY)

The The PROBLEM PROBLEM is is physicalphysical AND AND mental-emotionalmental-emotional– Binge eating, restricting and/or Binge eating, restricting and/or

purging over feelings (use food to purging over feelings (use food to numb or medicate feelings)numb or medicate feelings)

– Unresolved traumaUnresolved trauma– Possibly weight (sometimes Possibly weight (sometimes

underweight, sometimes overweight, underweight, sometimes overweight, sometimes normal weight)sometimes normal weight)

EATING DISORDERS(EMOTIONAL EATER)

EATING DISORDERSEATING DISORDERS

Binge Eating DisorderBinge Eating Disorder - Recurrent binge eating- Recurrent binge eating

- Sense of lack of control- Sense of lack of control

- Eating fast- Eating fast

- Eating until uncomfortably full- Eating until uncomfortably full

- Eating when not hungry- Eating when not hungry

- Eating alone- Eating alone

- Feeling disgusted about eating- Feeling disgusted about eating

- 2 days/week for 6 months- 2 days/week for 6 months

EATING DISORDERSEATING DISORDERS Bulimia NervosaBulimia Nervosa - Recurrent binge eating- Recurrent binge eating - Recurrent compensatory behavior- Recurrent compensatory behavior to prevent weight gainto prevent weight gain

• vomitingvomiting• fastingfasting• laxative uselaxative use• exerciseexercise• diureticsdiuretics

- Twice a week for 3 months- Twice a week for 3 months

EATING DISORDERSEATING DISORDERS

Anorexia NervosaAnorexia Nervosa

-- Refusal to maintain normal body weightRefusal to maintain normal body weight

- Intense fear of gaining weight even when- Intense fear of gaining weight even when

underweightunderweight

- Disturbance about body weight or shape- Disturbance about body weight or shape

- Denial of seriousness of low body weight- Denial of seriousness of low body weight

- Absence of at least 3 consecutive - Absence of at least 3 consecutive menstrualmenstrual

cyclescycles

The The SOLUTIONSOLUTION is is – mental-emotionalmental-emotional

Develop skills to cope with feelings other Develop skills to cope with feelings other than restricting, bingeing and/or purgingthan restricting, bingeing and/or purging

Resolve past trauma and irrational Resolve past trauma and irrational thinkingthinking

The The SOLUTIONSOLUTION is also is also – physicalphysical

as with the “Normal” Overeater (with as with the “Normal” Overeater (with obesity) (diet, exercise, support)obesity) (diet, exercise, support)

EATING DISORDERS

WHAT WORKSWHAT WORKS::– Moderation (along with feeling the Moderation (along with feeling the

feelings)feelings)

EATING DISORDERS

The The PROBLEMPROBLEM is is physicalphysical, , mental-emotionalmental-emotional AND AND spiritualspiritual (i.e. – 12 step solution as with (i.e. – 12 step solution as with alcoholic and drug addicted).alcoholic and drug addicted).– Physical craving (false starving) Physical craving (false starving)

produced by eating addictive foodsproduced by eating addictive foods– Mental obsession (false thinking)Mental obsession (false thinking)

FOOD ADDICTED(CHEMICALLY DEPENDENT)

The The SOLUTIONSOLUTION is is spiritualspiritual, , mental-mental-emotionalemotional, AND , AND physical.physical.– Abstinence from binge/trigger foods and Abstinence from binge/trigger foods and

abusive eating behaviorsabusive eating behaviors– Rigorous honesty about all thoughts and Rigorous honesty about all thoughts and

feelingsfeelings– A disciplined spiritual program (12 Step)A disciplined spiritual program (12 Step)– AndAnd the mental-emotional and physical the mental-emotional and physical

solutionssolutions

FOOD ADDICTED(CHEMICALLY DEPENDENT)

WHAT WORKSWHAT WORKS::– SurrenderSurrender to a food plan which to a food plan which

eliminates addictive foodseliminates addictive foods– SurrenderSurrender to rigorous honesty about to rigorous honesty about

thoughts and feelingsthoughts and feelings– SurrenderSurrender to whatever structure to whatever structure

and support is neededand support is needed

FOOD ADDICTED(CHEMICALLY DEPENDENT)

Dieting to lose Dieting to lose weightweight– Assumes you need Assumes you need

to take controlto take control– Focus on physical Focus on physical

recoveryrecovery

Abstaining to be in Abstaining to be in recoveryrecovery– Assumes control by Assumes control by

will alone is not will alone is not possible (addictive possible (addictive foods take over brain)foods take over brain)

– Works on mental-Works on mental-emotional and emotional and spiritual recovery as spiritual recovery as well as physical well as physical recoveryrecovery

THE COMPARISON BETWEENDIETING AND FOOD ABSTINENCE

DIETINGDIETING– Focus on putting Focus on putting

distractions out of distractions out of mindmind

– Time frame is Time frame is limited-you lose limited-you lose weight and you weight and you are doneare done

FOOD ABSTINENCEFOOD ABSTINENCE– Focus on sharing Focus on sharing

thoughts and feelings thoughts and feelings that are in the way that are in the way and dealing with and dealing with themthem

– The time frame is one The time frame is one day at a time for the day at a time for the rest of your life.rest of your life.

DIETING AND FOOD ABSTINENCE (CON’T)

DIETINGDIETING– The best plans are The best plans are

straight forward straight forward and reasonable and reasonable (i.e., sugar in (i.e., sugar in moderation moderation eliminates eliminates craving).craving).

– The work is a The work is a matter of matter of willpower.willpower.

FOOD ABSTINENCEFOOD ABSTINENCE– The best plans The best plans

sometimes seem sometimes seem paradoxical (i.e., paradoxical (i.e., eliminating sugar eliminating sugar decreases craving).decreases craving).

– The work is to The work is to gracefully surrender.gracefully surrender.

DIETING AND FOOD ABSTINENCE (CON’T)

COMPARISON BETWEEN EATING COMPARISON BETWEEN EATING DISORDERS AND FOOD ADDICTION DISORDERS AND FOOD ADDICTION

RECOVERY WORKRECOVERY WORK EATING DISORDEREATING DISORDER

– Traditional eating Traditional eating disorder therapy disorder therapy assumes the assumes the problem is not the problem is not the food .food .

– Biopsychosocial Biopsychosocial (emphasis on (emphasis on psychological)psychological)

FOOD ADDICTIONFOOD ADDICTION– Food addiction Food addiction

recovery work recovery work assumes the problem assumes the problem is the food, as well as is the food, as well as feelings, trauma and feelings, trauma and sometimes weight. sometimes weight.

– Biopsychosocial (all Biopsychosocial (all are emphasized)are emphasized)

The obese “normal” overeater can The obese “normal” overeater can diet successfully.diet successfully.

The morbidly obese “normal” The morbidly obese “normal” overeater is an excellent overeater is an excellent candidate for bariatric surgery.candidate for bariatric surgery.

IN SUMMARY:“NORMAL” OVEREATER

Anorexics, bulimics and binge-Anorexics, bulimics and binge-eaters are successfully treated by eaters are successfully treated by a range of therapies from CBT to a range of therapies from CBT to expressive, as well as guidance expressive, as well as guidance from a dietician, and sometimes from a dietician, and sometimes medication management.medication management.

IN SUMMARY:EATING DISORDERS

Medication Management for EDMedication Management for ED– SSRI’sSSRI’s– TopamaxTopamax– LuvoxLuvox– NaltrexoneNaltrexone

IN SUMMERY: EATING DISORDERS

Some food addicts have few Some food addicts have few underlying issues apart from their underlying issues apart from their chemical dependency on food.chemical dependency on food.

These people are successful in 12 These people are successful in 12 Step programs and can be Step programs and can be successful from the beginning successful from the beginning without much need for additional without much need for additional professional support.professional support.

IN SUMMARY: FOOD ADDICTED

We see concurrent obesity, eating We see concurrent obesity, eating disorder and food addiction.disorder and food addiction.

In these cases, when food In these cases, when food addiction is advanced, we have addiction is advanced, we have seen success when the food seen success when the food addiction is treated as the primary addiction is treated as the primary disease, along with therapeutic disease, along with therapeutic interventions for the eating interventions for the eating disorder.disorder.

HOWEVER, MORE COMMONLY

Diet and exercise alone do not work.Diet and exercise alone do not work. Therapy alone does not work.Therapy alone does not work. Successful long term recovery from Successful long term recovery from

food addiction almost always begins food addiction almost always begins with abstinence from the offending with abstinence from the offending food(s) and “weighing and measuring” food(s) and “weighing and measuring” if the problem is if the problem is volumevolume of all or some of all or some foods.foods.

TREATMENT OPTIONS FORFOOD ADDICTS

There are many variations in There are many variations in food plans.food plans.

Common addictive foods that Common addictive foods that must be abstained from include must be abstained from include sugar (most common), flour, sugar (most common), flour, wheat, fat, etc.wheat, fat, etc.

There are varying “degrees of There are varying “degrees of abstinence” (see chart 5).abstinence” (see chart 5).

FOOD PLANS FOR FOOD ADDICTS

Similar to other chemical Similar to other chemical dependencedependence

See charts 6 and 7See charts 6 and 7

FOOD ADDICTIONIS PROGRESSIVE

Present in the late stage food Present in the late stage food addictaddict

Present in other late stage Present in other late stage addictive disordersaddictive disorders

Must be addressed in order for Must be addressed in order for treatment to be successfultreatment to be successful

ADDICTIVE (BIOCHEMICAL)DENIAL

A decade ago, there was little A decade ago, there was little scientific evidence that food scientific evidence that food addiction exists as a chemical addiction exists as a chemical dependency.dependency.

Today there is abundant evidence.Today there is abundant evidence. Some of the most convincing Some of the most convincing

evidence includes the following evidence includes the following slides:slides:

SCIENTIFIC EVIDENCEOF FOOD ADDICTION

Genetic Evidence: A UCLA study Genetic Evidence: A UCLA study showed obese people who binged showed obese people who binged on simple carbohydrates, had the on simple carbohydrates, had the same Dsame D22 Dopamine receptor as Dopamine receptor as has been found in alcoholics and has been found in alcoholics and other drug addicts.other drug addicts.

E.P. Noble, MD, et al, 1994E.P. Noble, MD, et al, 1994

SCIENTIFIC EVIDENCEOF FOOD ADDICTION (CON’T)

Brain Imaging Evidence: Pet imaging Brain Imaging Evidence: Pet imaging studies show that loss of control studies show that loss of control overeating and obesity produce changes overeating and obesity produce changes in the brain similar to those produced by in the brain similar to those produced by drug of abuse.drug of abuse.

Mark Gold, MD, et al, 2004Mark Gold, MD, et al, 2004

SCIENTIFIC EVIDENCEOF FOOD ADDICTION (CON’T)

Evidence of Opioid Involvement: Evidence of Opioid Involvement: Several studies show that excess Several studies show that excess sugar intake produces endogenous sugar intake produces endogenous opioid release and dependency.opioid release and dependency.

Adam Drewnowski, et al, 1992, Carlo Calantuani, et al,Adam Drewnowski, et al, 1992, Carlo Calantuani, et al,

2002, Nora Volkov and Roy Wise, 20022002, Nora Volkov and Roy Wise, 2002

SCIENTIFIC EVIDENCEOF FOOD ADDICTION (CON’T)

Evidence of Cross Addiction from Evidence of Cross Addiction from Alcohol to Food: There are several Alcohol to Food: There are several studies that show those who are studies that show those who are addicted to alcohol are often helped addicted to alcohol are often helped to recover by abstinence of both to recover by abstinence of both sugar and alcohol.sugar and alcohol.

A.R. Lefever and M Shafe – 1991, Katherine A.R. Lefever and M Shafe – 1991, Katherine Kitchem and Kitchem and

L. Ann Mueller - 1986L. Ann Mueller - 1986

SCIENTIFIC EVIDENCEOF FOOD ADDICTION (CON’T)

Evidence of Malfunction of Serotonin: Evidence of Malfunction of Serotonin: Serotonin as well as dopamine is Serotonin as well as dopamine is involved in food addiction.involved in food addiction.

A. Katherine, 1996A. Katherine, 1996

SCIENTIFIC EVIDENCEOF FOOD ADDICTION (CON’T)

Case StudyCase Study 20 year old male20 year old male 5 year history of alcohol abuse5 year history of alcohol abuse 7 year history of binge eating7 year history of binge eating General anxiety disorderGeneral anxiety disorder 5 attempts at outpatient therapy (refused 5 attempts at outpatient therapy (refused

higher lever of care)higher lever of care) Overweight as of middle school (puberty, Overweight as of middle school (puberty,

inactive for months due to fracture in foot inactive for months due to fracture in foot and misdiagnosed heart condition)and misdiagnosed heart condition)

5’9” – 210#5’9” – 210# Lives with biological family and in collegeLives with biological family and in college

Case StudyCase Study 28 year old female28 year old female 10 year history of amphetamine abuse10 year history of amphetamine abuse 14 year history of bulimia nervosa, 14 year history of bulimia nervosa,

restricting, over exercising, excess caffeine, restricting, over exercising, excess caffeine, major depressive episodes-recurrentmajor depressive episodes-recurrent

6 attempts at inpatient treatment, including 6 attempts at inpatient treatment, including 1 year hospitalization, 18 months halfway 1 year hospitalization, 18 months halfway househouse

Average weightAverage weight Divorced family of origin, step families, raised Divorced family of origin, step families, raised

by other family membersby other family members

Case StudyCase Study

32 year old alcohol and cocaine 32 year old alcohol and cocaine addicted female in residential addicted female in residential treatmenttreatment

Night eatingNight eating Normal weightNormal weight Hoarding foodHoarding food

Additional InformationAdditional Information

History of ED?History of ED? History of obesity?History of obesity? Evidence of purging?Evidence of purging? Baseline weight?Baseline weight? Family history of ED or obesity?Family history of ED or obesity? History of trauma?History of trauma?

Differential DiagnosisDifferential Diagnosis

““Normal” OvereaterNormal” Overeater Eating Disorder – BED or BulimiaEating Disorder – BED or Bulimia Food AddictFood Addict Hyperphagia from cocaine Hyperphagia from cocaine

withdrawal (cocaine detox)withdrawal (cocaine detox)

Workup and Treatment Workup and Treatment PlanPlan

LabsLabs Food historyFood history TherapyTherapy Bathroom buddyBathroom buddy Eliminate trigger foodsEliminate trigger foods 12 Step meetings12 Step meetings

Case StudyCase Study

35 year old female35 year old female 15 year history of alcohol dependence 15 year history of alcohol dependence

and abuseand abuse 5 year history anorexia nervosa5 year history anorexia nervosa 1 attempt at inpatient treatment 1 attempt at inpatient treatment Substituted iced tea for alcohol in Substituted iced tea for alcohol in

treatmenttreatment Overly involved with food prep in Overly involved with food prep in

treatment settingtreatment setting Married with childrenMarried with children

Case StudyCase Study

48 year old female48 year old female ““Weight issues as far back as I can Weight issues as far back as I can

remember”remember” Repeated attempts at weight Repeated attempts at weight

management including 12 Step management including 12 Step programs with food plansprograms with food plans

Married with childrenMarried with children

THANK YOUTHANK YOU