Reflections on Obesity and DSM-5

food-is-one-of-my-favorite-parts-of-the-day_1552

Childhood Obesity News has been examining the premise that food addiction, in some form, under some nomenclature, should have been recognized in the latest edition of the Diagnostic and Statistical Manual (DSM-5). Okay, maybe calling food an addictive substance is not appropriate for whatever reason – perhaps because it is too vague or because the foods to which people become addicted are as mystifyingly diverse as chocolate and cheese. Dr. Pretlow has suggested that perhaps,

…overeating/obesity constitutes a behavioral addiction, where food’s pleasurable taste is the high, in conjunction with the displacement behavior of eating action. This is similar to gaming and gambling, where winning is the high, in conjunction with the displacement behavior of gaming and gambling action.

That idea is especially suggestive in conjunction with where gambling actually ended up in DSM-5: under the category heading of “Substance-Related and Addictive Disorders,” where it is the only member of the class “Non-Substance-Related Disorders.” In other words, even though gambling is not a substance, the disorder earned its place as a special case in the box where other substance-related disorders are cached. That is a stretch, but one that the creators of the book were comfortable with, while food addiction was left out in the cold.

It did not even get a spot under “Feeding and Eating Disorders,” along with anorexia and bulimia, where it might have appeared as an “Other Specified Feeding or Eating Disorder,” or even an “Unspecified Feeding or Eating Disorder.” But no. As Dr. Pretlow also remarked, “It’s a matter of semantics as to what constitutes addiction, and the addiction field is very much in flux.” In a spirit of academic cooperation, he began to consider whether we might be dealing with a Body-Focused Repetitive Behavior (BFRB).

BFRBs in DSM-5

In the book that is considered the Bible of the diagnostic art, the BFRB barely even exists. There is only a paragraph in a subsection of the “Obsessive Compulsive and Related Disorders.” The examples given are nail, cheek, and lip biting, mentioned here as “Other Specified Related Disorders.” In this section of DSM-5 where food addiction might conceivably have fit in, nail, cheek, and lip biting are described:

These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Well, compulsive overeating certainly fits that description. When a person is prevented by obesity from occupying a school desk or an airplane seat, or from being a cousin’s bridesmaid or groomsman, or from getting a job, function is certainly impaired and distress is most definitely a result. Maybe this is where food addiction belongs.

But wait – here is an interesting detail. The book includes a couple of other conditions that could potentially apply. Under Movement Disorders, there is a “Stereotypic Movement Disorder.” Could the constant and repetitive motion of bringing food to the mouth be one of those?

Two other possibilities are even more promising, though neither has even made the book yet. Instead, they hang out at the end, among the 8 “Conditions for Further Study,” meaning they might make the grade someday. The two disorders are “Nonsuicidal Self-Injury” and, better yet, “Suicidal Behavior Disorder.” Why not?

Your responses and feedback are welcome!

Source: “DSM-5 Table of Contents,” Psychiatry.org, 2013
Source: “What the DSM-5 Says About: Body-Focused Repetitive Behaviours,” CanadianBFRB,org, 06/27/14
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Addiction is its Own Thing

Whack a Mole Fever

Recently, Childhood Obesity News has considered how food addiction is not recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), while similar maladies are granted official recognition. It seems as if the compilers of the manual reached strenuously to include some things, while ignoring the obvious parallels between compulsive overeating and other addictive disorders. Gambling, for instance, is uncomfortably shoehorned in alongside Substance-Related Disorders, even though it is not a substance.

Although food addiction has not been granted the DSM-5 imprimatur, many psychologists and physicians, including Dr. Pretlow, persist in treating it anyway. Washington Post reporter Jennifer LaRue Huget once interviewed psychoanalyst Marilyn Mertzl, who characterized addicts as people for whom “the source of all pleasure has become the source of all pain.” Dr. Mertzl went on to say:

Addiction to food operates on the same neurobiological highway as addiction to drugs, sex, gambling or alcohol…With food addicts, they eat all day, and they eat all night. The turnoff valve is broken…Usually by the time they come to me, they’ve tried a variety of unsuccessful interventions.

“Persistent desire or unsuccessful efforts to cut down or control opioid use” is one of DSM-5’s checklist items for diagnosing Substance Use Disorder. Heroin addicts and users of other substances have often, in the words of Dr. Mertzl, “tried a variety of unsuccessful interventions,” before they finally get straight. The same is true of food addicts, yet somehow that doesn’t count.

Alcoholism is also generally recognized as a disease. Comic Jamie Kilstein wrote a fascinating piece for Jezebel.com about how the realization that he was an alcoholic led to the conviction that his relationship to food was also addictive. These quotes are only fragmentary, for several reasons including explicit language:

You feel alone. You feel hungry. You feel like your problems aren’t real, so you don’t fix them. Then, you feel full… Then you hate yourself. Then you hate yourself for hating yourself. Then you eat. Then you feel sick….

Kilstein is an expert in fatlogic and also in persuasive psychology for a good cause – “You’re gonna give in to those giant corporations that profit on you hating yourself?”

It’s All the Same Mole

Dr. Vera Tarman very much wanted to see food addiction included, along with other substance abuse disorders, as a legitimate diagnosis in DSM-5. For RecoveryWire Magazine she wrote a piece with the unequivocal title, “Finally Sober, Suddenly Fat: Food Addiction is Another Drug Addiction.” Based on her observations of some 6,000 patients, Dr. Tarman finds that addiction follows what some call the “Whack-a-Mole” pattern – it may be suppressed in one area, but will pop up somewhere else. She writes:

A person would come into treatment to be treated for their alcoholism. They eat voracious amounts of food, usually to their horror, frequently gaining as much as 20 – 30 pounds in the three weeks of treatment… After treatment, this pattern of over eating and binge eating continues. It is as if they can not stop.

Patient histories reveal that many alcoholics were uncontrollable comfort eaters before developing a drinking problem, and when the alcoholism is treated, the comfort eating returns with full force. “The phenomenon of addiction does not favor one drug over another,” Dr. Tarman warns. Addiction is its own thing, and will happily glom onto whatever is available, including potato chips and sticky buns. She says:

Food can be a drug like any other, and can fuel the addictive cycle, which impedes recovery and sobriety… The answer to sobriety and serenity is in what you eat and especially, what you don’t eat.

Your responses and feedback are welcome!

Source: “Conquering Food Addiction,” WashingtonPost.com, 01/18/11
Source: “DSM-5 Substance Use Disorder,” buppractice.com, Undated
Source: “I’m an Alcoholic Dude With an Eating Disorder. Hi.,” Jezebel.com, 09/03/13
Source: “Finally Sober, Suddenly Fat: Food Addiction is Another Drug Addiction,” RecoveryWireMagazine.com, 05/02/13
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More DSM-5 Oddities

Las Vegas Boulevard South

In a couple of Childhood Obesity News posts last week, we asked the following question about the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): while other, similar disorders are included in the manual, how did food addiction get left out? Binge Eating Disorder has the Feeding and Eating Disorder category all to itself – while food addiction receives nary a mention! Really, is this fair?

We recalled how most people who are unable to control their eating, are pretty much captivated by one problem food, or a handful of them. So when we say “food” we are not talking about all foods (where are the broccoli fiends?) or even one particular kind. For the purpose of this discussion, “food” is whatever a patient (or worse yet, not even a patient, but just a troubled person running around at large) finds heinously irresistible.

The Disorder of Gambling

Even gambling shows up in DSM-5 with a fancy title – it’s a “Non-Substance-Related Disorder,” and it’s the only one of those, but subsumed into a larger category called “Substance-Related and Addictive Disorders.” We will call this category SRAD for short. All the other disorders in the SRAD category are based on substances – alcohol, caffeine, cannabis, hallucinogens, inhalants, opiods, sedatives, stimulants, and tobacco. Since gambling is not substance-related, it must then logically be the titular Addictive Disorder.

So, gambling is just off-handedly granted addictive status, while food addiction, which has been struggling for years to be recognized, is ignored. But that’s not all. The SRAD category adopted every stray dog on Addiction Street by including “Other or Unknown Substance-Related Disorders,” a real slap in the face to food addiction, which was not mentioned at all.

Then the SRAD category went ahead and shoe-horned in a disorder that isn’t even about any substance: gambling. Elsewhere in the book, even Binge Eating Disorder was allowed through the gate, as a Feeding and Eating Disorder. Of course, there was no mention of food addiction in that neighborhood, either. The compilers of the book wrote,

Many scientists and clinicians have long believed that problem gamblers closely resemble alcoholics and drug addicts….

They had the nerve to say such a thing, and yet totally ignore the overwhelming resemblance between overeaters and people addicted to alcohol and drugs. They say gambling is a behavior that has common elements with substance use disorders. What about the fact that food addiction also has common elements with substance use disorders? First of all, food is a substance, which gambling is not. And yet food, a perfectly tangible substance if ever there was one, was not invited to the ball.

Your responses and feedback are welcome!

Source: “DSM-5 Table of Contents
Psychiatry.org, 2013
Image by David Stanley

The Gambling and Eating Connection

Gambling

Childhood Obesity News recently began discussing the fascinating evolution of the definition of pathological gambling according to the Diagnostic and Statistical Manual, commonly known as DSM-5. The definition has changed over the years as a result of much intellectual and political turmoil. The story of problem gambling is interesting to us because of the larger topic – the seeming arbitrariness of including some human malfunctions as official disorders while ignoring others. And of course there is the possibility that food addiction is a condition as disorderly as they come.

It is also significant because when we see how much discussion the gambling issue has inspired, and the changes the DSM-5 definition has gone through in this context, it opens up the likelihood that eating disorders are still being rethought and redefined in much the same way.

The National Center for Responsible Gaming (NCRG) reminds us that pathological gambling previously was classified under “Impulse Control Disorders Not Elsewhere Classified.” With the new edition, DSM-5, it graduated to the category of “Substance-Related and Addictive Disorders,”  and the official description of its harmfulness is strangely reminiscent of the damage that can be done by untrammeled eating and the resulting obesity. Yet food addiction has not earned a spot in the lexicon of mental disorders.

More Changes

Some researchers and clinicians disliked the old terminology, Pathological Gambling (PG), because pathological “is a pejorative term that only reinforces the social stigma of being a problem gambler.” Pathology just means a structural or functional deviation from the norm, which constitutes or characterizes a disease, and it seems appropriate, but apparently the colloquial usage of “pathological” has ruined it.

Another fascinating detail is that formerly, the clinical description of PG included a checkbox for illegal acts like embezzlement or forgery to acquire gambling stakes or pay gambling debts. Apparently, that kind of criminal behavior is so rare that its presence does not aid in making a diagnosis. The revised description in DSM-5, however, still mentions that illegal acts may be associated with this addictive disorder.

Other signs are frequent preoccupation with gambling and gambling as a response to feelings of distress. (Both of those things can be said of food addicts, but if the aberrant activity is just eating, it somehow doesn’t count.) There is also a time dimension. If four of the significant criteria are fulfilled, the diagnosis is made – but only if all four symptoms appeared during a 12-month period. The NCRG explains:

In other words, if the person had two symptoms years ago and two symptoms in the past year, he or she would not qualify for a diagnosis.

Dr. Pretlow is interested in all modalities that have been applied to any type of addiction, and expressed regret that the organizers of an international conference he once attended only seemed to focus on the “sexier” addictions like the Internet, gaming, gambling and, well, sex. One reason why this all matters is that methods that have been successful with other addictions have a good chance of being adaptable to treating food addiction.

Your responses and feedback are welcome!

Source: “The Evolving Definition of Pathological Gambling in the DSM-5
NCRG.org, 05/19/13
Image by Alan Cleaver

 

Good Ideas for Parents

canI eat it

Happy holidays! It’s a tough time of year for people who struggle with food addiction and obesity. Here are some assorted suggestions from many sources. No single one will keep your child from becoming obese or solve her or his existing problem. But every little step counts. Here are five general precepts compiled by Danielle Longhurst for Deseret Digital Media:

  • The choice cannot be if children are going to be active; it must be how
  • Parents must set the example
  • Have unscheduled family time? Get outside!
  • Walk/run/scooter/bike whenever possible
  • Explore new fitness options and set goals
  • Detroit’s Beaumont Hospital offers a tidy list of 13 hints for parents. Some are duplicates – the advice for parents to set the example, for instance, can never grow stale or be repeated too often – and they stress the importance of yearly checkups. Another of their important hints is not to use food as either a reward or a punishment. With this, Dr. Pretlow is in absolute agreement, saying:

    Obesity appears to result from eating for reasons other than hunger, for simple pleasure and as a coping mechanism for relief from sadness, stress, anxiety, and boredom. Parents enable this in their kids by using food to ease distress from an early age (“Give him a bottle if he cries”) and as treats to give and buy love from the child (Cool Whip commercial slogan – “Give the Cool Whip, get the love”).

    Childhood Obesity News has passed along hints from registered dietician Maryann Jacobsen before, and here is another one: educate yourself to understand the role of normal development in a child’s eating habits. For instance, toddlers of a certain age are very fond of saying “No,” and there is not much a parent can do except wait it out. Adolescence brings a whole different set of challenges. While it may be tempting to force a kid to eat one thing or another, Jacobsen explains why this is counterproductive, in a piece titled “What Forcing Kids to Eat Looks Like 20 Years Later.”She also advises parents to serve food with a confident and expectant attitude, as if you are certain the child will try some. No matter what you do, don’t fling around labels like “picky eater” because this will only reinforce the food-refusing behavior that you want to discourage.

    Time Is of the Essence

    This idea has been suggested before, but the Salk Institute recently did some research that seems to confirm the importance of eating at certain times and, more crucially, of not eating at other times. The study subjects mice, not humans, but hopes are high that, as in many other laboratory results, rodents and people share the basic mechanism. If a mouse’s food consumption is limited to a window of between 9 and 12 hours, that mouse will be slimmer than its counterpart who is allowed to snack at any point in the day or night – even if they take in the same number of calories. But here is the big news, as expressed by Dr. Andrew Weil:

    The research has also shown that allowing the mice to eat only during a specified eight-hour period reversed obesity and diabetes.

    Yes, that word is “reversed.” Needless to say, this line of inquiry seems well worth pursuing. And you don’t need a laboratory to do it. Try it out at home, on yourself and your kids, and please let Childhood Obesity News know the results!

    Your responses and feedback are welcome!

    Source: “5 ways to cure your little couch potatoes,” NewsOK.com, 12/04/14
    Source: “13 Ways to Prevent Childhood Obesity,” beaumont.edu, 09/02/14
    Source: “15 of the All-Time Best Strategies for Raising Healthy Eaters,” RaiseHealthyEaters.com, 02/07/14
    Source: “When You Eat May Matter More than What You Eat,” DrWeil.com, 12/11/14
    Image by Mike McCune

    Food and Gambling

    All In

    In a Rudyard Kipling poem so infamous we won’t even link to it, the poet concludes that “the Colonel’s Lady an’ Judy O’Grady/ Are sisters under their skins!” In other words, despite appearances, a respectable high-society wife and the wife of a lowly enlisted man are more alike than they are different. Could this be true of, for instance, food and gambling?

    Childhood Obesity News has been looking at some of the odd, contradictory, and confusing aspects of substance-use disorder as described by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A puzzling question remains: How is food addiction not recognized when other, similar disorders are included?

    Of course, not all foods are addictive to all people. That would be absurd. It only happens often enough to be a giant contributing factor to the obesity epidemic, that’s all.

    Different Strokes for Different Folks

    Obviously, diverse individuals are unhealthfully attached to various problem foods. Dr. Pretlow has polled the thousands of children and teenagers who find a safe haven at his Weigh2Rock website, and among them sweetness definitely rules. As we see, chocolate and other kinds of candy are the clear winners in the problem food arena. Hamburgers, chips, and pasta also come into play, as well as very specific sweet treats such as “swiss roll cakes.”

    As people age, their tastes often become more sophisticated, and the problem food may be cheese, or even something as seemingly benign as organic Medjool dates. Just for ease of communication, “food” is used here as a generic term, standing in for one or more of many different potential problem foods. (BTW, Dr. Pretlow’s W8Loss2Go smartphone app offers ways to defeat them all.)

    Yes, Food Can be Addictive

    To recap: according to the Weigh2Rock kids who respond to polls and questionnaires, or write extemporaneously about their personal experiences, and also according to a great many experts whose work has been mentioned by Childhood Obesity News, food is capable of performing in the role of addictive substance. Like any addictive substance, it is capable of being abused.

    It is generally understood in our society that a substance is being abused when it interferes with the normal physical and social processes of life. It is generally agreed that when this happens, the person has a disease or disorder. So, why isn’t food addiction a disease like alcoholism? Why isn’t uncontrollable use of food included in DSM-5 like, for instance, uncontrollable gambling?

    What About Gambling?

    Let’s look at what staff members of the National Center for Responsible Gaming say about gambling, and the attitude the DSM takes toward that habit. In the previous edition of the Diagnostic and Statistical Manual, pathological gambling (PG) appeared in the book section called “Impulse Control Disorders Not Elsewhere Classified.” During the long and arduous preparation of the new edition, DSM-5, the work group suggested moving PG into “Substance-Related and Addictive Disorders” for these reasons:

    The rationale for this change is that the growing scientific literature on PG reveals common elements with substance use disorders. Many scientists and clinicians have long believed that problem gamblers closely resemble alcoholics and drug addicts, not only from the external consequences of problem finances and destruction of relationships, but, increasingly, on the inside as well.

    Everything that paragraph says about gambling could be said with equal accuracy about compulsive overeating, the kind that usually leads to obesity and a constellation of consequences even more serious than financial and relationship problems.

    Sure, gambling can kill indirectly, as when debts are not paid and violent retribution is dealt out. But food addiction quite literally kills – not immediately, but over time, and the patient ends up just as dead as when the cessation of life is caused by, for instance, a heroin overdose. That is why the term “morbid obesity” exists. We will look more extensively at the similarities between various disorders, quite soon.
    Your responses and feedback are welcome!

    Source: “The Evolving Definition of Pathological Gambling in the DSM-5,” NCRG.org, 05/19/13
    Image by Darren Johnson

    Adrian Meule Forges Ahead Studying Food Addiction

    Size Comparison Photo sideways

    As a doctoral student at the University of Würzburg in Germany, Adrian Meule
    was influenced by Dr. Pretlow’s “Addiction to Highly Pleasurable Food as a Cause of the Childhood Obesity Epidemic: A Qualitative Internet Study” in Eating Disorders: The Journal of Treatment & Prevention.

    Meule advocated using the Yale Food Addiction Scale (YFAS) as a standardized measuring device, so researchers could better understand the phenomenon. He came across even then as an original thinker fascinated by orphaned facts and strange coincidences. He pointed out, for instance, that bulimia nervosa patients and binge-eating disorder patients are also drawn to addictive drugs, while patients with anorexia nervosa apparently are not. It is the type of puzzle that can inspire a career.

    Even though Meule believed in food addiction, he did not give it credit for causing the entire obesity epidemic. He wrote to Dr. Pretlow at the time, about this and other ideas and mysteries. For instance:

    In the studies of Gearhardt et al. (2011) and Davis et al. (2011), many obese individuals had at least 3 food addiction symptoms, but did not receive a “diagnosis” because they did not meet the clinically significant impairment criteria. So, the construction of the YFAS might lead to an underestimation. However, when I administered the YFAS to obese individuals seeking bariatric surgery, I experienced that – although some 40% received a diagnosis – many persons told me that all those questions did not apply to them at all.

    Having earned his doctorate, Meule is now at the Hospital for Child and Adolescent Psychiatry in Hamm, Germany. In the past few years he has published articles on emotional eating, bariatric surgery, impulsivity, food-cue affected motor response inhibition, and many more topics.

    Recently, along with Vittoria von Rezori and Jens Blechert, Meule returned to the tantalizing similarity between obese patients with binge eating disorder (BED) and patients with bulimia nervosa (BN). In BED patients, they find that:

    …eating patterns can show addictive qualities, with similarities to substance use disorders on behavioral and neurobiological levels.

    BN patients also show binge eating symptoms, although this has not been much attended to.

    Neither the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) nor the previous edition recognized food addiction as an entity, but the Yale Food Addiction Scale was created using the DSM symptom checklist for substance use disorders. Interestingly, there are people of normal weight who fulfill the food addiction criteria – and they are women with active BN.

    Meanwhile, among women whose bulimia is in remission, only a fraction as many qualified for a food addiction diagnosis according to the YFAS, and none of the normal control group. Because of these findings, the researchers tend to see bulimia nervosa as an “addiction-like eating behavior.”

    Your responses and feedback are welcome!

    Source: “Food Addiction and Bulimia Nervosa
    frontiersin.org, 08/11/14
    Image by thepeachpeddler

    Substance-Abuse Disorder, Unclarity, and Confusion

    Love Latte

    Exploring the definitions for eating disorders in the Diagnostic and Statistical Manual (DSM-5) is an Alice-in-Wonderland type of experience, full of surprises and contradictions. Many hundreds of professionals worked tirelessly to formulate the book’s information, yet paradoxes abound. Many questions remain unanswered, with a ragtag collection of odds and ends that may or may not add up to something.

    According to the checklist used to diagnose a substance-use disorder, there are 11 or 12 potential symptoms, depending on the substance. One of the signs – withdrawal – does not apply to hallucinogens or inhalants, while it does apply to the painful process of quitting a problem food. By that reckoning, food would appear to be even more addictive than some drugs.

    Every one of the symptoms on the list has been experienced by a real-life, self-identified food addict, an idea that Childhood Obesity News played with by creating a hypothetical compulsive eater who showed all the hallmarks. A drug user with only 7 of the checklist items would qualify as “severe” – the highest rating. Yet a food addict could easily fulfill every one of the criteria for substance-abuse disorder, and create a new category of seriousness that is even above “severe.” Maybe, as some researchers and clinicians believe, what people describe as food addiction could be a substance-abuse disorder, unrecognized as such by DSM-5.

    Coffee Break

    Caffeine is the world’s most popular psychoactive drug, and DSM-5 allows for both caffeine intoxication and caffeine withdrawal, although not caffeine addiction. Regarding caffeine intoxication:

    The official diagnosis can be made when any 5 of the following symptoms are present: restlessness, nervousness, excitement, insomnia, flushed face, diuresis (you keep passing urine), gastrointestinal disturbance (upset tummy, diarrhea), muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, or psychomotor agitation.

    Characterizing caffeine withdrawal as “a very unpleasant experience,” the website CaffeineInformer.com lists ten symptoms: headache, sleepiness, irritability, lethargy, constipation, depression, muscle pain/stiffness, lack of concentration, flu-like symptoms, and insomnia.

    That all sounds fairly serious, yet clinical psychologist Robin Rosenberg does not think either caffeine intoxication or caffeine withdrawal belongs on the roster of mental disorders. She says that the intoxication is temporary and,

    The symptoms of caffeine withdrawal are transitory, they take care of themselves. It’s just a natural response to stopping caffeine, and it clears up on its own in short order.

    The point is, Rosenberg specifically said she doesn’t understand why either one is included in the DSM-5. So, on the one hand, a substance (caffeine) with intoxicating effects and an uncomfortable withdrawal process is not categorized as addictive. Its proponents do not want it stigmatized by inclusion in the diagnostic manual as an addictive substance. Despite this, it appears in the DSM-5 as the cause of intoxication and withdrawal. On the other hand, a different substance (food) is accused by its adherents of being addictive according to every criterion, but does not appear in the DSM-5 section on addiction.

    Things are kind of mixed up.

    Your responses and feedback are welcome!

    Source: “Caffeine Overdose Symptoms: Facts and Fiction,” CaffeineInformer.com, undated
    Source: “Normal or Not? How Coffee Drinking May Brew a Mental Disorder
    LiveScience.com, 05/28/13
    Image by PoYang_博仰

    Mysteries of the Feeding and Eating Disorders

    Trilogy 4

    Childhood Obesity News has discussed the change that took place in the latest edition of the Diagnostic and Statistical Manual, which now places Binge Eating Disorder (BED) in its own category, under Feeding and Eating Disorders. (The others are Pica, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder, Anorexia Nervosa, Bulimia Nervosa, Other Specified Feeding or Eating Disorder, and Unspecified Feeding or Eating Disorder.)

    Also mentioned was the distinction made by Dr. Vera Tarman between BED and food addiction. Along with her colleague Phil Werdell, Dr. Tarman was active in trying to get food addiction included in DSM-5, to no avail. She calls the omission “a poor reflection of our clinical reality.”

    What are the diagnostic features of BED?  It’s not a one-time occurrence, but happens over and over again, and the habit causes great personal distress. Unlike the anorexic, the binge eater does not try to make up for all those extra calories by vomiting them up or exorcising them with exercise. As with other DSM-5 disorders, there is a checklist. When a patient shows up with 3, 4, or all 5 of these hallmarks, the clinician can be fairly confident of the diagnosis.

    • Eating until feeling uncomfortably full
    • Eating large amounts of food when not feeling physically hungry
    • Eating alone because of being embarrassed by how much one is eating
    • Feeling disgusted with oneself, depressed, or very guilty after overeating
    • Eating much more rapidly than normal

    On the other hand, those guidelines leave some room for misinterpretation and error. Four of the elements are not scientifically verifiable, being based (necessarily) on self-reporting. Only one can be tested against observable reality: the rapid eating. How is anyone to know if they eat faster than other people? Sure, kids around the cafeteria table will make merciless fun of gobblers. But as people grow older and learn to dissemble, what they do in public is not always the same as what they do in private. On any given day, a person might meet ten closet binge eaters, and never know. Furthermore, according to Horace Fletcher, almost everybody eats too fast anyway, and even if it is normal, it shouldn’t be.

    In “Why Are Children Overweight?” Dr. Pretlow’s 2010 presentation to the Royal College of Physicians National Obesity Forum, he hypothesized that binge eating might be an amalgam of comfort eating and a displacement activity.

    A recent study published in the International Journal of Obesity reported that the brains of overweight and obese kids are hypersensitive to sugar.  There is, in the words of Prof. Kerri Boutelle, an “enhanced response” to the chemical. She explains:

    This elevated sense of ‘food reward’ – which involves being motivated by food and deriving a good feeling from it could mean some children have brain circuitries which predispose them to crave more sugar throughout life….The brain images showed that obese children had heightened activity in the regions of brain involved in perception, emotion, awareness, taste, motivation and reward.

    Some binge eaters specialize in sweets, and comfort eating very often involves sugar-intensive foods. In the realm of food addiction, sugar has been accused of being an addictive drug. How does this information fit in with all the rest? How does it conform with the long list of causes for obesity compiled by Lauren Rossen, PhD, in her book Obesity 101. Sometimes it seems as if an overarching yet elusive Unified Field Theory of obesity lies tantalizingly close but as yet unguessed-at.

    Your responses and feedback are welcome!

    Source: “New in the DSM-5: Binge Eating Disorder,” nationaleatingdisorders.org, 06/05/13
    Source: “Why obese kids feel better than thin kids after eating food,” TheHealthSite, 12/12/14
    Image by Fat Amy

     

    The Food Addiction Institute Viewpoint

    Trilogy 3

    Last time, Childhood Obesity News referenced a quotation  by Dr. Vera Tarman to the effect that Binge Eating Disorder (BED) is related to “what is eating you” (emotional and psychological problems). In food addiction, “what you are eating” is the villain (highly processed food-like substances laced with chemicals and oodles of hidden sugar). The person gets hooked on one particular “problem food” (or maybe a few). That food is a problem because it has approximately the same effect on a food addict as cocaine does on a drug addict.

    Dr. Tarman was very disappointed to find no Food Addiction diagnosis in the revised Diagnostic and Statistical Manual, DSM-5. She foresees this consequence:

    We will have many food addicts funneled under the new categorization of Binge Eating disorder, and they will probably be given treatment that could ultimately undermine their recovery. Modified diets do not work for the food addict.

    In other words, DSM-5, the “bible” that is meant to guide a clinician in formulating a diagnosis, appears to recommend a course of treatment that will worsen the patient’s condition. And yet history records that the venerable Hippocrates admonished physicians to “First, do no harm.”

    Dr. Tarman and Phil Werdell of the Food Addiction Institute co-authored the book Food Junkies: The Truth About Food Addiction, scheduled for publication later this month. Werdall vigorously advocated the inclusion of food addiction in DSM-5 as a legitimate diagnosis, and Tarman calls him “a true pioneer: far sighted, dedicated and persistent.” Here are some words from the Food Addiction Institute:

    Initial scientific estimates, according to Dr, David Kessler, former Commissioner of the U.S. Food And Drug Administration, are that about 50% of the obese, 30% of those overweight, and 20% who are at what we consider a healthy weight, are actually addicted to a specific food, combinations of foods or, in some cases, volume of food in general….At least half of the obesity crisis would be better understood and more suitably named the food addiction crisis.

    That is a bold statement! If only more members of the medical establishment agreed with it, or were at least willing to consider the possibility.

    Disappointing as the final DSM-5 lineup may have been, the manual did something right, or at least close enough to justify a Food Addiction Institute article titled “DSM-V Acknowledges Food Addiction.” In Werdell’s view, the inclusion of BED paves the way for the recognition, in future editions, of food addiction as a substance use disorder. To support this optimism he quotes the Feeding and Eating Disorder section of DSM-5 (page 329):

    Some individuals with disorders described in this chapter report eating-related symptoms resembling those typically endorsed by individuals with substance-use disorders, such as strong craving and patterns of compulsive use.

    This recognition….is of extreme importance. It gives clinicians encouragement to look for a psycho-socially caused eating disorder, a biochemically caused food addiction, or both.

    Werdell makes the important point that both disorders should be acknowledged by health insurers, who seem a little too interested in avoiding anything that might cut into profits. Appropriate treatments for BED include therapy, mindfulness training, and medication, along with the modalities more often associated with addiction treatment – abstinence from the problem food, and education about dependency, along with “preparation for 12-Step-type aftercare.”

    Your responses and feedback are welcome!

    Source: “Binge Eating Disorder in the DSM 5: Good News or No News for the Food Addict?,” Addictionsunplugged.com, 01/30/13
    Source: “Food Addiction as a part of the Obesity Epidemic,” foodaddictioninstitute.org/, undated
    Source: “DSM-V Acknowledges Food Addiction,” FoodAddictionInstitute.org, 08/18/13
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