Binge Eating Disorder, Food Addiction or Eating Addiction?
Binge Eating Disorder (BED) is recognised as a significant public health concern, and individuals can face severe stigmatisation, from themselves and others, perceived as a loss of control over the consumption of food.
In this context, we explore the potential alignment of BED with the criteria associated with 'addiction'.
About Binge-eating disorder (BED)
BED is a new formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The definition of BED is recurrent episodes of binge eating unusually large amounts of food while experiencing a feeling of loss of control, and the absence of compensatory behaviours considering weight (e.g., laxative/diuretic abuse or self-induced vomiting) that define Bulimia Nervosa.
Additional criteria are that binge eating occurs ‘on average once a week during the past three months’, characterised by at least three of five behavioural indicators signalling a loss of control and over-eating, and this is linked with marked distress. Empirical research underpins the diagnostic validity and clinical utility of BED (Wilfley et al; Wonderlich et al, 2009) and its distinctiveness from obesity and other forms of eating disorders, even though they may co-occur (Grilo et al., 2009; 2010).
BED is more prevalent in the US than anorexia nervosa and bulimia nervosa combined, affecting an estimated 2.8 million 18+ adults (Mokdad et al., 2004). And in Europe, the estimated lifetime prevalence of BED is around 1.9% for women and 0.3% for men (Hay, 2014). The statistics obscure the suffering considering specific populations such as adolescents, (Swanson, et al. 2011), young women (Fairburn, et al. 2000) and athletes (Williams, 2016) requiring further research to highlight the implications for differential therapeutics for BED.
BED recognition as an eating disorder in the DSM-5 presents a complex situation regarding the notion of ‘food addiction’. Food addiction is not recognised in Psychiatry, despite the overlap with BED, where highly processed foods, for example, may possess addictive-like properties that can underlie problematic eating behaviours. Unlike substance addiction, however, food is essential for survival, making long-term abstinence impossible, and raising questions about the possibility of specific foods inducing addictive behaviours.
To add to the debate, DSM-5, revised its chapter on addictions to include “Substance-Related and Addictive Disorders”, recognising addictions to tobacco, alcohol and caffeine, but not food. While gambling is the only ‘behavioural addiction’ acknowledged (Fairburn & Cooper 2011). Europe follows the World Health Organisation’s 11th ed.; ICD-11 (International Classification of Diseases), where BED falls under “feeding or eating disorders”, so food addiction is also not recognised.
Binge Eating Disorder vs. Food Addiction
BED poses challenges for clinicians and researchers in understanding the concept of ‘binging’ and disordered eating, and the overlap with "food addiction." Some studies have explored the association between BED and food addiction. For example, Gearhardt and colleagues (2011) study found that the YFAS or Yale Food Addiction Scale, designed to identify those exhibiting signs of addiction, characterises BED sufferers as meeting a proposed diagnostic threshold for food addiction against the YFAS scale. The scores predicted increased binge eating frequency toward certain types of food like high-sugar foods and high-fat foods. These are ultra-processed foods as compared with natural sugars in fruit and good fats found in nuts or avocados, for example. Later findings from Hebebrand et al. (2014) on “eating addiction” underscored the behavioural element of food addiction in BED.
A wider study from NeuroFAST (2016) set up by the European Commission, was interested in the behaviour behind ‘eating addiction’ investigating neuro-psyche-biological mechanisms associated with eating behaviour. NeuroFAST was made up of a multidisciplinary team that placed emphasis on existing epidemiological and clinical research, including the ‘neurobiological interface between food intake, reward and stress’. Adding to the literature by testing whether BED eating behaviours and addiction share common susceptibility factors. They also examined common modulators of food reward in the brain and body, including hormones, neurotransmitters and the gut microbiome. Further, they looked to understand the interaction between the feeding regulatory circuitry in the brain and the reward pathways of the brain such as dopaminergic control of the feeding circuit), that may associate with any underlying eating disorder” (NeuroFAST Report (Summary, 2016).
Other research in this domain is limited, but some examples of human studies have presented several supporting theories on the neuro-psyche-biological basis for BED:
· Abnormalities in the reward centre and impulse-control-related brain regions in binge-eating patients, regarding satiation and satiety (Bellisle et al., 2012) (Balodis, et al. 2013).
· ‘Grey matter irregularities within the self-regulation regions of the brain’, implicating disinhibited eating (Schafer, et al. 2010).
· Clinical correlates include loss of control eating, emotional eating and eating when not hungry (Tanofsky-Kraff et al., 2008, Vannucci et al., 2013, Gianni, 2013).
· Reward sensitivity and brain activity to food images vs. primary stimulus (food) (Schienle, et al, 2009); a hallmark of dependence (Volkow, et al. 2013).
· Dopamine dysregulation (Davies, et al. 2011), a characteristic of reward- and addiction-related behaviours (Cocores and Gold, 2009).
· Potential (pavlovian) cues based on conditioned incentive salience reinforcing response (Wyvell, et al. 2000) (Clark & Bernstein, 2006).
Future Research
The re-categorisation of addictions in the DSM-5 and the engagement of NeuroFAST at a European level, represent small steps forward for developing BED literature. And may potentially support including BED as a behavioural addiction, alongside gambling as new science emerges.
Neuroscience research is adding to the literature, looking into specific distinguishing aspects of BED. Such as elevated impulsivity and compulsivity, possibly involving the mesocorticolimbic dopamine system, reward centres and impulse control regions of the brain and regional grey matter volume abnormalities. Clinical correlates include loss of control eating and emotional eating, reward sensitivity, and conditioned incentive salience reinforcement.
So we can also speculate on food addiction in regard to what might explain the individual variation of distorted eating behaviours. Some of the listed studies above discuss societal factors (there is evidence of ‘obesogenic environments’ being conducive to weight gain). Potential psychological underpinnings (there is some evidence of ‘emotional eating’ and ‘trauma eating’), and genetic underpinnings (there is some evidence of ‘heritability’ in behavioural-type addiction).
Moreover, a study by Kings College London, looking at genetic predisposition in body weight regulation, showed a link between clinical eating disorders (binge eating and bulimia) and a higher genetic risk of obesity and high-BMI weight traits, which also appeared to share genetic risk with depression (Hübel C et al., 2021).
We return to BED sufferers engaging in persistent and recurring binge eating who through self-reporting detail ‘significant impairment or distress’ and delay or avoidance tactics from seeking treatment. Delay may be due to having other psychopathology, including depression and anxiety disorder (Hudson et al, 2007).
Common public perception stigmatising binge eating as self-perpetuating does not help, and is a 'false morality', equivalent to the moral model of substance addiction. False morality may, in fact, perpetuate food or eating addiction in sufferers being and feeling stigmatised, or poor diagnosis due to bias in clinical practice.
Individuals with BED often face challenges in seeking treatment due to their health practitioner also missing the potential for associated psychopathology, including depression and anxiety disorders, keeping the focus instead at a symptom level of ‘weight loss’, ‘poor self-control’ and ‘low self-esteem’.
The challenge of being stigmatised by healthcare and public perception of binge eating as a loss of control is indeed a false morality when we consider a significant proportion of the general population engages in habitual overeating without maladaptive consequences, other than the potential for obesity and related metabolic conditions. Caution must also be exercised across this domain to prevent the pathologisation and demonisation of food, considering its essential role in human survival; excellent healthspan and lifespan.
The content presented in this blog incorporates factual information along with perspectives and opinions. It is designed to stimulate discussions and exploration of emerging research. However, it does not represent official advice or exhaustive factual claims. Readers of course consider multiple sources when forming a viewpoint. Alternative viewpoints are highly encouraged and welcomed at Blindspot.