Food is essential for life, so how can you have food addiction?

1. Food is essential for life, so how can you have food addiction? NZ Food Addiction Symposium Christchurch, 6 September 2013 Prof Doug Sellman National Addiction Centre University of Otago, Christchurch

2. Acknowledgements Ria Schroder Daryle Deering Jane Elmslie Frances Carter Jim Mann David Schroeder 25 fellow travellers

3. Journey out of skepticism • My own experience of weight loss • The stories of 25 fellow travellers • Growing scientific evidence for “food addiction”

4. Public attitudes about addiction as a cause of obesity Colleen Barry (2012) • Large random sample of news articles in the US about childhood obesity 2000 – 2009 • 53% of the news stories identified individual behaviour (parent and/or child) as a cause • Only 1% mentioned food addiction as a possible cause 

5. From the front lines Philip Werdell (2012) • Has worked with over 4000 “late-stage food addicts” since 1986 • Recently developed the Food Addiction Institute in Sarasota, Florida • “[In my experience] most doctors, dieticians and therapists discount or minimize chemical dependency on food”

6. Can an obese compulsive overeater get treatment in NZ? • Survey of: 21 addiction services 20 eating disorder services • July/August 2012 • Services rung by a fake inquirer – a sister of a person who has a weight problem • Auckland, Wellington, Christchurch Whangarei to Dunedin, Greymouth to Gisborne

7. Hullo, my name is Natalie Smith and I'm ringing up on behalf of my sister Shiree. The problem is that Shiree is about 110kg in weight …and seems to have an addiction to food. She doesn't have any other addictions as far as I know …and seems to have an eating disorder. She doesn't binge or purge as far as I know and has never been anorexic. She just compulsively eats food. I really want to find out what help your service can give her or where to go for help.

8. Addiction Service Findings • 4 of the 21 services not surveyed • Of the 17 services surveyed: - 2 said yes, come for an assessment (12%) - 6 declared it was an eating disorder (35%) - 7 advised Overeaters Anonymous (41%) - 10 advised GP consultation (59%)

9. Not us - “We don’t deal with eating disorders, first place to go is to your GP who will refer you on to an appropriate service like a dietitian and an exercise regime” - “It’s really an eating disorder so you’ll need to go to your GP and get a list of people who deal with eating disorders or get a referral for counselling”

10. Come for an assessment - “Food addiction is similar to other addictions so it would be appropriate to come in for an assessment” (large city) - “Not a normal focus for us but as it is an addiction there is no reason we couldn’t work with her” (small city)

11. Eating Disorder Service Findings • 3 of the 20 services not surveyed • Of the 17 services surveyed: - 1 said yes, come for an assessment (6%) - 0 declared it was a food addiction (0%) - 4 advised Overeaters Anonymous (24%) - 12 advised GP consultation (71%)

12. Come for an assessment - “We’re happy to help with overeating as well as undereating, just come in for an assessment” (small city)

13. Not us - “You will be horrified to hear this, but as an eating disorder service we only treat people with undereating problems” • “Obesity is not considered an eating disorder and therefore we are not funded to work in that area” • “Overeating is an eating disorder but its not in the DSMIV… there’s a possibility in the new DSM so we may be able to cater for it then” • “We could see her if she had underlying psychological issues”

14. Main points from both surveys • Less than 10% of either addiction or eating disorder services said yes to an assessment (of a morbidly obese person with out-of-control overeating) • 28% advised OA • 55% advised a GP consultation

15. BMI < 18.5 underweight 18.5 – 24 normal weight 25 – 29 overweight 30 – 34 obese 35 – 39 clinically obese > 40 morbidly obese

16. Percentage of overweight people in the Anglosphere United States 74% New Zealand 68% Australia 67% United Kingdom 63% Canada 61% Ireland 47%

19. Five Strategies Take Control Get Active Eat Well Persist Enjoy Life

20. Adult Obesity in NZ 2008/09 Adult Nutrition Survey • 28% of people 15+ years were obese • 45% of Maori • 58% of Pacific • Increase in males from 17% in 1997 to 28% in 2008/09 • Increase in females from 21% in 1997 to 28% in 2008/09

21. Demographics

22. % Weight Loss at Last Weigh in (Up to 18 months)

23. Nestle Aero Singles “In the event of a chocolate craving, please take care of your craving first before helping others with theirs. Remove bar. Bite to release bubbles. Enjoy normally. Be prepared! Ensure Aero Singles are stowed in close proximity”

24. Food Addiction: A Personal Story Anne Rosenberg (2012) Am I really and truly a “food addict?” I am not a scientist and I am not too concerned with the exact label. But I do know I could not eat just one of those Nestle Aero Singles. And I am not alone. Nestle is banking on that!

25. What is addiction? • From the Latin addictus - devotion/attachment • Outdated term of the 1950’s and 1960’s, replaced by “dependence” in the 1970’s • Currently undergoing a revival - good for destigmatisation

26. Theodosius Dobzhansky, 1973 (1900 - 1975) “Nothing in biologymakes sense, Except in the light of evolution”

27. Charles Darwin1809 -1882 “I have called this principle, by whicheach slight variation, if useful, is preserved, by the term Natural Selection.”    (from ‘The Origin of Species’)

28. Approximate Time Estimates • 13.8 billion years ago – The Universe began • 4.5 billion years ago – Earth began • 3.5 billion years ago – Life on Earth began • 2.5 billion years ago – Photosynthesis began • 0.6 billion years ago – Adequate ozone layer • 0.5 billion years ago – Abundant complex life

29. ERA PERIOD EPOCH Cenozoic Quaternary Holocene (65 million - present) (10,000 - present) Pleistocene (1.8 million – 10,000) Tertiary Pliocene Miocene Oligocene Eocene Paleocene Mesozoic Cretaceous (248 - 65 million) Jurassic Triassic Paleozoic Permian (544 - 248 million) Carboniferous Devonian Silurian Ordovician Cambrian

31. What is drug addiction?George Koob (1947 - present) A chronic relapsing disorder characterised by: Compulsion to seek and take the drug Loss of control in limiting intake Emergence of a negative emotional state (dysphoria, anxiety, irritability)

33. Inhibitory Dysfunction Reward Overdrive Drug Drug Use Craving

34. NEURAL CIRCUITRY OF ADDICTION (Hammer 2002)

35. In non-hungry, non-thirsty rats, sweetened water is more rewarding than intravenous cocaine, independent of prior cocaine history Most heroin dependent rats eventually cut down heroin use to drink more sweet water Ahmed (2012)

36. Interaction between normal regulation of food intake and reward pathway • The major anorexigenic hormones – leptin, insulin, PYY (incentive modulation) - plus the single orexigenic hormone, ghrelin, act on VTA dopaminergic system as do “drugs of abuse” (Mason et al 2012) • Many neuropeptides that regulate food intake and body weight including proappetitive peptides orexin, ghrelin and neuropeptide Y, as well as appetite suppressing hormones - leptin and melanocortin – also shown to regulate addictive behaviours (Dagher 2012)

37. Ghrelin Orexin Neuropeptide Y (NPY) Mouse (on the left) unable to produce leptin becomes obese Melanocortin Leptin Peptide YY (PYY) Insulin

38. The increasing prevalence and impact of obesity in our society and the urgent need to develop better therapeutic interventions that help mitigate the pathologically intense drive for food consumption are clear. • We have an opportunity in DSM-V to recognize a component of obesity as a mental disorder. (Volkow & O’Brien, AJP 2007)

39. Alcohol addiction Food addiction

40. How many people with obesity have “food addiction”?

41. Diagnosis of food addiction based on DSM-IV SUBSTANCE DEPENDENCE 1. Consumption is often more than intended (quantity or time) 2. Unsuccessful attempts to cut down or control consumption 3. Much time is spent in consumption (time +++) 4. Important activities given up or reduced 5. Continued consumption despite knowledge of associated medical or psychological problems 6. Tolerance (acquired) 7. Withdrawal

43. How many people with obesity have “food addiction” according to the Yale Food Addiction Scale (YFAS)? • YFAS validation study • 67 weight loss surgery patients • 63% female, 87% Caucasian • Mean age of 43 years

44. How many people with obesity have YFAS “food addiction”? Use often more than intended 22% Failed attempts to reduce or stop use 71% Time+++ 24% Giving up other important activities 10% Continued use despite 28% Tolerance 14% Withdrawal 16% 54% met YFAS criteria for food addiction

46. Behind every addiction is an engineered moreish product

47. Non-essential, energy-dense, nutritionally-deficient (NEEDNT) foods Dr Jane Elmslie Dietitian - NAC

48. George Eman Vaillant, 1988 (1934 - present) “What is needed is that addicts alter their whole pattern of living”

49. Key elements of an addiction approach to recovery • Permanent lifestyle change • Details unique for each individual • Ongoing support and encouragement for at least five years • New food rules as “addiction interrupters”

50. A research-based self-help obesity recovery networkKia Akina“Be encouraged and supported”