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This year more than 60,000 Americans will struggle with morbid obesity (classified as being 100 pounds or more overweight), and some of those individuals will walk into your office seeking treatment. More than a billion people worldwide, including 22 million children under the age of 5, are now overweight or obese — and the rate in America is increasing. Obesity presently plagues approximately 64.5 percent of adults and 15 percent of children ages 6 to 19 in the U.S. (Grady, 2002).
There have been several models proposed to explain addictive behaviors whether they involve drugs, gambling, sexual acting out — or overeating. The moral model focuses on the weakness of character to explain why an individual can’t stop the behaviors. For example, obese patients are frequently confronted concerning their “lack of will power.” Some in our society believe obese individuals could lose weight if they only had some self-control. The media constantly tells people if they just follow certain patterns, they too, can be thin and fit.
The self-medication model looks at eating as a way of “dulling the pain” — whether it is physical or emotional in origin. The term “comfort food” fits with this model. Patients will eat when feeling lonely, bored, tired, or frustrated. The social model looks at behaviors learned by growing up in an environment supporting certain behaviors. Some families use food or family dinners as a way to communicate or socialize.
However, it is the disease-concept model that makes the most sense when examining compulsive overeating and food addiction. For example, most people are comfortable with the idea of diabetes being a “disease.” Yet when asked why, it usually brings a puzzled look to many faces. If you examine the disease criteria met by diabetes, it is evident why the same criteria apply to eating behaviors — a biological cause is identified in a disease.
In obese individuals, several genetic twin studies have examined the biological causes of weight gain. Adopted children have similarities in body mass to their biological parents, but not their adoptive parents. Several genes in mice have been identified which affect appetite. Mutations of each gene lead to obesity and each of these genes have a human homolog. These genes regulate leptin or leptin receptors (Tierney et al., 2003). Leptin is a hormone produced by fat cells. When the leptin amount is decreased in the body, the brain sends out signals to decrease metabolism and increase eating. It was once thought that obese people had decreased leptin levels leading to increase in appetite — but this is not the case. Obese individuals have levels that are normal or above normal (Manrzoros, 1999; Heymsfield et al., 1999).
Several other biological studies have involved hormones. Ghreline is produced in the stomach and small intestine and is the only natural appetite stimulant to be made outside the brain. People who receive shots of ghreline eat 30 percent more than normal. The level drops in gastric-bypass patients, which may account for the drastic decrease in appetite after surgery (Grady, 2002). Research is underway to determine its role in weight loss. Another gut hormone, PYY, is released in response to food. It circulates to the brain where it decreases the urge to eat. It is reduced in patients who have had stomach bypass surgery (Tierney et al., 2003).
Current studies have shown that a subgroup of obese patients has “BED” (binge eating disorder), a DSM-IV classification of eating disorder now under investigation (Fairburn, 1995; Goldfein et al., 1993). These patients are able to eat a large amount of food at one sitting, which correlates with the stomach being able to expand (measured using a gastric balloon) more than controls who did not have BED. This increased ability to tolerate more food is consistent with studies that show patients with anorexia experience a decreased gastric expansion, leading to the increased feeling of fullness that is so poorly tolerated by anorexic patients. The obese individual will rarely recognize satiety and if they do, will eat through the feeling of “fullness.” Another type of obese patients will constantly consume portions of high calorie foods throughout the day.
Eating can also be triggered by what some patients swear is an addiction to sugar. These individuals are fine without sugar in their diet, but once they consume a food product high in sugar they continue to crave large amounts of sweets. This group complains of a “dullness” of thinking following the sugar load. The common denominator in any of these patterns of eating is the excessive number of calories consumed, which ultimately leads to weight gain.
One common theme compulsive over-eaters share is the feeling of “loss of control.” Several theories have been proposed to explain binge eating, the restraint theory (Fairburn, 1995; Cooper, 1995), the affective theory (Heatherton and Polivy, 1992) and recently a psychosocial model involving dietary restraint, negative affect, weight cycling, history of teasing and body dissatisfaction (Womble et al., 2001). Several studies have also looked at the relationship between increased WHR (weight to hip ratio) as a symptom of chronic hypothalamic arousal induced by a defeatist reaction to psychosocial pressure (Bjorntorp, 1991). The combination of neurochemical involvement, hormonal involvement, and genetic predisposition gives enough evidence for the biological link to obesity.
The second “disease” criterion is a distinct set of symptoms. The “symptoms” associated with obesity are well documented — hypertension, insulin resistance, high LDL-cholesterol, low HDL-cholesterol, shortness of breath, knee and ankle pain all start the long list of physical problems. Certain cancers are higher in obese patients such as colon, rectal, and prostate in men; while uterine, biliary tract, breast, and ovarian cancer dominate in women. Those who are obese have a greater risk of endocrine abnormalities, coronary artery disease, and thromboembolitic disorders. Less than one percent of obese patients have an identifiable secondary cause of obesity such as Cushing’s syndrome, Prader-Willi syndrome, or hypothyroidism (Tierney et al., 2003). The shame and guilt an obese patient feels about their body may keep them from seeking medical care and supervision. Many patients feel that their physicians are not sympathetic or supportive and therefore they would rather suffer than get help.
Patients with a disease meet the third criteria of a “progressive course.” Untreated diabetes can lead to blindness, loss of limbs, kidney failure, and skin breakdown. Obese individuals have a 50-100 percent risk of premature death over individuals with a BMI of 20-25. Their increased medical problems cost the nation $117 billion in 2000 alone and data indicates that 1 in 4 adults are obese (U.S. Dept. of Health and Human Services, 2001). Meanwhile, obese patients complain that their weight continues to go up due to poor food choices and lack of knowledge of portion size. In addition to the physical problems associated with obesity, there are mental problems as well — such as higher rates of depression. Obese individuals are acutely aware of the way society regards them. They are faced with constant reminders as they watch television, read magazines, go to the beach, or watch people enjoying sports. Patients go to extreme lengths to hide their bodies, and even describe their bodies with loathing and disgust (Fairburn, 1995). The idea of going to a gym is terrifying because of the mirrors and the majority of fit people working out. They listen to ads and try to find the “quick fix.” Many obese individuals lose weight multiple times, but are unable to keep the weight off. The search for a “magic pill” continues which leads to the fourth and last disease criteria — treatment.
Hope in a bottle
Several medications are available to obese individuals. Phentermine is a central adrenergic agonist that can lead to appetite suppression and weight loss. Sibutramine works to suppress the appetite primarily by inhibiting the reuptake of the neurotransmitters norepinephrine and serotonin. It can increase thermogenesis and decrease food intake. Orlistat is an inhibitor of pancreatic lipase and blocks about 30 percent of ingested dietary triglycerides. However, patients can experience diarrhea and therefore vitamin supplementation is needed. Only sibutramine (Meridia) and orlistat (Xenical) are approved by the Food and Drug Administration for long-term weight management (McMahon et al., 2000; Hauptman et al., 2000; Glazer, 2000; Davidson et al., 1999; Sjostrom et al., 1998). The problem with using a medication to treat the disorder is that when the medication is discontinued — the symptoms reappear. An individual with diabetes can stabilize on insulin, but as soon as that person stops taking the insulin the symptoms return. Studies show that patients who combine medications with long-term patient-practitioner contact, lifestyle changes, dietary supervision, and exercise have improved weight control (Wadden et al., 2001; Perri et al., 1989). Physicians may limit the use of medications to a 12-15 week period, which allows the patient to learn healthier ways of eating and exercising. This gives the patient some assistance in controlling their appetite while starting a healthier lifestyle.
Patients who have several medical complications as well as a BMI > 35 kg/m2 meet criteria for surgical intervention. Many patients have to lose weight first before being considered a candidate for procedures carrying additional surgical risks. The most popular gastric operations are the vertical banded gastroplasty (VBG) and the Roux-en Y gastric bypass (GBP). Laproscopic methods are used in some patients and both procedures lead to substantial amounts of weight loss. Complications can occur in up to 50 percent of patients undergoing surgery and can include peritonitis, leakage at the anastomotic sites, ulcers, stenosis, and infection. The mortality rates are less than one percent (Carson et al., 1994; Nguyen et al., 1999). The psychological changes that happen with extreme weight loss are just as important to address in order to help the patient adjust to the physical changes.
A patient rarely seeks treatment with a single diagnosis of Eating Disorder NOS (currently the DSM-IV diagnosis for a compulsive overeater). There may be a co-occurring drug addiction, anxiety disorder, or major mood disorder. It is important to get a good history from the patient and to find out which came first — the eating disorder or the co-morbid problem. It is not unusual for obese patients to previously have seen a therapist or psychiatrist and tried antidepressants or over-the-counter medications.
Several of the depression medications include weight gain as a side effect and at times a patient may gain 40-60 pounds. This type of result causes the obese patient to fear medications. The goal of using medications is to decrease the obsessive thinking around food and to control the compulsive behaviors. There are some medications available that do not cause the weight gain and it is important to review the options with each patient’s physician. The combination of cognitive, behavioral, and additional therapies in combination with medication can help the patient focus on the issues driving his or her behavior. The treatment of obesity in an in-patient setting is an option that unfortunately is not considered by many individuals who have struggled with the disease for years. The majority of in-patients have tried different “solutions” for years without success. Only 20 percent of patients will maintain a 20 lbs. weight loss over a two-year period, and only 5 percent will maintain a 40 lbs. weight loss (Tierney et al., 2003). It is unclear what keeps people from succeeding in their efforts to decrease their weight. The chance to put some sort of resolution to grief, family of origin, spiritual, interpersonal and self-esteem issues may be essential to helping people change their eating patterns.
The counselor’s goal
The task of the counselor is to help the patient realize that they don’t have to fight obesity alone. The thought of having to lose 100 lbs. can be overwhelming to anyone. The idea is to help the patient set small, reasonable goals. For example, an obese patient can think about losing 10 lbs. and can start to lose the “diet” focus. Patients will frequently comment after treatment that they were surprised at how easy it was to lose the weight while in treatment. The part they don’t realize is that they are conscious of “feeling full” for the first time and are listening to the cues that their body is sending them. The important part of the process is to have a support system along with a team of people helping the patient identify triggers for overeating. Counselors will feel overwhelmed if they have to deal with all the aspects of a patient’s treatment.
The use of 12-Step groups can help the patient examine several aspects of their own behavior and many respond to OA (Overeaters Anonymous) or EDA (Eating Disorders Anonymous). If a patient is resistant to a 12-Step focus, suggest joining a process group. Food buddies may be useful in helping the patient set strict boundaries with family members and enable them to take control of their own recovery. Too often, the patient enlists the spouse or parent as the “co-recovery” coach, which is a recipe for failure. The obese individual needs to understand that he or she is responsible for their own personal recovery process.
Why do they overeat? The underlying cause of compulsion
There are several reasons why a person might compulsively overeat. The number of patients with trauma or abuse histories is alarming. Women will identify sexual abuse as a starting point for overeating. “I never wanted to be attractive to a male again” is a frequent statement by women who would suddenly start to put on weight as an adolescent or after being sexually abused.
The “protective fat” is used as a way to isolate and “feel safe.” Studies have correlated an association of eating disorders in patients with histories of sexual trauma (Wonderlich et al., 2001; Steiger et al., 1990). The luxury of an inpatient setting is that the patient has time to do the trauma work in a protected environment and has support 24-hours-a-day. A patient with an abuse history may come into a therapist’s office and talk about her anxiety or depression rather than the abuse. It is important to ask directly about any abuse history whether it is physical, verbal, emotional, or sexual.
Patients will finally come into treatment in order to address the fear that they may not be able to physically parent their children. The lack of mobility may lead to the inability to keep a toddler safe if the child runs into the street or falls into a pool. The thought of being unable to participate in sports with a child can lead to feelings of failure and loss.
Patients are embarrassed to talk about their loss of sexual intimacy with significant others due to their weight. These sensitive issues are extremely difficult to discuss with therapists or physicians.
Whether a patient is seeking inpatient or outpatient treatment, education is essential in the therapeutic community to consider the “disease concept” and treat the obese patient with compassion and sensitivity. A team approach can help the patient to combine exercise, nutritional support, therapy and spiritual growth to meet their goals and live a healthier lifestyle.
Vicki Berkus, MD, PhD, CEDS, has treated patients with eating disorders for nine years in an inpatient setting. She is the current president of IAEDP (International Association of Eating Disorders Professionals). She can be reached at
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References
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Carson, J.L., Ruddy, M.E., Duff, A.E., Holmes, N.J., Cody, R.P., Brolin, R.E.(2000). “The effect of gastric bypass surgery on hypertension in morbidly obese patient.” Archives of Internal Medicine.154:193-200.
Cooper, P.J. (1995). “Eating disorders and their relationship to mood and anxiety disorders.” In D.D. Brownell & C.G. Fairburn (Eds.), Eating Disorders and Obesity: A comprehensive handbook. Fuilford Press: New York, New York.
Davidson, M.H. et al. (1999). “Weight control and risk factor reduction in obese subjects treated for two years with orlistat: A randomized controlled trial.” JAMA, 281:235.
Fairburn. Christopher. (1995). Overcoming Binge Eating. The Guilford Press: New York, New York.
Glazer,G. (2000). “Long-term pharmacotherapy of obesity 2000. A review of safety and efficacy.” Archives of Internal Medicine. 2001:161-1814.
Goldfein, J.A., Walsh, B.T., LaChaussee, J,L., Kissileff, H.R., & Devllin, M.J. (1993). “Eating behavior in binge eating disorder.” International Journal of Eating Disorder 14, 427-431.
Grady, D. (Nov. 26, 2002). “Why we Eat (and Eat and Eat).” The New York Times.
Hauptman, J. et al. (2000). “Orlistat in the long-term treatment of obesity in primary care settings.” Archives of Family Medicine 9:160.
Heatherton, T.F. & Polivy, J. (1992). “Chronic dieting and eating disorders: Apiral model.” In J.H. Crowther, D.L. Tennenbaum, S.E. Hobfoll & M.A. Stephens (eds.) The etiology of bulimia nervosa: the individual and familial context. Hemishpere: Washington D.C.
Heymsfield, S.B. et al. (1999). “Recombinant leptin for weight loss in obese and lean adults: a randomized, controlled, dose-escalation trial.” JAMA 292:1568.
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Nguyen, N.T. et al. (1999). “Laproscopic roux-en-Y gastric bypass for super/super obesity.” Obesity Surgery. 9:403.
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The Case of Patty
Patty is addicted to food and like 60 percent of all Americans — she is overweight. Often she would sit in her living room at night and try to resist the sweets that called to her from the kitchen. As hard as she would try to ignore the call, she would eventually eat the entire box of cookies or cake, sometimes going out to buy more. The addicted person has a body chemistry that is different from the non-addicted individual. Food addiction cannot be understood or managed without recognizing this physical problem.
Some foods can be as addictive as cocaine, alcohol, or any other addictive substance. Addiction to particular foods is not due to a lack of willpower, nor is it a behavioral problem, but rather it is a physical condition with symptoms and characteristics that can be recognized. Food addiction refers to a pattern of food use characterized by obsession with food, obsession with weight, and loss of control over the amount eaten. These elements are included in the DSM-IV criteria for the diagnosis of bulimia nervosa and binge eating disorder. The term “food addiction” implies there is a physiological, biochemical condition of the body that creates craving for refined carbohydrates. This craving (and its underlying biochemistry) is comparable to the alcoholic’s craving for alcohol. The need to abstain from the addictive substance is common to both alcoholics and food addicts. It involves the compulsive pursuit of a mood change by repeatedly engaging in episodes of binge eating despite adverse consequences.
Food addicts, like other addicts, experience painful symptoms of withdrawal in the first days of abstinence from “trigger” foods. Since there is a physical need to keep a certain amount of carbohydrates in the body at all times, withdrawal from refined carbohydrates results in physical and emotional discomfort. On her third day detoxifying from addictive foods, Patty said, “Only this tortured body could provide the evidence I needed of the power of the substances I was eating.” She reported sleep disturbances, headache, severe body aches and pains, frequent urination, and extreme lethargy.
Food addiction is progressive. Early signs involve development of distinct attitudes and behaviors concerning food such as extreme concern about being deprived of binge food, stealing food, lying about food consumption, and using food to relieve tensions as well as other uncomfortable feelings. Patty carried candy in her purse and pocket, ate secretly in the classroom and the bathroom, and used sweets to soothe angry and fearful emotions.
As the intake of addictive food increases, certain changes take place in the body tissue, raising the physiological level of tolerance. The body begins to experience the basic truth of all addictions: increased tolerance demands increased intake. This is why a food addict may eat his or her way to hundreds of pounds of additional weight.
Sensitivity and defensiveness surround the use of food. Patty hated conversations that made reference to the amount of food she ate and her weight. Since, her efforts to control eating and weight failed repeatedly, she tried every new approach for weight control. Diets, shots, exercise programs, and pills failed because they treated the symptoms of obesity and ignored the serious condition of addiction. Each new disappointing weight loss regimen produced frustration and a sense of failure
Good information is the key to recovery. When Patty entered recovery, she discovered that abstinence from all trigger food was the key to success. Food addicts cannot safely use refined and processed foods that alter brain chemistry and result in mood changes. To accomplish abstinence, Patty learned to scrupulously identify all of the ingredients in the food she consumed, thereby avoiding cravings.
An individual who is truly addicted to food cannot be cured. The addict’s biochemistry remains a permanent physical condition. Food addiction, however, can be arrested by participation in 12-Step programs, therapy with specialists/counselors in food addiction treatment, and compliance with food planning guidelines to avoid relapse.
Kay Sheppard, MA, is a licensed mental health counselor and certified eating disorders specialist. She is the best-selling author of Food Addiction: The Body Knows, From the First Bite: A Complete Guide to Recovery from Food Addiction, and Food Addiction: Healing Day By Day scheduled for publication this fall. Her web site is www.kaysheppard.com
This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4, n.3, pp. 51-57.
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