Nutritional therapists and dietitians play an indispensable role on the front lines of obesity treatment, as most physicians likely refer their obese patients to a nutritionist at some point. In addition, many nutritionists receive self-referrals from patients who are ready to face their weight problems. Typical obesity therapy by nutritionists consists of instructing the client about healthy eating and supplying meal plans. But does this nutritional approach actually help obese clients?
Nutritionists, whom I’ve informally surveyed, are unaware that new evidence suggests obesity is not a nutritional problem, but rather a psychological one. In my years of practicing pediatrics, I taught overweight kids about healthy eating, exercise, and portion control. My successes were limited.
Most of my patients struggled to lose weight, even though they hated being fat; and if they lost weight, they soon gained it back. I was frustrated. Something else was going on and defeating their efforts. This mystery frustrates nutritionists as well. In my determination to find answers, I set up an interactive, open-access website where I invited overweight and obese kids to share their stories and struggles.
After receiving several million visitors, and 134,000 anonymous messages over 10 years, I’ve learned a lot about childhood obesity. These kids proclaim that they’ve “overdosed” on healthy eating information, which they’re taught in school, as the following results from a poll on our site illustrate.
Participants indicate they need information on how to resist cravings for highly pleasurable foods. Furthermore, 37% of those sharing their weight struggles on our bulletin boards explicitly describe turning to food when they’re depressed, stressed, angry, anxious, lonely, fatigued, or bored. In the words of one 17-year-old girl (5’4”, 184 lbs.), “I want/need to lose weight […] yet I’ll just keep eating those chocolate bars to numb whatever feelings I have at that moment.” For many, or perhaps most, comfort eating appears to be unconscious or mindless, as another 17-year-old girl (5’7”, 181 lbs.) related, “I’ve been stopping myself from emotional and comfort eating and I’m only realizing how big of a problem it was for me that I was in total denial of.”
Even when they realize that they comfort eat, the kids may be unable to stop, as a 13-year-old girl (5’6”, 177 lbs.) agonized, “I hate when I comfort eat… I DON’T KNOW HOW TO STOP. IT’S KILLING ME.” Many get trapped in vicious cycles, where they eat to comfort the anguish of being obese, as one 14-year-old (5’6”, 171 lbs.) lamented, “Every time I’m stressed I eat, and my weight is making me stressed.”
I’ve observed that kids initially overeat because “the food is there.” It simply tastes good. But once their brains realize that pain, stress, or boredom are eased by the pleasure of food, kids may become unknowingly dependent on comfort eating and unable to stop, even when they become distressingly obese. Actual tolerance may develop. One 14-year-old girl (5’2”, 201 lb) remarked that food is “like a drug. What used to satisfy you before, now has no effect. I feel like I’ve become immune to the foods that used to comfort me. And like drugs, you keep moving on to bigger, worse things in order to get the same feeling as when you started out.”
This compelling evidence points to a serious dependence on the pleasure of eating, quite similar to dependencies on tobacco, alcohol, and even drugs, as the main cause of the child and adult obesity epidemic. The way these youths describe their relationship with food comes close to satisfying all of the DSM-IV substance dependence criteria, which is the gold standard for diagnosis. Many kids use food as a “drug of comfort” that is more acceptable than alcohol and drugs. Dependence on highly pleasurable foods appears to be on a continuum. Overweight kids would seem to be partially dependent, obese kids fully dependent, and morbidly obese kids are likely in addictive tolerance mode where they eat more and more, or eat higher pleasure-level foods, in order to obtain the same degree of comfort.
Comfort eating may induce brain changes. Neuroimaging studies reveal that low dopamine D2 receptor levels in the striatum are strikingly similar in obese and drug-addicted persons. A recent study in the March 2010 issue of Nature Neuroscience found that fatty foods, such as bacon and frosting, can cause a cocaine-like addiction in rats. Once the rats became obese from eating fatty foods, they would endure an electric shock to get to it. The rats’ brains showed the same low dopamine receptor changes as in the human studies when the rats were allowed unlimited access to cocaine or heroin. A 16-year-old girl summed it up this way: “A teen who does drugs or smokes would get in trouble if their parents found out. But no one’s going to ground you for eating, which can be equally as damaging, and is equally as difficult to stop.”
Nutritionists should be asking obese kids about their lives and how they feel when they seek food. They should be advising parents to listen to their kids’ answers, which may alert them to a comfort-eating dependence. A 12-year-old girl (5’3”, 186 lbs.) remarked, “If parents took the time to actually listen to their kids… less kids would go to the fridge when they were depressed.” Too often, parents ascribe blame to their overweight children, which may induce further comfort eating.
Obese kids need major support to break their dependence on the pleasure of eating, including ways to cope with life without turning to food, such as hobbies, pets, meditation, and counseling. Kids may not be in touch with their emotions and may be unaware that they use food to cope; they may simply say, “I just love to eat.”
The mainstay of successful substance dependence treatment is abstinence. In response to my 2008 letter to the editor in Pediatrics, Jennifer J. Bowdoin, MS, claims that the addiction model for obesity will not work because “food is necessary for life […] and is not a substance from which children can simply abstain.” Nevertheless, a poll on our site shows that most participants have a problem with mainly one food.
Furthermore, the foods the kids have the most problems with are chocolate, fast food, chips, and candy. Those foods are not necessary for life.
Abstinence from the most addictive foods — hyperpalatable foods such as junk food — is challenging but feasible. It may seem unreasonable to advise a client to completely abstain from a food, even junk food. However, if clients are allergic to the food, they would need to avoid that food, perhaps forever. Obesity is really no different. People don’t become addicted to broccoli or dry toast. Nutritionists can help clients sort out the foods to which they are addicted and substitute with non-addictive foods. Nutritionists also can help clients reduce their stress level and find non-food ways to cope.
Substituting low-calorie foods as “coping” foods may not be a good idea, as food is still used for emotional reasons, and the client may become addicted even to 100-calorie packs. Nutritionists should help clients establish a “nutritional” relationship with food, rather than using food for comfort, coping, and entertainment, which can lead to dependence. This is not advanced psychology and is well within the domain of nutritionists. Furthermore, there is no stigma associated with seeing a nutritionist, whereas seeing a psychologist or psychiatrist may imply “mental” problem.
A Food Addiction Road Map
Nutritionists may first want to ask the following five questions when evaluating overweight/obese clients:
- Do you ever feel stressed, sad, or bored?
- Do you find yourself eating to make yourself feel better (maybe, mindless eating)?
- Do you struggle to resist cravings or urges for rich food, like junk food or fast food, knowing full well that you don’t want to gain any more weight?
- Do you feel that your eating is out of control?
- Do you find yourself eating to comfort the distress of being so heavy?
As I manage my overweight patients with comfort-eating patterns, I’ve shifted my focus from portion control to stress control. Here is my written prescription for my patients. I hope it works for your clients as well.
Prescription for overweight clients:
- Write down your reasons to not overeat, such as: so I won’t be out of breath; so I won’t be teased; so I can fit into cool clothes; so I can get dates; so I can play sports; and for my health.
- Do three things to reduce your stress each day, such as relaxation, deep breathing, meditation, taking a walk, practicing a hobby, shooting hoops, or playing a musical instrument.
- Write down a list with a description of each of your problems, leaving space underneath each, such as: “I just can’t understand algebra” and “My mom bugs me about my weight.” Underneath each problem write a plan, such as, “Ask the school for a math tutor” and “Write a letter to my mom saying that her nagging makes me eat more. Ask my minister to help me with my mom.”
- Talk about your problems with your parents, friends, doctor, religious leader, or counselor.
- Avoid junk food and fast food, including sugar-sweetened drinks. Ask your parents to not have them in the house.
- To get unhooked from problem foods, try to stay completely away from the one food that is most problematic. Your cravings for that food should improve in 1 to 2 weeks. Don’t abuse a new food once you get off the most problematic one. Do this withdrawal process with as many problem foods as you can, one at a time.
- Find sources of comfort other than food, such as pets, volunteer work, books, hobbies, and clubs.
— Robert Pretlow, MD, MSEE, FAAP, the founder and director of Weigh2Rock, an online weight loss system for teens and preteens, is board-certified in pediatrics and is a fellow of the American Academy of Pediatrics. For more information, Pretlow may be contacted at: firstname.lastname@example.org or 206-448-4414.
Originally published 6/27/10 at TherapyTimes.com.
Reprinted with permission.
Image by Tobyotter (Tony Alter).