Last month we asked you to submit your questions to Dr. Vera Tarman, a food addictions specialist and author of the book Food Junkies. We received a number of excellent questions and Dr.Tarman was generous enough to answer many of them in detail so we will split this into two parts with the second part coming up in the October issues of our CONDUIT (public) newsletter.
Q1. I am fairly new to the concept of food addiction, it is just not something we have heard a lot about. My question for you is if you can clarify what the difference is between binge eating disorder and food addiction. Is FA an eating disorder or type of disordered eating?
Great question! How to diagnose and distinguish food addiction from binge eating disorder is the perhaps most controversial task in disordered eating field. The symptoms of both disorders look the same at the outset and both conditions even overlap, so that an individual can be suffering from both disorders.
Clinicians use tools to identify each condition: There are a number of psychological questionnaires to flag binge eating disorder (i.e. Eating Disorder Diagnostic Scale) and one peer-approved Yale Food Addiction Scale to diagnose food addiction. Both tools are highly sensitive, in that they will capture both conditions if they exist, but they are not specific. This means that neither scale can rule the other condition out.
Is it binge eating disorder (BED) or food addiction (FA)? The diagnosis is very important as it determines the treatment.
The treatment of BED includes psychological interventions, such as trauma therapy and mindful and moderate eating of all foods, including trigger foods. Food addiction on the other hand, proposes a food plan that removes trigger foods first, and then only after sobriety has been achieved, psychological tools are introduced. These tools are used not to achieve sobriety but to assure complete abstinence of trigger foods in the long term.
Different treatments: Moderation of trigger foods for the binge eater and abstinence for the food addict. Because it is so difficult to determine which condition the patient has, typically clinicians determine the diagnosis by trying to see which treatment seems to work the best.
If the person is able to eat moderately, after having addressed their other mental health issue that drove them to ‘emotionally eat’, then the person is likely suffering from an eating disorder. The food addict however eats uncontrollably whenever the trigger food is re-introduced, regardless of mental status. They will over / under-eat when they are happy, sad or mad or bored. Once the person has had even one small bite of a trigger food, a binge or some food issue typically follows. If the trigger food is removed, and the patient feels at ease around food, chances are there is a food addiction in the picture.
I am convinced that the high rate of recidivism, or relapse in eating disorder treatment, is because the person has been misdiagnosed or has both conditions. It is always useful to do a trial of trigger food abstinence for at least one to three months. By this time, the feeling of deprivation (which in the addiction field we call withdrawal cravings) will pass if the person is a food addict. The food addict will no longer want that food and is often reluctant to re-introduce it to their food plan, intuitively knowing the danger this presents to their sobriety.
Please honor this hesitation, the same way as we honor the disinclination that an alcoholic has to have just one drink.
Q2. When we talk about addiction, is it a sugar addiction? A carb addiction? A generalized food addiction? Or an addiction to the process of eating? Or are there different varieties of addiction?
Addiction physicians now use the DSM5 to diagnose addiction. They see the inability to control use of a drug (in this case sugar) on a continuum from mild to moderate to severe. The various stages of addiction can be seen as stop points on that continuum. A mild addiction may be illustrated as an attachment to sugary products, a moderate may be to sugar and its close cousin, simple carbs like flour, and a severe food addiction, to grains, dairy, or sweeteners.
Sugar is a simple carb. Thus, any carb addiction usually starts off as sugar addiction.
Not surprising, the progression of the food addiction continuum often follows the continuum of the glycemic index. If sugar is the most addictive, any carb that is metabolized quickly into sugar, like bread, potatoes, beer, has the potential to be addictive. The closer it is to sugar (100), the more addictive. Pretty much any food on the high end of the glycemic index (more than 60 – 70 / 100) can be too powerful to control for very long.
For the less extreme food addict, sugar may be the only real trigger, but over time and increasing exposure to sugar, flour becomes problematic and eventually, at the extreme end of the continuum, even grains can be a problem. The more addicted, the more foods that trigger the binges and disordered eating.
At some point, even food volume becomes an addiction, as the person develops a dependence on the process of eating itself i.e. the person who needs to graze all day. My clinical experience is this occurs in the later stages, when people have been on multiple diets, succeeded and failed, and ‘learned’ to associate particular eating patterns as triggering.
I am convinced that many anorexics are actually addicts who are addicted to being hungry, which is a highly sensitive dopimerigic state of mind. Bulimia can follow a similar pattern, where the person is starving, which induces high dopamine state, and then over-feeding on highly charged trigger foods.
Q3. Hello, one of the push-backs on food addiction that I have heard is that it is difficult to believe that you can be addicted to something you need to survive, how would you counter that discussion and how would you suggest someone who believes they have a food addiction issue begin recovery when their “vice” is fully embedded into their environment? A traditional addict (alcohol or drugs for example) could be abstinent by eliminating it from their environment, this is much more difficult I find for food – it is everywhere and part of our everyday life? Much thanks for discussing this important topic!
Thank you for this question. The idea that food cannot be an addiction, because we “all have to eat food” is indeed a major argument that naysayers of food addiction repeatedly use. It comes from our current view that sugary foods and processed foods in general are healthy foods. It misses the point completely that we don’t have to eat sugar or flour or any other highly processed foods.
The addiction model (among others) claims that we have normalized foods that should rightly be designated as toxins. Sugar in its natural unrefined or unprocessed form, as found in an apple, banana, beet or carrot, is completely healthy and is not addictive for most people. Neither is tobacco or even alcohol in its natural element – they may be mildly intoxicating, but not strongly addictive.
It is when we take the intoxicant out of its natural element and potentiate the intoxicant – which is basically the work of the food industrialists, that we get a substance that has become a powerful toxin and inebriant. In other words – a drug.
Then add advertising that sugary products are normal and even tokens of love, and you have a food environment that obscures the true nature of the product. And when we acknowledge that there is an addictive element – we are encouraged to dismiss that truth with humor: “Why not give in to a ‘guilty pleasure?” “Better to live happy then die hungry and slim”.
The good news is that the person can of course eat food! Just healthy unprocessed foods: vegetables, proteins, fats, nuts, seeds and fruits. The even better news is that once the person has moved past the withdrawal phase of craving, these foods become delicious. There is NO feeling of deprivation. No need to die unhappy. Food sobriety becomes food serenity.
Q4. I have tried to be sugar and flour abstinent a few times and have felt good while doing it, but I have really struggled with relapse and a spiral downwards. I can’t seem to stop myself when I fall and when I do it is almost as if I am driven to “make up” for the period of abstinence. What can people be doing to protect from this?
Relapse and the painful downward spiral of ‘food hell’ or deeper addiction can be seen with all addictive substances.
People who quit their pack a day of smoking may start with one cigarette in early relapse, but before they know it, they find that they are smoking up to 2 packs a day. Heavy drinkers who try to control their worrisome drinking find that they become dangerous binge drinkers as a result and eventually may even become daily drinkers. Outside the world of addiction, we call this phenomenon “making up for lost time”.
The person struggling with an addiction is often seen as “white knuckling”, battling deprivation to the point of finally giving in to the long-awaited for drug. A binge follows. It is for this reason that many who have tried to stop eating, say that they have dieted their way into binges into obesity.
The disease of addiction is chronic and progressive. In other words, the desire to use is chronic -though it may be “quiet” when latent or “loud” when active. It does not go away. And the desire to use gets stronger or harder to resist over time. Cravings, or the desire to use, can lay dormant for years, only to be recharged to a previous intensity when the ‘flame to the fire’ (the trigger food or drug) is brought to the “kindled fire”.
Casting this phenomenon within the addiction framework may help you to understand what is happening. If a person has an addiction, there is very likely a dopamine or dopamine receptor impairment. This means that any reintroduction of the trigger can “spark the smoldering fire”, to bring on the condition of uncontrolled craving. Furthermore, if the person has been dealing with their addiction by substituting their addiction with a different drug i.e. cigarettes for sugar (or vice versa), or amphetamines to suppress food cravings, the fire may be actually building momentum with the different drug.
A relapse blatantly brings home that the addiction has been alive and well but is quietly, progressively, getting worse.
The solution? If it is not too late, avoid the first relapse! Then, avoid the second and the third relapse. Building in failure from previous attempts makes each relapse harder to manage. Best to think: stopping NOW is the easiest it will ever be, so stop NOW.
The best protection towards relapse is knowledge that the first time is the easiest and likely the most powerful. Stick with people who know how “cunning, baffling and powerful” addiction can be – learn to spot the sly messages that you may tell yourself that you are not addicted, that you can manage eating trigger foods. Ask your friends to support you rather than undermine your sobriety. A true addict knows the belief that they can negotiate and eat trigger foods is not a peaceful place to live in long term.
The opinions expressed in Ask the Expert are those of the profiled expert, and not necessarily those of Obesity Canada. Content does not constitute medical advice.