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Food addiction and obesity

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J.Neurol.Sci.[Turk]

Journal of Neurological Sciences [Turkish] 33:(2)# 48; 392-400, 2016

http://www.jns.dergisi.org/text.php3?id=960

Review

Food Addiction and Obesity

Reci MESERİ1, Ayşegül BİLGE2, Özge KÜÇÜKERDÖNMEZ3, Ender ALTINTOPRAK4

1
Ege Üniversitesi İzmir Atatürk Sağlık Yüksekokulu, Beslenme ve Diyetetik Bölümü, İzmir,
Turkey 2Ege Üniversitesi Hemşirelik Fakültesi, Ruh Sağlığı ve Hastalıkları Hemşireliği
Anabilim Dalı, İzmir, Turkey 3Ege Üniversitesi Tıp Fakültesi, Ruh Sağlığı ve Hastalıkları
Anabilim Dalı, İzmir, Turkey

Abstract
The aim of this review is to discuss the concept of food addiction and its association with
obesity. The DSM-5, published in May 2013, defines substance related and addictive
disorders as clinical disorders indicated by inappropriate substance use within the last 12
months that meets at least two of the following 11 criteria: impaired control (4 criteria), social
impairment (3 criteria), risky use (2 criteria) and pharmacological response (tolerance and
withdrawal, 2 criteria). An important novelty in the DSM-5 is that, even though it is not
induced by a chemical agent, a behavioral disorder, gambling, is classified as an addiction.
Eating and sex, instincts that are essential for survival and wellbeing, are also called natural
rewards. Dopamine, a reward neurotransmitter, regulates pleasurable and motivating
responses to food intake. Repeated stimulation of these reward pathways, as in substance
abuse, weakens control over food intake and causes compulsive food consumption. Imaging
studies have shown that obese people have impairments in the dopaminergic pathways that
regulate their control and reward systems. Studies indicate that even in post-prandial satiety,
obese people show reward response to hyper-palatable foods. Thus, food addicts' efforts to
lose weight are frustrated by addiction, and they have difficulty in adopting healthy nutritional
habits. Studies of food addiction have proliferated recently around the world, but very few
have been conducted in Turkey. Community-based studies of food addiction should be
conducted to determine its prevalence. Obese people who are also addicted to food should be
treated with multiple treatment methods.

Keywords: Food addiction, addiction, obesity, dopamine

Gıda Bağımlılığı ve Şişmanlık

Özet
Bu derlemenin amacı gıda bağımlılığı kavramını ve gıda bağımlılığının şişmanlıkla ilişkisini
tartışmaktır. Mayıs 2013'te basılan DSM-V'e göre ‘Madde Kullanımı ve Bağımlılık
Bozuklukları' son 12 ayda, bozulmuş kontrol (4 kriter), sosyal bozukluk (3 kriter), tehlikeli
olduğunu bildiği halde kullanmayı sürdürme (2 kriter), farmakolojik/klinik yanıt (tolerans ve
yoksunluk-2 kriter) olmak üzere toplam 11 kriterden en az ikisine sahip olma ile kendini
gösteren klinik bozukluğa yol açan uygunsuz madde kullanımı olarak tanımlanmaktadır.
DSM-V'deki önemli değişikliklerden biri, kimyasal etkisi olmasa da bir davranış
bozukluğunun (Kumar Oyna Bozukluğu) “Bağımlılık” başlığı altında değerlendirilmesidir.
Yemek yemek, seks gibi yaşamın sürdürülmesi için gerekli, insanlara mutluluk veren
içgüdüsel davranışlara doğal ödüller denilmektedir. Dopamin, ödül nörotransmitteri olarak

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J.Neurol.Sci.[Turk]

adlandırılmaktadır, besin alımını güdüleyici yanıtları ve besinden alınan hazzı düzenler. Ödül
yollarının tekrar uyarılması, madde kötüye kullanımındaki benzer biyolojik mekanizmaları
uyararak gıda alımındaki kontrolü zayıflatmakta ve kompulsif gıda tüketimine yol açmaktadır.
Görüntüleme çalışmaları, şişman bireylerin ödül ve kontrol sistemlerini düzenleyen
dopaminerjik yolaklarında bozukluklar olabileceğini göstermiştir. Yapılan çalışmalarda
şişmanların doyduktan sonra bile yüksek enerjili besinlere ödül yanıt geliştirdiği, gıda
bağımlılığı olan bireylerin zayıflama konusundaki çabalarının da, bağımlılıkları nedeniyle
zarar gördüğü, sağlıklı beslenme alışkanlıkları kazanmakta güçlük çektikleri saptanmıştır.
Gıda bağımlılığı dünyada son yıllarda sıkça tartışılan bir konu olmakla birlikte ülkemizde bu
konuda yapılmış çalışmalar yok denecek kadar azdır. Toplumda gıda bağımlılığı ile ilgili
çalışmalar yürütülmeli, sıklığı saptanmalıdır. Gıda bağımlılığı olan şişman bireylerde ise
çoklu tedavi yöntemleri kullanılmalıdır.

Anahtar Kelimeler: Gıda bağımlılığı, bağımlılık, şişmanlık, dopamin

to data collected by the World Health

INTRODUCTION
Organization (WHO), there are over 400
Obesity is a health problem that is million obese and more than 1.6 billion
increasingly more common both in Turkey over-weight people in the world, and these
and in other parts of the world(3,22,27). This numbers are projected to reach 700 million
problem is usually associated with poor and 2.3 billion, respectively, in 2015(3).
diets and a sedentary lifestyle(3). Obesity The MONICA (Multinational MONItoring
may result in physical illnesses such as of trends and determinants in
diabetes and heart disease and mental CArdiovascular disease) study conducted
disorders such as depression and social by the WHO in six regions of Asia, Africa
phobia(10,17,28). The fact that the and Europe over a 12-year period found
consumption of some foods is pleasure- that in ten years, the frequency of obesity
inducing, combined with the observation increased by 10% to 30%(27).
that some people have difficulty Epidemiological studies show that
controlling the consumption of these foods, demographic factors such as age and
despite an awareness of obesity-related gender, socio-cultural factors such as
problems, indicates that some foods may marital status and level of education,
be addictive. Many of the major theories of biological factors, nutritional habits and
addiction also identify an important role of life-style factors such as smoking, alcohol
stress in addiction processes(38). This consumption and lack of physical
literature review shows that there are many activity(3).
studies on food addiction, and that children
Childhood obesity is on the increase and in
and adolescents are at particular risk of
the fight against obesity, the prevention of
developing this addiction. This review
child and adolescent obesity is a priority
aims to examine the relationship between
health issue(16,19,37,46). Current childhood
food addiction and obesity on the basis of
obesity rates are reported to be 10 times
studies conducted in Turkey and other
the rate they were in the 1970s. Unless
countries.
effective measures are taken, it is estimated
Obesity and Mental Health that the frequency of obesity will continue
Obesity is a global epidemic. It is defined to rise, and the number of obese children
as the accumulation of excessive bodily fat and adolescents in Europe will reach 15
that threatens physical and mental million(1,17). Childhood obesity rates
wellbeing(22). Obesity is seen both in increased by 5% in the Unites States
developed and developing economies and between the years 1963 and 1970, and by
is increasingly more common. According 17% from 2003 to 2004(19). In a study

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J.Neurol.Sci.[Turk]

conducted in the United States in 2007 and dissatisfaction and lower self-esteem(10,28).
2008, the percentage of children and Body dissatisfaction also acts as an
adolescents with BMIs above the 95th intervening variable leading to lower levels
percentile was found to be 16.8%(31). From of self-esteem(41). According to a meta-
20% to 25% of adolescents in the Unites analysis conducted by De Wit et al. (2010),
States are reported to be obese(15,16), and obesity increases depression-proneness in
this figure is projected to rise to 30% by adults, especially among women(13). Obese
2028 and to 40% by 2048(45). children and adolescents face
According to Turkey's 2010 Childhood discrimination and labeling, which is
detrimental to their mental and social
Obesity Survey, conducted by member
states of the European Region of the World wellbeing(47). Thus, obesity is an emerging
serious situation which effects both
Health Organization, the number of
physical and mental health.
overweight and obese people has
increased. Approximately 40% of its Food Addiction as a Form of Substance
population are overweight, and 15% are Addiction
obese(40).
The Psychodynamic and Behavioral
In Turkey, childhood obesity is increasing. Causes of Addiction
Bereket et al. reviewed the studies According to Freud, the founding father of
conducted between 2004 and 2010 and classical psychoanalysis, addiction is
showed that between 10% and 15% of caused by problems during the oral stage
children and adolescents from 6-18 years of psychosexual development that lead to
of age were overweight, and their rate of the development of an oral personality.
obesity was between 2% and 7%(5). Excessive maternal attachment, greed,
Turkey's Health and Nutrition Survey despair, depression, sentimentality and
(2010), conducted by the Ministry of inconsistency are among the indicators of
Health, found that 14.3% of children and this personality type. Among people with
adolescents from 6-18 years of age were this mental disorder, oral craving remains,
overweight, and their rate of obesity was but changes direction later in life. Objects
found to be 8.2%(24). such as water, milk and mother's breast are
According to WHO data, overweight and replaced with alcohol, cigarettes, or some
obesity are responsible for 80% of Type 2 other substance(32).
diabetes, 35% of ischemic heart disease Behavioral models of substance abuse
and 55% of hypertension among adults in underline the importance of learning in the
Europe, causing more than a million deaths development of this disorder. Through
a year(17). When mothers put on too much classical or operant conditioning, a
weight during pregnancy, it may result in connection is formed between events and
their children being obese in information related to these events, which
adolescence(25,29), and childhood obesity in turn reinforces substance use. For
may lead to adulthood obesity, possibly example, alcohol consumption is
leading to chronic diseases such as connected to numerous stimulants in the
coronary disease, diabetes and
(15,16,46,48) environment in which alcohol is
hypertension . Many studies find consumed. The smell or taste of an
that chronic diseases in adulthood are alcoholic drink is among the most
associated with nutritional habits in
powerful of these stimulants. More subtle
adulthood and adolescence(35,36,46). stimulants include the physical
Obesity creates mental disorders as well as environment (such as bars) in which the
physical illness. Studies find that obese substance is consumed and the mental state
people have significantly higher levels of of the consumer. Substance abuse develops
depression-proneness and body as repeated substance use associated with

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J.Neurol.Sci.[Turk]

environmental factors turns these factors by addictive substances and hyper-

into conditioned stimuli. These learned palatable foods: they increase dopamine-
connections later create the idea and the and opioid-related neural system activity,
expectation that the substance will be used trigger artificially heightened levels of
whenever these stimulants are present(32). reward, rapidly enter blood circulation,
stimulate neurobiological systems, are
Classification of Addiction
encountered by balancing mechanisms that
The fifth edition of the Diagnostic and result in heightened tolerance, give rise to
Statistical Manual of Mental Disorders desires that are triggered by symbols, are
(DSM-5) treats addiction in the section on difficult to stop consuming and continue to
“Substance-Related and Addictive be used despite harmful effects(18). There
Disorders," which are defined as clinical seems to be agreement in the literature that
disorders indicated by inappropriate food addiction, like substance dependence
substance use within the last 12 months and alcohol dependence, results in elevated
that meets at least two of the following 11 tolerance, symptoms of withdrawal, risky
criteria: impaired control (four criteria), consumption and other health problems.
social impairment (three criteria), risky use
(two criteria) and pharmacological/clinical Can food be addictive?
response (two criteria, tolerance and Instinctive behaviors such as eating and
withdrawal)(2,8). The DSM-5 treats having sex that are necessary for the
disorders related to the use of alcohol, survival of the species and are pleasure-
caffeine, cannabis, hallucinogens, inducing are called natural rewards(12,21). In
inhalants, opioids, sedative-hypnotics and pre-industrial societies, the typical diet
anxiolytics, stimulants, tobacco and other consisted of unprocessed or minimally
substances in separate codes. One of the processed meat, whole grains, fruits and
most important changes in the DSM-5 is vegetables. The consumption of meat
that gambling addiction is included in this products and fruits with high levels of
section because it stimulates the reward protein, fat or sugar content was limited
pathways in the brain, like substance due to their limited availability. In the
abuse, and results in similar behavior. This process of evolution, the human brain
is an important development because adapted to this condition and developed
repetitive, detrimental behavior that is reward mechanisms to stimulate increased
difficult to control is now treated as an consumption of high-calorie foods to
indication of an addictive disorder. Other increase chances of survival. However, in
repetitive behaviors such as sex addiction, the last century, our lifestyles have
exercise addiction and shopping addiction changed greatly, and due to developments
are also discussed in the DSM-5, but not such as urbanization and advances in food
included in this chapter because their production, high-calorie foods are no
classification as formal disorders requires longer limited. To the contrary, the
further research(2,20). consumption of processed, artificial, high-
calorie and high-fat foods has now become
Barry et al. (2009) adapted the DSM-5's
commonplace(18).
criteria for substance use disorder to
overeating(4). Table-1 shows this
adaptation.
Gearhardt et al. (2011) identified the
following common characteristics shared

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J.Neurol.Sci.[Turk]

Table 1. Applying substance dependence criteria to overeating disorder (based upon Barry et al.
(2009)

Substance dependence criterion Possible criterion for overeating

disorder
Criterion Example Example
Impaired control Alcoholic plans to stop at the Obese individual goes to a restaurant
local bar for one beer, ends up to eat one serving of salad, ends up
staying until closing and having eating a whole plate of fried
several drinks, makes repeated vegetables and dessert, keeps eating
unsuccessful attempts to stop after a large meal, makes repeated
drinking. unsuccessful attempts to diet.
Social impairment Alcoholic fails to show up at Obese individual loses self-esteem
work after a night of heavy because of labeling, which results
drinking, stops associating with from overeating, avoids going to the
non-drinking friends. beach, shopping for clothing, or places
where physical activity is required,
stops associating with slim people.
Risky use Alcohol dependent individual Obese individual continues to eat
continues to drink after being sugar and fatty foods after being
diagnosed with fatty liver. diagnosed with diabetes or
hypertension.
Pharmacological/ Tolerance: Alcohol dependent Tolerance: Obese individual requires
clinical response individual requires five drinks to very large servings to feel full instead
(tolerance and feel intoxicated instead of three. of smaller ones.
withdrawal) Withdrawal: Alcohol dependent Withdrawal: Dieter experiences
individual experiences symptoms symptoms of depression, smokes or
such as nausea and sweating drinks caffeinated beverages to
when he or she doesn’t have compensate, has headaches, feels
alcohol. restless and feels a strong desire to
stop dieting.

Recent neurobiological studies examine disease is characterized by impaired

the relationship between food addiction movement due to dopamine deficiency and
and obesity and discuss whether overeating is accompanied by cognitive, behavioral
needs to be considered a form of and emotional disorders. Dagher et al.
behavioral disorder because food (2009) found that Parkinson's disease
consumption is followed by certain types patients usually do not develop
of neurological activity(4). The focus in dependencies, whereas some patients
these studies is on food's relationship with treated with drugs such as levodopa, which
reward pathways in the central nervous is a precursor of dopamine, develop
system and with dopamine. Dopamine is a behavioral disorders such as gambling,
reward neurotransmitter(23) and regulates shopping and sex addiction(11).
responses that stimulate food intake and Dopamine and dopaminergic pathways are
pleasure from food. A study that sheds very important because they ensure
light on this issue was conducted with survival by motivating food intake. The
Parkinson's disease patients. Parkinson's

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J.Neurol.Sci.[Turk]

mesencephalic dopamine system may smokers and past smokers than non-
trigger a response to food stimulants even smokers(30).
in the presence of post-prandial satiety At the most basic level, weight gain occurs
signals and increase food consumption. when there is an imbalance of energy, that
When this happens, eating behavior is to say, when energy intake is greater
switches from a homeostatic state to a than energy expended. As a result, the cure
hedonic corticolimbic state(44). Recent for obesity involves increasing energy
studies find that consumption of large
expenditure and limiting energy intake(4).
amounts of sugar and fat results in Although the relationship between energy
overstimulation of the reward system of imbalance and obesity is simple at this
the brain and increases dopamine release. most basic level, obesity is a very complex
When appetizing foods are displayed, condition and is difficult to treat.
reward mechanisms are activated and
dopamine release in the brain increases Studies conducted on twins or adoptees
automatically and reflexively, similar to showed that both genetic and
what happens in cases of substance environmental factors may contribute to
dependence. Foods rich with sucrose and obesity. As in alcoholics, in obese patients,
glucose have been found to activate the higher prevalence of Taq A1 allele was
brain's reward system and increase glucose found, resulting a lower density of
concentrations in the brain. Studies find dopamine D2 receptors. Smith and
that the ventral striatum, prefrontal cortex Robbins explains this phenomenon as, due
and amygdala are responsive to pleasure to low baseline dopamine D2 receptor
from food. Repeated supraphysiological level which is the reward deficient state,
stimulation of these reward pathways patient seeks for highly palatable food and
triggers neurobiological adaptation by consumes it. This consumption yields to
stimulating biological mechanisms similar down regulation of dopamine receptors
to those seen in substance abuse. which leads to habituation of seeking and
consuming high palatable foods(39).
Reward deficiency syndrome was
Moreover, drugs that blocks dopamine D2
described as the chemical imbalances in
receptors increase appetite which cause
the brains reward system that result in
weight gain(43). Imaging studies show that
many behavioral disorders. According to in obese individuals, the dopaminergic
Blum and his colleagues, decreased pathways that regulate reward and control
dopaminergic process may cause seeking systems might be impaired(42). Thus,
“reward” and abstinence behaviors. In reward deficiency syndrome may
addition, in a study conducted on alcoholic contribute to obesity epidemic.
and non-alcoholic cadavers, they found out
that D2 receptor polymorphism (Taq 1A) Studies of the diagnosis of food addiction
was associated with alcohol abuse which have found that specific regions of the
lightened the studies that show the brain are stimulated during the anticipation
association between genetic make-up and and the consumption of appetizing foods,
addiction(6,33). According to a study as they are in other addictions(34).
conducted by Blum and colleagues, Likewise, studies with college students
alcoholics have significantly more A1 have found that excessive overeating leads
allele compared to non-alcoholics who to low stress tolerance like tobacco
have mainly A2 allele. The ones who carry addiction and substance dependencies, and
A1 allele have a lower density of dopamine that food addiction is characterized by
D2 receptors which result in anger, anxiety strong impulses and cravings(26). In a study
and craving for substances(6,7). Noble et al. of adults in weight loss programs,
found similar results for smoking; the Burmeister et al. (2013) found that food
incidence of having A1 allele was higher in addiction was accompanied by depression,

397
J.Neurol.Sci.[Turk]

emotional eating, excessive eating, Received by: 27 August 2015

negative attitudes about weight, body Revised by: 03 February 2015
shame and low self-efficacy. Individuals Accepted: 15 March 2016
with high levels of food addiction are less
successful at losing weight and have
difficulty developing healthy eating habits,
and their efforts at weight loss are The Online Journal of Neurological
hampered by addiction(9). In another study, Sciences (Turkish) 1984-2016
Dimitropoulus et al. (2011) found that This e-journal is run by Ege University
obese individuals develop reward response Faculty of Medicine,
to high-energy foods even after large Dept. of Neurological Surgery, Bornova,
meals, whereas individuals with normal Izmir-35100TR
weights do not display this response once as part of the Ege Neurological Surgery
satiety is reached(14). These findings also World Wide Web service.
point out that there is a complex Comments and feedback:
associations between obesity and reward E-mail: editor@jns.dergisi.org
system. URL: http://www.jns.dergisi.org
Journal of Neurological Sciences (Turkish)
CONCLUSION
Abbr: J. Neurol. Sci.[Turk]
Nutrition is essential for survival, and ISSNe 1302-1664
eating is a natural way to meet bodily
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